QU OF NT AT A FE RU

BERMUDA

HEALTH INSURANCE (HEALTH INSURANCE PLAN) (ADDITIONAL BENEFITS) ORDER 1988

BR 58 / 1988

[made under section 13 (2) of the Health Insurance Act 1970 and brought into operation on 1 September 1988]

[NB Formerly the Hospital Insurance (Health Insurance Plan) (Additional Benefits) Order

1988. Title amended, and references to “hospital insurance”, “Hospital Insurance Fund”

and “Commission” substituted by “health insurance”, “Health Insurance Fund” and “Council” by 2004:22 s.19 & Sch para 2 effective 1 January 2006; “Council” substituted by “Committee” by 2009:49 s. 15(1) effective 15 December 2009. These amendments are not individually noted]

Citation and commencement

1 This Order may be cited as the Health Insurance (Health Insurance Plan) (Additional Benefits) Order 1988 and shall come into operation on 1st September 1988. [Regulation 1 amended by 2004:22 effective 1 January 2006]

Interpretation

1A In this Order— “policy year” means a period beginning on 1 April in any year and ending on 31 March in the following year. [Paragraph 1A inserted by BR 63 / 2015 para. 2 effective 1 September 2015]

Additional benefits

2 The additional benefits (including the items of treatment) covered by the health insurance plan are specified in the Schedule.

HEALTH INSURANCE (HEALTH INSURANCE PLAN) (ADDITIONAL BENEFITS) ORDER 1988

Revocation of BR 36/1987

3 [omitted]

HEALTH INSURANCE (HEALTH INSURANCE PLAN) (ADDITIONAL BENEFITS) ORDER 1988

SCHEDULE

(paragraph 2)

SPECIFIED

1. ADDITIONAL BENEFITS COVERED BY HEALTH INSURANCE PLAN

2. to a maximum of 4 units.

3. to a maximum of 30 units. )

4. to a maximum of 100 units. ) hospital

5. to a maximum of 40 units. )

6. to a maximum of 4 visits per month.

7. by the Health Insurance Committee, to a maximum of 90 units.

8. Office visits to a maximum of 4 visits.

8A. One Annual Health Exam (Physical), up to $250 for non-complex

9. and diagnostic imaging services.

(a) at clinical laboratory facilities which are approved by the Health Insurance Committee, and

(b) in respect of which the reimbursement rates have been approved by that Committee.

10. Cardiac diagnostic services—

(a) at facilities which are approved by the Health Insurance Committee, and

(b) in respect of which the reimbursement rates have been approved by that Committee.

10A. Radiation therapy services that are approved by the Committee, at

11. facilities and at rates that have been approved by the Committee.

12. not exceeding $50,000.

Committee—

(a) Basic dental care, including endodontia, at the approved rate;

(b) [Revoked by 2019 : 24 s. 4]

(c) [Revoked by 2019 : 24 s. 4]

(ca) surgical and minor restorative at the approved rate; and

(d) fluoride, polishing and root planing at the approved rate.

13. HEALTH INSURANCE (HEALTH INSURANCE PLAN) (ADDITIONAL BENEFITS) ORDER 1988

practitioner physician to an amount not exceeding $565 per policy year, consisting of no more than 2 initial consultation visits (to an amount not exceeding $170 per visit), and 3 follow-up visits (to an amount not exceeding $75 per visit).

13A.(1) The following personal home care services, as approved by the Committee, to a total amount not exceeding $60,000 per policy year—

(a) personal caregiving services in an amount of $17.13 per hour, but to an amount not exceeding $2,610 per month on a prorated basis;

(b) nursing aide services in an amount of $25 per hour, but to an amount not exceeding $1,525 per month on a prorated basis;

(c) nurse visits to an amount not exceeding $75 per hour for a maximum of 12 visits per policy year; and

(d) adult day care services to an amount not exceeding $867 per month on a prorated basis.

(2) [Revoked by BR 112 / 2025 para. 2]

(3) [Revoked by BR 112 / 2025 para. 2]

(3A) [Revoked by BR 112 / 2025 para. 2]

(4) [Revoked by 2018 : 30 s. 4]

13B.

(1) A wellness promotion benefit covering a maximum of 6 counselling sessions per policy year to an amount not exceeding $35 per session.

(2) In subparagraph (1), “wellness promotion benefit” means a programme of counselling sessions, approved by the Committee for persons with chronic diseases, to promote the self- management of health and reduce the risks associated with chronic disease. Prescription drugs approved by the Committee: 100% of the drugs’

13C.

(whether brand name or generic) cost to the beneficiary, to an amount not exceeding $3,000 per policy year.

