When a Policy ends for an individual enrolee or for an entire group.
The minimum health plan coverage that each person residing in Cayman must have. A SHIC plan provides (in Cayman dollars): $1,000,000 lifetime maximum; $100,000 per annum maximum (mostly available towards hospitalisation and inpatient or outpatient surgery, dialysis, chemotherapy and oncology radiation). Some other SHIC plan highlights are: $400 per annum for medical visits, labs/x-rays & prescriptions; $200 per annum for wellness services; $15,000 air ambulance; $5,000 emergency and $500 pre/ante-natal care.
The process of directing or redirecting (as a medical case or a patient) to an appropriate specialist or agency for definitive treatment. Your health plan may require written referral requests for any overseas care.
Payments that you or your employer pay to the health insurance company to keep you insured.
Also called coverage determination. A decision by your health plan about whether a service is medically-necessary and covered by the Policy. Often certain types of care or dollar amounts trigger the need for the insurer to pre-authorise services. Note that proposed fees do not have to be submitted by the provider for a pre-authorisation so the patient is advised to ask about the fees vs. coverage levels too.
An internet service which most insurers offer in which you can sign up to be able to view your Explanations of Benefits (EOBs) and other insurance information on-line.
In Cayman, when a person is covered on a Cayman-compliant plan for 12 or more months with no more than a 3 month break in coverage, the person is said to be portable to their next Cayman-compliant plan up to similar coverage levels which the prior coverage had. Financial accumulators, such as lifetime maximum and annual maximum, and prior exclusions / restrictions may be carried forward by the new insurer. However, no new exclusions or limitations may be placed on the new Policy (unless the applicant fails to disclose). If the person is applying to an upgraded coverage, the insurer may limit the new plan to their prior plan levels.
The legal contract outlining the full benefits, eligibility and procedures followed by your insurance company for your coverage. A “benefit grid” or “schedule of benefits” is a brief overview of the Policy, and the Policy has more of the specifics and legal guidelines.
The part of the costs which are the patient’s responsibility. Charges for services and supplies not covered under your plan including deductibles, coinsurance and charges which exceed the allowed charges or the maximum benefits of your plan.
When an applicant fails to provide accurate details about pertinent medical history when they apply for coverage or upgrade. May be cause for retroactive termination or a permanent exclusion to be applied to a Policy.