Every resident of the Cayman Islands is required, by law, to have an active health insurance policy in place. Employers are mandated, at the very minimum, to provide a Standard Health Insurance Contract (SHIC) plan for their employees from the first day of employment, regardless of the type or length of their work permit.
These provisions also apply to self-employed people, those in a partnership and those on permanent residency without the right to work. This requirement of employers extends to any un-employed dependent spouse and child(ren) living in the Islands. Legally, an employer only has to pay half of the single premium, based upon the lowest-costing plan made available to the staff, and the employee pays the other 50%. However, you can negotiate with your employer that they pay more than the minimum contribution level, particularly in relation to the cost of your dependants (for which you will potentially have to pay 100%) and any premium differentials for any upgraded benefit package that you might choose.
Insurance may be purchased by residents on an individual or family basis, or you will be enrolled on group coverage via your employer. Employer groups, especially those with over 20 employees, will have more insurance companies and plan options to choose from. Individuals and employers may work directly with the various insurance companies, or may secure the services of an independent broker to obtain and evaluate their insurance options. The insurance companies pay the brokers for the assistance they deliver, so most brokers’ services are at no cost to the client. Some brokers may be agents of a particular insurance company, or may only acquire quotes from one, or from a very limited number of insurers, so you may wish to query which insurers they work with before choosing.
For the basic SHIC plan, the insurance companies will ask for 12 months of medical history, plus details on current conditions and medications. For upgraded policies, the applications may ask for a more extensive medical history, thus it is a good idea to bring copies of your medical records with you (and those of your dependants). This will also assist your new doctors in Cayman in providing your care. If you have chronic medical conditions or immediate surgical needs, expect that these could be excluded from your coverage. There are many recorded cases of insurance companies choosing not to cover pre-existing conditions which could cost them money and force them to raise premiums in the long run. Thus, persons coming from overseas with medical issues are recommended to request that their proposed employer seek a pre-approval of their insurance, as part of their decision-making process.
Once you are covered with a Cayman insurer for 12 or more months, with no more than a three-month break in coverage, even if you have developed problems in the meanwhile, the next insurer cannot add new exclusions to a similar level of coverage. The only exceptions are cases of non-disclosure on the application form, or if you are seeking a large upgrade in your coverage. Since pre-existing conditions may be excluded, be sure to check before cancelling your insurance at home – it is possible you could get global coverage on your existing health insurance, which will cover you in Cayman. However, you will still be required by law to have the minimum SHIC plan from one of the local providers; only then you can coordinate the benefits between the two health plans.
Plans vary from the basic SHIC to some very comprehensive major-medical plans. The Cayman Islands Monetary Authority and the Health Insurance Commission both license and regulate the health insurance companies. The SHIC plan is the primary Government-regulated contract and covers about a quarter of Cayman’s residents, but most employers offer higher than mandated coverage. The SHIC benefits form the basis of all other health insurance plans and were increased in 2013. They now cover up to KY$100,000 per annum for each person with a KY$1,000,000 lifetime maximum. They cover hospital, surgical, chemotherapy and radiation services along with emergency care. All SHIC plans have limited local outpatient benefits and any overseas care is usually restricted to major care, which has been properly referred and is unavailable in Cayman. The more comprehensive plans offer wider access to overseas services, larger per annum and lifetime allowances (e.g. $500,000, $1,000,000 and $2,000,000 or higher could be available within a calendar year), fuller prescription coverage, more outpatient services and options to have dental, routine optical and/or life insurance benefits.
The cost of insurance plans will vary with age, gender, benefits and employer size. A basic SHIC plan without dental and vision, for an individual, costs in the vicinity of CI$167 per month per employee, whereas a medical plan with enhanced outpatient benefits typically runs 20-30% higher than SHIC. A medical plan with comprehensive benefits, including doctor and specialist visits, extra preventative care, dental, vision and prescription coverage can cost up to CI$500-CI$900 per month, per individual, and about CI$450-CI$850 without dental and vision. The premium rates are roughly doubled for a couple and about tripled for a family rate. The Government’s CINICO (Cayman Islands National Insurance Company) SHIC plan offers low income participant rates based upon age, but some requirements must be met and applications for enrolment may only be accepted in certain months each year. The high cost of our health insurance has been known to discourage people from retiring here. Keep in mind that under some group plans, the amount available per annum may reduce at the typical ‘retirement age’ and most employers in Cayman do not extend health insurance benefits to retirees.
