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Civil Servants and Pensioners

  • Plan Description
  • Eligibility Criteria
  • Benefit Schedule

ENROLLMENT REQUIREMENTS 

In order for a Plan Member to be enrolled in the Plan they must comply with the enrollment procedures outlined by the PoCS for Employees, or PSPB with regard to Retirees. Current procedures are included in Appendix A of the Plan.

 

EFFECTIVE DATES

A Plan Member will be covered under this Plan as of the first day that they satisfy the:

  • The Eligibility Requirements of the Plan (see page 12 of the Plan);
  • The Enrollment Requirements of the Plan (please see Appendix 5 of the Plan).

 

A Dependent's and Dependent Offspring’s coverage will take effect on the day that it is demonstrated (a) that the eligibility requirements are met; and (b) the Plan Member is covered under the Plan; and (c) the enrollment requirements are met.

 

RETROACTIVE ENROLLMENT

Retroactive enrollment is permitted up to a maximum of 90 calendar days.

 

ENROLLMENT REQUIRMENTS FOR NEWBORN CHILDREN

A newborn child of a Plan Member is<00zh> automatically enrolled in this Plan for 90 days from birth. Charges for covered benefits (including nursery care), will be applied toward the Plan of the <00xh>newborn child. If proper documentation is not received within the first 90 days from birth, coverage for the newborn will terminate on the 91st day. Coverage will be reinstated upon receipt of the relevant documentation.

 

CHANGE IN FAMILY CIRCUMSTANCE

The Plan permits a change of benefit coverage during the plan year if a qualified change in family circumstance occurs. The procedures for making changes to family circumstances will be determined by the Employer or in the case of Retirees the Public Service Pensions Board (PSPB). Plan Members are, by law, responsible for notifying the Employer or PSPB when family circumstances affecting eligibility for medical coverage change.

 

EMPLOYER/PSPB LIABILITY

Where the potential Plan Member has met the eligibility and enrollment requirements of the Plan but the Employer/PSPB has failed to comply with the enrollment requirements of the Plan on their behalf, the liability for medical expenses incurred in that period by the Employee/Retiree and their Dependent will be met by the Plan Members Employer (the Ministry/Portfolio/Department)/PSPB.

 

TERMINATION OF COVERAGE

The Plan Participants coverage under the Plan will terminate on the earliest of these dates:

  • The date the Plan is terminated.
  • The first day of the month following the date they cease to be eligible under the plan.

The Plan Administrator is required to provide Plan Members with the opportunity of purchasing up to 3 months additional coverage under the Plan, once eligibility for this plan automatically ends.

A former Employee who is re-hired after a break of more than 6 months, will be treated as a new hire and be required to satisfy all eligibility and enrollment requirements.

 

This health plan provides health care coverage for the entire Civil Service and their dependents, as well as retirees. In addition, a number of Statutory Authorities & Government Companies also subscribe to this plan.

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ENROLLMENT CRITERIA

(Exclusivly for Cayman Islands Government Civil Servants and Pensioners & Employees of participating Statutory Authorities and Government Companies)

New Employees and their Dependents 

  • Eligibility for Plan benefits for Employees and Dependents will be negotiated as part of the recruitment and selection process and documented in the Employee Agreement.  
  • The required supporting documentation must be provided by the Employee as part of their pre/new employment administration.
  • The Ministry/Portfolio/Department must ensure entry of relevant information into the HRIRIS system on commencement of employment.
  • Information regarding Plan eligibility will be automatically transferred electronically to CINICO’s NHIS database, and CINICO will produce and distribute CINICO cards for the Employee and Dependent(s).

