Stronger health insurance mandates approved

Significant changes in the way health insurance works in the Cayman Islands are on the way.

Minister of Health Gilbert McLean tabled in the Legislative Assembly on yesterday an Amendment to the Health Insurance Regulations.

Some of the changes included having doctors submit medical bills to insurance companies for payment, having four standardised health insurance contracts and a provision that makes coverage more portable when an employee changes jobs.

Mr. McLean said the changes came after his Ministry conducted a consultative process with the health insurance industry on how to best streamline the health insurance process in Cayman.

‘While I have not hesitated to correct, through legislation, many health insurance issues directly impacting the people, during the process I have also been mindful of the need to create an environment where the industry could continue to exist in the Cayman Islands,’ he said.

Still, some of the changes will likely spark controversy with doctors, and particularly with companies offering health insurance.

Under the new regulations, patients will not have to pay out of pocket for all medical services.

‘Patients will no longer have to be insurance specialists,’ Mr. McLean said. ‘It will now be the responsibility of the medical practitioner to complete claim forms and submit them to the insurance company for reimbursement.

‘Patients… no longer will have to pay out of pocket for all services, submit bills to the insurance company for reimbursement, hope that their claims were submitted properly, and then wait for their refund.’

However, Mr. McLean said patients would still be required to pay deductibles, co-pays and co-insurance.

The Minister of Health said he realised doctors might find the process a burden at first.

‘But we also recognise the fact that (doctors) have the tools, the knowledge and the training to properly record and code claim forms for submission to the insurance companies,’ he said.

Mr. McLean said the new system will allow patients to focus on their own healing.

‘Furthermore, if practitioners want to get paid, they will submit their claims completely, correctly and in a timely fashion.’

Insurance companies are also likely to be unhappy about a couple of the changes.

With only four standardised health insurance contracts, all insurance companies will offer the same plans.

‘This will make the purchase of health insurance simpler and more transparent,’ Mr. McLean said.

He also said it would make it easier for consumers to compare prices between insurance companies and to determine what is covered and what is not under any particular plan.

Mr. McLean acknowledged that health insurance companies are unhappy about having only four standard health insurance plans.

‘This is a contentious point with the private insurers of these islands,’ he said. ‘We have met and discussed this matter on many occasions to listen carefully to their views, but their view is simply that they should be able to offer whatever they feel.

‘I realise that not all persons would agree with these changes,’ he said.

Another change the insurance industry is not likely to agree with concerns the portability of insurance when employees change employers.

With the new regulations, an employee who had at least one year of continuous health insurance coverage, who then changes employers, and who has not had a lapse in coverage exceeding 60 days, cannot be refused coverage by the insurer of the his or her new employers.

The regulation also pertains to the employee’s family, and cannot be subject to exclusions or limitation in coverage that were not specified in the previous coverage.

The coverage for the employee will also be deemed to have begun on the date of the coverage with his or her former employer when considering pre-existing conditions.

‘This is necessary for an employee to retain (his or her) health insurance benefits after changing employers,’ Mr. McLean said, adding that it would also prevent people from changing jobs for the purpose of starting a new contract of health insurance because their benefits were depleted under the previous contract.’

Not all of the changes in the regulations are detrimental to health insurance companies.

Under the new system, Health Insurance Companies will be able to change their rates under a file and use basis, meaning they can implement rate increases immediately after they are filed with the Health Insurance Commission.

However, the Commission will have the right to review the increased rates and take retrospective action if it finds they are excessive or unfair.

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