Healthcare payout eligibility not monitored

Gov’t healthcare covers unverified ‘indigents’

The Cayman Islands government is supporting about 1,200 indigent people on its public sector healthcare dole, but it was unable – in most cases examined by auditors – to justify why those individuals should be receiving free health coverage.

The information was revealed by the Internal Audit Unit in 2013, shortly after the government’s standard health insurance contract doubled the amounts paid via insured workers’ healthcare plans to help pay for indigent care. The unit’s report has just been made public under the Freedom of Information Law.

In order for a person to be considered “indigent” for the purposes of qualifying for government-sponsored healthcare coverage, they must meet certain criteria. Those criteria include if an individual is temporarily unemployed due to health reasons or inability to find a job; permanent medical conditions that make the individual unfit for work, and poor relief payment recipients who are deemed to qualify for healthcare coverage. Only Caymanians or those with Caymanian status are eligible to receive services such as poor relief payments with healthcare coverage attached from the government Department of Children and Family Services.

The Internal Audit Unit reviewed 30 files of various indigent people receiving healthcare coverage through the Cayman Islands National Insurance Company between 2011 and 2013 and found the following:

None of the 30 had proof of their status as Caymanians on file with the Department of Children and Family Services; 29 did not have proof of residency in the islands on file.

Twenty-two of the 30 people did not have up-to-date checks conducted on their bank accounts, and 26 did not have up-to-date checks on their property conducted by the department, to verify whether they were indigent.

Twenty-five of the 30 cases examined showed no financial assessment had been done recently.

Twenty had not provided up-to-date medical records.

The lack of supporting records for those people determined to be indigent does not necessarily mean that they are not indigent, only that the government had not verified their status.

According to explanations for the situation provided by the director of Children and Family Services: “[The department] was not dealing with indigent medical matters between the late 1980s until about 2003, when [the responsibility was returned to the department.

“Many of the beneficiaries were enrolled prior to the implementation of the eligibility criteria for CINICO benefits. Full assessments have only been done in recent years, so beneficiaries that were dealt with in the early 2000s were not subject to the full evaluation. These beneficiaries were automatically enrolled to the medical benefits once approved for indigents’ benefits.”

Due to “staffing shortages,” no reassessments of indigent status were conducted for those permanent beneficiaries under the CINICO healthcare plan.

“Noncompliance with the eligibility criteria and documentary pre-requisites undermines the purpose of the eligibility criteria for indigents,” auditors noted in their report. “Providing benefits without ensuring they meet the qualifying criteria may expose the government to unnecessary costs.”

Random checks on indigents who receive healthcare coverage and the technical requirements for doing so are expected to form part of regulations to the Poor Persons Relief Law when they are brought to Cabinet this year.

Fees charged to healthcare plan recipients to assist in supporting indigent healthcare doubled from between $5 and $10 per month because of changes to the government’s standard health insurance contract in 2012.

The collections aimed at offsetting a portion of the cost of indigent care were just more than $2.4 million for the 2011/12 fiscal year, prior to the costs increasing. Those payments are placed in a “segregated insurance fund,” which is managed by the Health Insurance Commission. The increase in collections is expected to raise about $5 million a year for the fund.

Almost one-fifth of the Cayman Islands government’s budget goes toward healthcare costs. Of that amount, 22 percent is spent on indigent care – about $20 million a year. The costs covered by the segregated insurance fund are a small percentage of the amount Cayman pays each year for indigent care.

The government regulates the standard health insurance contract plans, but it does not regulate other plans offered by insurance companies.

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