Most General Practitioners, Medical Specialists and Dentists accept local insurance ‘on assignment’ provided that the insurance company guarantees payment and the deductible, if applicable, has been met. This means that the doctor or dentist will claim directly from the insurance company for work done on your behalf. Be aware that all charges may not be paid by the insurance company, as the law allows the physician in Cayman (as with all other professionals) to decide their own fees. The law also only obligates the insurance companies to pay ‘Standard Health Insurance Fees’. Anything not paid by your insurance company is your responsibility. You should always confirm the cost of the impending treatment before going ahead. All medical payments by insurers are based on the Standard Health Insurance Fee (SHIF) schedule, which can be found at www.dhrs.gov.ky. (Look for the Standard Health Insurance Fees on the Health Insurance Commission page.) Medical providers are not required to charge within the SHIF fees, and balances above the SHIF fees are the patient’s responsibility. For large medical services, it is not unreasonable to ask for a written quote, which is called a ‘predetermination of benefits’ or ‘preapproval for medical necessity’. Clients should review their benefits for any exclusions or benefit limits too, as some areas are not entirely covered.
If a retiree or visitor to Cayman requires medical assistance on the Island, they will usually pay up front for services, keep all receipts and submit a claim once they return to their home country. The receipts will usually need to be fully itemised with diagnosis information. The visitor should request that a claim form be completed using Cayman’s standard claim form. It is imperative before travelling to Cayman, that you call your insurance provider to verify how your benefits will work here. You may also wish to check if they have any relationship with any local providers. It is possible that insurance companies have already set up a relationship with local providers, which can save you out-of-pocket costs. However, it is not mandatory for medical facilities to accept overseas insurance. Residents who will have relatives visiting are recommended to inquire about their visitors’ insurance too. If your visitors’ insurance will not cover them whilst in Cayman, they should be encouraged to seek a travel policy to protect them.
Health Insurance for Cayman Children
Although decades ago medical care for children was free at the George Town Hospital, this is no longer the case. Cayman has adopted 3rd-party American style health insurance instead of socialised medicine. Cayman Laws mandate that every citizen, including children, must have at least a Standard Health Insurance Contract (SHIC).
The only instances when Public Health may cover some, or all, medical costs are those relating to children’s immunisations, tuberculosis, HIV/AIDS and pre-natal expenses:
• In order to maintain Cayman’s high vaccination rates, and maintain the freedom we have had from measles and whooping cough outbreaks, Public Health will waive the balance of the costs of children’s Cayman-required immunisations not covered by insurance policies.
• Some Caymanian women may qualify for financial assistance with pre-natal expenses, via Public Health, if their insurance benefits have been exhausted. This does not include delivery costs though!
• Because of the threat that tuberculosis and HIV/AIDS pose to the community, the cost of residents’ treatment for these conditions can be covered by Public Health.
There are no insurers in Cayman that offer child-only individual policies for under 18s, so children must be added to their parent’s plan. Any parent working in the Cayman Islands should have health coverage offered by their employer, as the employer is required to extend coverage options to any legally-resident dependents. This extension applies to spouses not covered by their own employment and their children, step-children or adopted children living in Cayman (even if the child is attending school overseas). The employers do not have to pay towards the children’s premiums, although some do contribute. Health insurance for family members can be a large expense in the budget, thus, should be discussed as part of your employment process. Unemployed or self-employed parents must insure their children also via an individual policy.
Planning for Pregnancy
If you plan on having a child, review how your plan will cover pregnancy, childbirth and newborn care well in advance to help ensure the costs will be covered. If you try to join the insurance plan after you are pregnant, your pregnancy will be viewed as a pre-existing condition, thus may be limited to the SHIC basic plan benefits: $500 in prenatal coverage and an annual cap of $100,000 for major care for mother and baby. If you try to upgrade whilst already pregnant, the expenses are usually allowed at the original plan’s benefits only.
Similarly, if a dependent daughter becomes pregnant and is on her parent’s plan, the pregnancy will usually be limited to the SHIC benefits, and her baby’s expenses may have limited cover, or none at all, via the grandparent’s plan. In such situations, mother and baby are usually better off on their own plan.
Planning Ahead for When the Baby Arrives
Once a baby arrives, those on individual plans must take the necessary steps with the insurer to add the baby to the plan themselves. Employees on a group plan, however, need to have the plan administrator to authorise the addition of any dependent.