14. HEALTH INSURANCE (HEALTH INSURANCE PLAN) (ADDITIONAL BENEFITS) ORDER 1988

(1) Subject to subparagraph (1A), medically necessary treatment received outside Bermuda is covered, but only if—

(a) the treatment is not available in Bermuda and is not an elective treatment; or

(b) the treatment consists of radiation therapy services which, although available in Bermuda, are for the time being approved by the Committee to be provided at a facility outside Bermuda.

(1A) Treatment received outside Bermuda is not covered if—

(a) it is provided outside the approved network of hospitals; and

(b) the hospital or other facility does not meet the requisite criteria, in respect of treatment or billing, determined by the Committee.

(2) The reimbursement amount for cover under subparagraph (1) is—

(a) in respect of treatment provided by an approved hospital, 60% of the usual and customary charges of an approved hospital; or

(b) in respect of treatment provided outside the approved network of hospitals, subject to subparagraph (1A), 40% of the usual and customary charges.

15. The amount recoverable under paragraph 14—

(a) shall, in respect of in-patient treatment of a particular disability, be limited to expenses incurred over a period of not more than 45 days during a twelve month period;

(b) shall not include the cost of transportation to or from the approved hospital;

(c) shall not include the cost of any hospice care;

(d) shall not include the cost of any treatment for alcoholism or drug addiction.

16. In this Schedule—

“approved hospital” means a hospital outside Bermuda which is—

(a) licensed or approved as a hospital by the government hospitals authority in whose jurisdiction the hospital is located; and

(b) part of the approved network of hospitals; “approved network of hospitals” means a network of hospitals approved by the Committee; “Committee” has the same meaning as in section 11A of the Health Insurance Act 1970; “the general hospital” has the same meaning as in section 1(1) of the Bermuda Hospitals Board Act 1970.

HEALTH INSURANCE (HEALTH INSURANCE PLAN) (ADDITIONAL BENEFITS) ORDER 1988

17. Any benefit specified in this Schedule that, instead of an office

Bermuda, at the same reimbursement rate as for the office visit. For the purposes of items 1 to 6 above the expression “unit” used for the assessing insurance liability to members of the medical profession outside the hospital is the appropriate unit for the practitioners concerned and the services rendered according to the fee schedule agreed between the Bermuda Medical Doctors Association and the health insurers for comparable services in the hospital. [Schedule amended by BR 57/1995 effective 25 November 1995; by BR 4/1996 effective 1 April 1996;substituted by BR 2/1997 effective 1 April 1997; rescinded and substituted by BR 15/1998 effective 1 April 1998; amended by BR 85/2001 effective 1 January 2002; by BR 13/2002 effective 1 April 2002; by BR 25/2003 effective 1 April 2003; by BR 42/2003 effective 20 June 2003; paras 9 and

10 inserted by BR 14/2004 effective 1 April 2004; amended by 2004:22 effective 1 January 2006; para 7 amended by BR31/2006 effective 31 March 2006; paras 7 and 8 substituted by BR15/2007 effective 1 April 2007; paras 11 through 13 inserted by BR 36/2008 effective 1 August 2008; para 7 revoked by 2009:10 s.24 effective 1 April 2009; paras 14-16 inserted by BR 48 / 2014 effective 1 June 2014; para 13 revoked and substituted, paras 13A and 13B inserted and para 14 amended by BR

63 / 2015 para. 3 effective 1 September 2015; amended by 2016 : 3 s. 24 effective 1 April 2016; paragraph 11 amended by 2017 : 25 s. 8 effective 1 June 2017; amended by BR 93 / 2017 para. 2 effective 27 September 2017; Schedule amended by 2018 : 30 s. 4 effective 1 July 2018; Schedule amended by 2019 : 24 s. 4 effective 29 July 2019; Schedule amended by 2021 : 3 s. 3 effective 1 February 2020; Schedule amended by 2021 : 39 s. 5 effective 1 November 2021; Schedule amended by BR 112 / 2025 para. 2 effective 8 December 2025]

[Amended by: BR 57 / 1995 BR 4 / 1996 BR 2 / 1997 BR 15 / 1998 BR 85 / 2001 BR 13 / 2002 BR 25 / 2003 BR 42 / 2003 BR 14 / 2004

2004 : 22 BR 31 / 2006 BR 15 / 2007 BR 36 / 2008

2009 : 10

2009 : 49 BR 48 / 2014 BR 63 / 2015

2016 : 3

2017 : 25 BR 93 / 2017

2018 : 30

HEALTH INSURANCE (HEALTH INSURANCE PLAN) (ADDITIONAL BENEFITS) ORDER 1988

2019 : 24

2021 : 3

2021 : 39 BR 112 / 2025]