NATIONAL HEALTH INSURANCE
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1 NATIONAL HEALTH INSURANCE Government of the Virgin Islands "Your Security For A Lifetime" BENEFIT PACKAGE
2 Table E.1 Sample of Laboratory Tests to be Covered under the Benefit Package Name of Test Name of Test Name of Test Albumin Direct Coombs Myoglobin Alcohol Drug screen Ova and Parasite Alkaline Phosphatase Electrolytes Packed Red Blood Cells (PRBC) Alanine aminotransferase (ALT) Electrophoresis (Hemoglobin) Peripheral Smear Amylase ESR(erythrocyte sedimentation rate) Phenobarbital Antibody identification Estradial (Estrogen) Phosphorus Antinuclear antibody test (ANA) Fecal Occult Blood Platelets Anti streptolysin O Titer (ASO) Ferritin Potassium Aspartate aminotransferase (AST) Folate Prenatal + HIV + HEP B B 12 Fresh Frozen Plasma Prenatal Panel Bilirubin (BUBC) Follicle Stimulating Hormone (FSH) Progesterone Blood Type & Rh Gamma Glutamyl Transferase (GGT) Prolactin Bun/Urea Glucose Prostate Specific Antigen (PSA) Cancer Antigen 125 (CA125) Glucose Tolerance 2HR Prothrombin Time (PT) w International Normalized ratio (INR) Calcium Glucose Tolerance 3HR Partial Thromboplastin Time Carbamazepine (Tegretol) Glucose-Fasting Blood Sugar/Random Rheumatoid Arthritis Factor (RA) Blood Sugar/Post prandial Carbon Dioxide Glucose-Osullivan Renal + Cardiac + Lipid Cardiac Panel Glucose-Profile Renal + Cardiac Panel CD4 Helicobacter Pylori antibody Renal + Liver Complete Blood Count (CBC) Hemoglobin (Hb) Renal + Liver + Lipid CBC + Blood Type Hemoglobin A1c Renal function Panel CBC + ESR Human Chorionic Gonadotropin (HCG)- Quantitative Reticulocyte Count CBC + RETIC CT Human Chorionic Gonadotropin (HCG)- Rapid Test Rheumatoid Panel CBC + TYPE + Sickle Hepatitis B surface Antibody Rapid plasma regain (RPR) Carcinogenic embryonic antigen Hepatitis B surface Antigen Rubella (CEA) Chloride Hepatitis B core antibody Sickle Cell screen Chlamydia Hepatitis C antibody SMAC 20 Chloride Human Immunodeficiency Virus I/II antibody SMAC 20 + Lipid Cholesterol-Total Human Immunodeficiency Virus- western blot Triiodothyronine T3 Creatine Kinase MB (CKMB) Human T-cell Lymphotropic Virus (HTLV) I/II antibody Thyroxine T4 Creatine phosphokinase (CPK) Indirect Coombs Testosterone Creatinine Infectious Mononucleosis Thyroid Function Creatinine Clearance Influenza Total Iron Binding Capacity (TIBC) Cross Match Iron (Fe) Total Protein C-Reactive Protein (CRP) Lactate Dehydrogenase isoenzyme (LDH) Triglyceride Cerebrospinal (CSF) Cell Count Lupus Erythematosus (LE) Troponin I Cerebrospinal (CSF) Glucose Luteinizing Hormone (LH) Thyroid Stimulating Hormone Cerebrospinal (CSF) Protein Lipid Panel Uric Acid Culture and sensitivity Lithium Urinalysis D-Dimer Liver Panel Urine protein (24 hour) Dengue Magnesium Valproic Acid (Depakote) Digoxin Malarial Parasite Viral Load Dilantin (Phenytoin) Microalbumin Source: BVI Health Services Authority, 2011
3 General Policy Terms Lifetime Limit - $1,000,000 Table E.2 Terms and Conditions of the Benefit Package NHI Coverage NHI Coverage NHI Coverage (On-island) (On-island) (Overseas) Public Sector Private Sector Deductible (in-network) $0 $0 $0 Deductible (out-of-network) - $0 $0 (applicable only to emergency and in cases pre-authorized) Co-payment (in-network) 0% Community Health Clinics; 10% 20% 5% Peebles Hospital Co-payment (out-of-network) - 20% 40% (applicable only to emergency and in cases pre-approved) Emergency medical services and related procedures and pharmaceuticals Outpatient Health Benefits Air ambulance Annual maximum of $20,000 Annual maximum of $20,000 Annual maximum of $20,000 Emergency medical transportation by sea Annual maximum of $1,000 Annual maximum of $1,000 Annual maximum of $1,000 Ground ambulance Annual maximum of $500 Annual maximum of $500 Annual maximum of $500 Second Opinion Subject to pre-authorization General medical examinations (annual physical) Annual maximum of $500 Annual maximum of $500 No overseas coverage Mammography, gynaecological, prostate, Mammography 1 per year from age 40 Mammography 1 per year from age 40 colonoscopy and other preventative health years; 35 years in the event of hereditary years; 35 years in the event of hereditary examinations susceptibility susceptibility Colonoscopy 1 every 3 years from age 50 years. Colonoscopy 1 every 3 years from age 50 Subject to pre- approval by MRC years. Subject to pre- approval by MRC Gynaecology 1 per year Prostate 1 per year from age 40 years Gynaecology 1 per year Prostate 1 per year from age 40 years