You will need to speak to your HR department or insurance company about how to add your newborn. Bear in mind adding the baby should be done within 30 days of birth. Do not wait until you return to work after maternity leave or your medical bills may not be paid, and if the baby is found to have medical issues, more restrictions could be applied. Sometimes the forms can be pre-signed to enrol the baby. Then, once you have given birth, let HR know the date of birth and baby’s name, so that the forms can be sent to the insurer. You also may need to provide a birth certificate.
It is also worth noting that you do not need to be the primary custodial parent nor be married to the child’s other parent to provide for their health insurance plan.
Mum’s Plan or Dad’s Plan?
If you and your spouse (or other parent) are on different health plans, you should choose to add your child to one or other plan, or apply for both parents’ plans. When deciding which plan to go with consider the following:
• What are the benefits of each plan?
• Which parent is likely to stay in their job longer? Although it is possible to change plans, it can be time-consuming and things like deductible credits may be lost.
• What are the monthly premiums and what amount does each parents’ employer contribute towards dependent’s coverage?
• Ask your employer about renewal dates (the rates you are quoted today may change at renewal time, so what appears to be the best deal right now may not be the best deal in a few months time).
• When calculating the costs of insuring children, remember to take into account the variance in pay periods: if you are paid every two weeks, will you be looking at deductions on every pay check, including those months when there are three pay cheques?
Whilst there is a clause in the Health Insurance Laws & Regs regarding the mother’s health plan covering a newborn’s 1st 30 days of life, the coverage can, and often is, limited by the insurer to the basic SHIC benefit levels. Since premature birth or congenital problems (which are not always immediately diagnosed) can exceed those limits, it is recommended that the child be enrolled from date of birth to the best coverage available.
Whilst the law requires a minimum coverage it does not block additional coverage, so in some cases it is possible to put a child on two plans. If both parents have the same insurer, double enrolment is not an option. In double coverage, the benefits should be coordinated between the two plans: the primary plan should pay first, and eligible differences can be submitted for coverage by the second. In Cayman, the father’s plan is usually considered the primary plan in cases of coordinating benefits (COB). It is important to consider, however, whether the potential benefits warrant paying the additional premiums. A possible instance when double-coverage could be beneficial is if a baby is ill or premature and one plan’s benefits will not suffice.
Insurance for School & College Age Children
Whilst they are dependents, children are to be insured on their parents’ plan but once a child marries or begins regular work (not counting holiday jobs), they are usually no longer considered dependents eligible for the parents’ plans and should go on their spouses’ or own employer’s plan (even if under age 18).
It is not unusual for parents to worry that their child’s employer’s health plan is too expensive, or does not provide as adequate coverage. It is important to be aware though, that it may not help to keep a young person who is in employment or married on the parent’s plan. Insurers may deny claims when the eligibility criteria are not met and thus at a time of need, the plan may provide no cover at all. In the event that the child loses his or her job, returns to school or becomes financially dependent again, it is possible to add them back on to their parents’ plan.
Young adults aged between 18/19 (depending on the insurer) and age 30, who are in school or college or otherwise financially dependent on their parent, may remain on their parent’s plan as an ‘overage dependent’. In order to cover an overage dependent, however, proof that they are a full-time student and/or dependent on the parent must be provided. It is the parent’s responsibility to maintain valid proof at all times. Some insurers require proof from the school annually or each semester, (so as little as three months may elapse between semesters) or a statement of financial dependency as often as every six months.
Parents need to know and follow their insurer’s requirements in this important matter. Failure to provide such proof – even when premiums are paid – may result in claims being pended/not paid, and the insurer will not be able to verify coverage in emergency situations, or coverage may be terminated entirely.
Children & Travel
Parents whose children travel either on school trips or to study overseas, should make sure the insurance plan covers them wherever they may be. If studying overseas, it is not necessarily a good idea to drop their Cayman plan in favour of a college plan, especially if the college plan does not cover them during vacation travels or whilst in Cayman.
Equally, children studying in Cayman may travel to other countries for sports or school trips. In such cases it is important to find out what coverage their plan provides abroad. Many of the basic plans have minimal or no emergency benefits and require Cayman referrals signed by two doctors or the Chief Medical Officer in order to receive major care overseas. Parents may therefore need to purchase additional medical travel insurance for the periods when their children make trips overseas.