Existing Employees and their Dependents

  • Employees must notify their Department immediately of changes to their circumstance or that of their Dependents impacting eligibility for Plan benefits.  This is required under Schedule 1 Section 13(1)(b) of the Personnel Regulations.  The table below identifies the supporting documentation needed to support each request.  A Change Of Circumstance Form must be completed and submitted in each case.
  • The Ministry/Portfolio/Department  must consider whether the request requires a variation to the employee’s terms and conditions and must issue an amendment to the Employee Agreement where a contractual change is being authorized.
  • The Ministry/Portfolio/Department must ensure the update of relevant information into the HRIRIS system with immediate effect.
  • Updated HRIRIS information regarding Plan eligibility will be automatically transferred electronically to CINICO’s NHIS database and CINICO will produce/distribute/deactivate CINICO cards as appropriate.

 

Change of Circumstance Supporting Documentation
Marriage Marriage Certificate and Spouse'

Birth Certificate

Becoming step-parent

Marriage Certificate and child’s 

Birth Certificate

Birth of Child

Child’s Birth Certificate

DNA test results where a male employee

is not listed as the parent of the child

on the Child’s Birth Certificate.

Adoption of Child

Adoption Certificate

Child’s Birth Certificate(If adoption is 

accompanied by a name change see

name change section below)

Child aged 18 to 23  in full-time education

Proof of enrolment in full-time course at

school/university

Marriage of child aged 18 to 23 in full-time education

Marriage Certificate

Child under 18 commencing employment

Letter from employer identifying child is

covered fo medical benefits under

the employer

Death of Spouse of Child

Death Certificate

Divorce

Dissolution of Marriage Certificate (If

divorce is accompanied by a name

change see name change section below)

Name Change

Copy of Deed Poll

Change of Postal Address

Nothing in addition to the Change of

Circumstance Form

 

Dependent Offspring of Existing Employees (optional at the expense of the member and with prior

 approval). 

  • Employees must request eligibility for Plan benefits for Dependent Offspring from the Ministry/Portfolio/Department.
  • The Ministry/Portfolio/Department (in conjunction with PoCS) must consider whether or not a Dependent Offspring can be added to the Employee’s Plan in accordance with the policy of the PoCS.
  • The Ministry/Portfolio/Department must ensure entry of relevant information into the HRIRIS system (including salary deductions where appropriate).
  • Updated HRIRIS information regarding Plan eligibility will be automatically transferred electronically to CINICO’s NHIS database and CINICO will produce and distribute CINICO cards as appropriate.
     

Terminated Employees and their Dependents/Dependent Offspring 

The Employer will be responsible for maintaining and timely furnishing to CINICO, current and accurate

 Plan eligibility.

  • Changes affecting the status of any of the Plan Participants must be submitted to CINICO within 10 business days after the Employer becomes aware of any such change.
  • CINICO will not be responsible for errors or omissions arising out of the failure to maintain current and accurate eligibility data held on HRIRIS.
  • In the event of retrospective changes in status of more than 30 days, CINICO reserves the right to seek recovery of paid claim(s) from the Ministry/Portfolio/Department.
     

New Retirees and their Dependents 

  • On the retirement of a Plan Participant from the Civil Service (who was entitled to a Pension, or was already a member of the Public Service Pension Scheme that he/she can now claim under, and the Government was their principal employer for at least 10 consecutive years), PSPB will enter the pensioner’s details (and their Dependents) onto the NHIS database.
  • In cases where the eligibility conditions detailed above appear not to have been met, the pensioner may be referred to PoCS to determine whether PSPB should still add them to the NHIS database.  PSPB will only act in these cases on the written instruction of PoCS.
  • Once CINICO cards have been received, PSPB will contact the pensioner for pick up.
     

 Amending Retiree (pensioner) and Dependent Details

  • Upon notification of changes to a Retiree’s circumstances and on receipt of required documentation, PSPB will make the necessary amendments to the NHIS database.
  • If the amendment requires new CINICO card(s) to be issued, then PSPB will contact the Retiree/pensioner on receipt of the card(s) to arrange pick up.
  • If the maximum age is reached for Retiree’s Dependents, or notification is received that their Dependents have ceased to be in full time education, then their Dependents will be end dated by PSPB on the NHIS database.
     