4 NHI Coverage NHI Coverage NHI Coverage (On-island) (On-island) (Overseas) Public Sector Private Sector Immunization Outpatient Health Benefits - continued No overseas coverage 0-4 years Preventative, no co-insurance Preventative, subject to co-insurance (guided by the Expanded Programme of Immunization of the MoH) 5-18 years Preventative, no co-insurance Preventative, subject to co-insurance (as medically necessary) Above 18 years Preventative, subject to co-insurance Preventative, subject to co-insurance (as medically necessary) Maternity Ante-natal services Maximum of $1000 per pregnancy Maximum of $1000 per pregnancy Other expenses for delivery covered under (no complications); (no complications); In-patient services Maximum of $ 1,500 per pregnancy Maximum of $ 1,500 per pregnancy (high risk cases) (high risk cases) No coverage overseas, except in cases of high risk pregnancies 1 Post-natal services Maximum of $300 per pregnancy Maximum of $300 per pregnancy Domiciliary care Maximum of $500 per pregnancy Maximum of $500 per pregnancy (3 visits per pregnancy) (3 visits per pregnancy) Mental health conditions Treated as any other illness. Subject Treated as any other illness. Subject Treated as any other illness, subject to co-insurance to co-insurance to pre-authorization Alcohol/Substance abuse Treated as any other illness. Subject Treated as any other illness. Subject Annual maximum of $500, subject to co-insurance to co-insurance to pre-authorization Haemodialysis Annual maximum of $70,000 Annual maximum of $70,000 Annual maximum of 12 overseas sessions, subject to pre-authorization Rehabilitation services physical and speech Subject to pre-authorization Subject to pre-authorization Subject to pre-authorization therapy Chemotherapy, radiation therapy and nuclear Subject to pre-authorization Subject to pre-authorization Subject to pre-authorization medicine HIV/AIDS-related illnesses Treated as any other illness. Subject Treated as any other illness. Subject No coverage overseas to co-insurance to co-insurance 1 No coverage overseas unless specifically approved by the NHI. (Exceptions would be for high risk cases where the services on-island are inadequate to protect the lives of the mother and foetus.)
5 NHI Coverage NHI Coverage NHI Coverage (On-island) (On-island) (Overseas) Public Sector Private Sector Out-patient surgical procedures Outpatient Health Benefits - continued No coverage overseas Nursing services Annual maximum of 30 visits up to Annual maximum of 30 visits up to No coverage overseas $2,500. Subject to pre-authorization $2,500. Subject to pre-authorization General diagnostic testing (laboratory, Annual maximum of $500 Annual maximum of $500 No overseas coverage contrast studies and imaging i.e. X-ray, ultrasound) and other testing Specialized diagnostic testing (CAT scan, Annual maximum of $1,500 Annual maximum of $1,500 Annual maximum of $1,500, MRI, other specialized imaging) Subject to pre-authorization Subject to pre-authorization Subject to pre-approval Prescription pharmaceuticals Subject to co-insurance Subject to co-insurance Subject to pre-approval 2 (inclusive of prescription contraceptives) 2 The coverage of pharmaceuticals outside of the Territory only applies for beneficiaries who undergo approved medical care or emergency care overseas and are prescribed drugs by the overseas practitioner.