Besides an ID card, it is a good idea to provide the child or his/her caregiver guidance how to use the plan overseas (e.g. point out the website or phone # for finding network providers and where to access claim forms to print) and when pre-authorizations for care may be required.
If a parent has children living overseas who come to visit them in Cayman, they too should ensure that the child(ren) have a home policy including overseas benefits, or a travel policy, to cover them in Cayman, with the major medical benefits being the most important part of the coverage to review.
Changing Plans: Portability Protection & Importance of Declaring Pre-Existing Conditions Accurately
It is possible to change plans, whether between a parents’ plan or when the child moves onto their own plan, and ‘Portability protection’ means that if you or your child have been covered for 12 or more months with no more than a three month break in coverage on a Cayman-based compliant plan, the next Cayman insurer cannot refuse your entry nor add new restrictions onto your enrolment for a similar level of plan. The insurers may rate the premiums higher for the risks presented.
Note that if you downgrade your family’s plan to save money, you will then only be portable to the new level of plan if you change jobs or plans later. If you move your child off of your local coverage onto an overseas plan whilst away at school, your child will likewise lose portability due to the break in coverage.
Importantly, portability still requires, as always, the applicant to fully answer all questions accurately. Typically there will be more questions on forms for higher cover plans – allow time to complete accurately and do not make the mistake of thinking the insurers have records of the past medical history. Pre-existing conditions not fully declared may have related claims denied in full, without even SHIC benefits available, which is a totally avoidable situation just by being thorough and truthful.
What Can You Afford?
As a rule of thumb, the wisest course of action is to choose the highest coverage you can afford as even the most mundane of procedures quickly climb in costs. If, however, you opt for a lesser coverage in order to save on monthly costs, consider putting some of those savings aside for an ‘emergency fund’ which you can dip into if and when you need extra care or tests not covered by your plan.
As per the Health Insurance Law, if you are Caymanian and cannot afford the premiums to cover yourself and/or your child(ren), you may apply for medical coverage through the Needs Assessment Unit (NAU), which is part of the Community Affairs Youth & Sports Ministry’s Department of Family & Children’s Services. Applications and relevant documentation should be submitted before a medical emergency arises. It also worth noting that Government may allow a Caymanian to sign IOUs or put their property up for collateral for urgent medical care not covered by their insurance but then they will be in control of which medical options are available. This does not, however, apply to expatriates.
Eligibility Details Summarized
• According to the Health Insurance Law, children can be birth children, step children or legally adopted children.
• The insurers may require a copy of birth certificates and/or immigration status to enrol a child and marriage certificates if enrolling step-children.
• Most insurers require children to be bona fide residents of Cayman (with exception of children normally resident in Cayman attending school abroad).
• Grandchildren are not eligible for enrolment unless the grandparent has court-issued papers of guardianship.
• No insurers in Cayman offer child-only (under 18 year old) individual policies (but children who start working before age 18 may be enrolled on their employer’s plans).
• After the age of 18 or age 19 (depending upon the insurer) up to maximum age 30, children will need proof of attending school or evidence of being financially dependent upon the parent to stay on their parent’s plan as “overage dependents”.
• Proof of this must be maintained by the parents.
• Some insurers require this statement of financial dependency (often to include a notary seal) as often as every six months.
• Even if premiums are paid continuously, without such valid proof, claims will be pended / not paid and most importantly, the insurer will not be able to verify coverage in emergency situations.
• The law requires minimum coverage but does not block additional coverage from being placed.
• If your child is eligible for other plans via their college or other parent, consider if the potential benefits possibly warrant the extra costs.
• Beware of dropping their Cayman plan for a college plan as the college plans may not cover them during vacations periods or whilst in Cayman – sometimes you will need both plans.
• Usually children can be enrolled on both parents’ plan but the additional premiums may outweigh the additional potential benefits.
• If the child marries or is working (except holiday jobs), that child should go on their own employer’s or spouse’s plan.
• Parents may worry that the child’s employer’s plan is too expensive or that the quality of it isn’t as good as their own; however, since insurers can deny claims when eligibility criteria is not met, the parent’s plan could provide nil protection when most needed.
You pay a monthly premium to your insurance company, regardless of whether you use any health care services. Then when you receive care, you will be asked to pay the whole amount and claim back from your insurers, or just pay the co-pay amount, depending on which insurance company you are with.