MEDICAL CARE BENEFITS In- Network (Health Services Authorities) On-Island or Overseas Providers without Referral * On-Island or Overseas Providers with Referral within CINICO Preferred Provider Network On-Island or Overseas Providers with Referral outside CINICO Preferred Provider Network
** Maximum Lifetime Benefit Amount: CI $5 Million
Covered Services: All Covered Expenses are payable subject to a fee schedule or negotiated rate
Hospital Services
Room Board 100% of the semi-private room rate No Coverage 100% of the semi-private room rate 90% of the semi-private room rate
Skilled Nursing Facility 100% of the facility's semi-private room rate No Coverage 100% of the facility's semi-private room rate 90% of the facility's semi-private room rate
Physician Services
Inpatient visits 100% No Coverage 100% 90%
Office visitis 100% No Coverage 100% 90%
Surgery 100% No Coverage 100% 90%
Allergy testing 100% No Coverage 100% 90%
Allergy serum & injections 100% No Coverage 100% 90%
Home Health Care $6000 maximum per month, in accordance with approved Home Health Care Plan
Prescription Drugs 100% No Coverage 100% 90%
Ambulance Service (Ground & Air) 100% No Coverage 100% 90%
Occupational Therapy 100% No Coverage 100% 90%
Speech Therapy 100% No Coverage 100% 90%
Physical Therapy 100% No Coverage 100% 90%
Durable Medical Equipment 100% No Coverage 100% 90%
Prosthetics 100% No Coverage 100% 90%
Orthotics 100% No Coverage 100% 90%
Spinal Manipulation/Chiropractic 100% Maximum 20 visits per annum No Coverage 100% Maximum 20 visits per annum 90% Maximum 20 visits per annum
Mental Disorders
Inpatient 100% No Coverage 100% 90%
Partial Hospitalization 100% No Coverage 100% 90%
Outpatient 100% No Coverage 100% 90%
Substance Abuse-Inpatient Detoxification Services Only 100% No Coverage 100% 90%
Preventive Care - Includes office visits, paps smear, mammogram, prostate screening, gynecological exam, routine physcal examination, x-rays, laboratory blood tests and immunizations.
Routine Well Adult Care 100% No Coverage 100% 90%
Routine Well Newborn Care 100% No Coverage 100% 90%
Routine Well Child Care 100% No Coverage 100% 90%
Immunizations - Children to Adult   No Coverage 100% as ordered by a physician 90% as ordered by a physician
Organ Transplants 100% No Coverage 100% 90%
Pregnancy 100% No Coverage 100% 90%

* Overseas Medical Emergency Care only covered at a 100%
** Any benefit which exceeds the maximum lifetime benefit amount is an assumed risk of the Government Entity through whol the Plan Participant is eligible.

VISON CARE BENEFITS
One eye examination per Pan Participant in 24 month period, up to a maximum of $60 (or for Pilots – one eye examination in a siz month period, or for Scenes of Crime Officers – one eye examination in a twelve month period).
One pair of prescription glasses in a 24 month period, up to a maximum of $300 (including frames), or equivalent in contact lenses.

 

DENTAL CARE BENEFITS
Class A (Preventative and Diagnostic) – 100%
Includes – routine oral examinations, one bitewing once per calendar year, two full mouth x-rays every 24 months, four fluoride treatments per calendar year for Dependent children under 19 years old, two visits per calendar year for scaling and polishing of teeth, and emergency palliative treatment for pain.
Class B (Basic Procedures) – 100%
100%. Includes oral surgery, periodontics, endodontics, extractions, re-cementing and fillings (other than gold, or material more expensive than gold).
Class C (Major Procedures) – 100%
Includes the installations and creation of crowns.
Class C (Major Procedures) – 50%
Dentures & Orthodontia. Installing, replacing or repairing removable dentures.
Not Covered
Gold restorations, including inlays, onlays and foil fillings, implants and bridgework.
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