6 Table E.2 (Continued) Terms and Conditions of the Benefit Package NHI Coverage NHI Coverage NHI Coverage (On-island) (On-island) (Overseas) Public Sector Private Sector General Policy Terms Lifetime Limit - $1,000,000 Deductible (in-network) $0 $0 $0 Deductible (out-of-network) - $0 $0 (applicable only to emergency and in cases pre-approved by MRC) Co-payment (in-network) 5% Peebles Hospital 10% 20% Co-payment (out-of-network) - 20% 40% (applicable only to emergency and in cases approved by MRC) Inpatient Health Benefits In-patient stay (accommodations) at health Annual maximum of 30 days* Annual maximum of 30 days* Annual maximum of 30 days, facility* Subject to pre-authorization Subject to pre-authorization subject Subject to to pre-approval Physicians, specialists and surgeons services, including ambulant surgery Anesthesia, use of operating room and recovery room Inpatient services at health care facility, including delivery 3 Standard surgical supplies, including oxygen, surgical appliances and implants Medication and drugs Subject to pre-approval Subject to pre-approval Subject to pre-approval Subject to pre-approval Subject to pre-approval * Where the NHI certifies that a patient must be hospitalized for more than thirty (30) days, the patient may claim full or part payment of the cost of the benefit in excess of thirty (30) days. 3 No coverage for delivery overseas, except for high-risk cases where on-island services are inadequate to protect the lives of the mother and foetus.
7 Table E.2 (Continued) Terms and Conditions of the Benefit Package NHI Coverage NHI Coverage NHI Coverage (On-island) (On-island) (Overseas) Public Sector Private Sector General Policy Terms Lifetime Limit - $1,000,000 Deductible (in-network) $0 $0 $0 Deductible (out-of-network) - $0 $0 (applicable only to emergency and in cases pre-approved by MRC) Co-payment (in-network) 0% Community Health Clinics; 5% Peebles Hospital 10% 20% Co-payment (out-of-network) - 20% 40% (applicable only to emergency and in cases pre-approved by MRC) Vision and Dental Eye Examination 1 per 12 month period, up to $50 1 per 12 month period, up to $50 Overseas coverage limited to USVI and Puerto Rico Lenses 1 pair per 12 month period, up to $200 1 pair per 12 month period, up to $200 Overseas coverage limited to USVI and Puerto Rico Frames 1 pair per 24 month period, up to $100 1 pair per 24 month period, up to $100 Overseas coverage limited to USVI and Puerto Rico Dental Preventative, Restorative, and Major Annual maximum of $1,500 Annual maximum of $1,500 No overseas coverage Including dentures, caps and Orthodontics
8 Table E.4 Exclusions from the Benefit Package Exclusions 1. Consultations and treatment for (i) infertility including in-vitro fertilization, artificial insemination (ii) sex change procedures (iii) over the counter contraceptive drugs or devices or sterilization. 2. Weight loss procedures and treatments. 3. Cosmetic surgery unless medically required and pre-approved. 4. Self-referred second opinion by overseas providers. 5. Chiropractor visits. 6. Counselling and therapy for marital and family difficulties. 7. Mortal remains repatriation Treatment or participation in any health service deemed to be experimental. Experimental, for this policy, refers to treatment, medicine or other procedures which are a part of a research programme and have not been approved by the relevant medical board and/or accreditation authority. 9. Applicable beneficiary co-insurance amounts. 10. Expenses beyond the coverage limits stated in the benefit package. 4 Repatriation of mortal remains to the BVI will only be applicable where off-island care of the (deceased) beneficiary was preapproved by the MRC prior to his/her death.
9 NHI LOCAL PROVIDERS 0% co-payment BVI HEALTH SERVICES AUTHORITY Community Health Clinics 5% co-payment BVI HEALTH SERVICES AUTHORITY Public Hospital 10% co-payment (plus any additional Provider charges) 5 DOCTOR MEDICAL & WELLNESS APEX MEDICAL CENTER B&F MEDICAL COMPLEX LTD BOUGAINVILLEA CLINIC CROWN DENTAL DR. K.P. ADAMSON LTD DR. DAWN BAIN MEDICAL OFFICE DR. HODGE CLINIC / DR. HORACE GRIFFITH EUREKA MEDICAL CLINIC JULIEN PHYSICAL THERAPY MEDICURE LIMITED MEDICAL DIAGNOSTIC LABORATORY PICSMITH MEDICAL SERVICES PENN MEDICAL CENTER PREMIER DENTAL QWOMAR TRADING LTD. RHYMER S DENTAL CARE SMILE DENTAL SPA TORTOLA VISION CENTER THERAPY WORKS BVI LIMITED THERAPY WORKS VIRGIN GORDA LIMITED THE WELLNESS CENTER BEHAVIORAL HEALTH CLINIC THERAPY SERVICES VI MEDICAL CLINIC VANTERPOOL ENTERPRISES WELLNESS PTS Local out of network providers 20% co-payment
10
11 National Health Insurance NHI Brochure NHI Benefit Package NHI Healthcare Providers
12 National Health Insurance Your Security For A Lifetime
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