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YOUR NI GOLD HEALTH CARD.

In order to continue to access your health care benefits after June 30, 2004, you will need your NIS pensioner identification card. Contact the Ministry of Labour & Social Security for further information.

You will be required to pay a nominal amount for some services when you visit a participating Blue Cross® health care provider. Carry your NI Gold health card at all times so you can receive the full range of benefits under the health care programme.

Keep your card handy. When making enquiries about your policy you will need to provide your membership information. You should indicate your subscriber (membership) number and/or your pensioner number.

Keep track of your balances. When you visit a participating provider for dental, optical, medical or prescription drugs services ensure that the provider adjusts your balances in the area provided on the back of your NI Gold membership card.
Do not lend your card. Remember, only the person who is eligible for the NIS pension benefit or an officially appointed agent can use the NI Gold health card.

BLUE CROSS PARTICIPATING HEALTH CARE PROVIDERS

Blue Cross® works with doctors, hospitals, pharmacies, dentists, optical providers and laboratories to provide service for our subscribers. We have contracts with participating providers that, in most instances; allow Blue Cross® to be billed directly for services rendered to NI Gold members.

This means that on presentation of your NI Gold health card to a Blue Cross® participating provider, you are not required to pay the full amount for covered service. You will be charged only the co-payment which is a percentage of the cost according to your NI Gold Health Benefit Schedule. Blue Cross® is obligated to pay the remainder to the participating provider up to your maximum benefit. You must pay in full for services and supplies that are not covered by your health plan.

If a Blue Cross® Provider refuses to accept your health card for services without a valid reason, you must report it to Blue Cross® Customer & Provider Services Department immediately at 978-2601-9. Blue Cross® will investigate and take the appropriate action.

NON-PARTICIPATING PROVIDERS

If you visit a non-participating provider (a provider who has no contractual agreement with Blue Cross of Jamaica Limited) you will be required to make full payment for services received and submit a claim to Blue Cross® for reimbursement.

HOSPITALIZATION
Participating hospitals will call Blue Cross® to determine the eligibility and coverage for NI Gold members who require hospitalization. If you are admitted be sure to present your NI Gold health card to the admission officer.

For room and board, we will pay up to a maximum amount of $800 per night.

In-hospital miscellaneous expenses will cover charges for dressings, treatment, medical supplies and other services provided while in hospital. For the benefit period, Blue Cross® will pay up to $6,000 per disability. This means, if you are admitted for a heart condition, the stated maximum will apply. If you are admitted on a second occasion for bronchitis, before the card's expiration date, the stated maximum will be applied again.

Hospital Outpatient Care
Treatment in the hospital outpatient department means that you are not going to stay overnight in hospital. For hospital outpatient service, the health plan allows for payment of up to $2,000 per disability or condition.

SURGICAL BENEFITS
When you need surgery, your health plan helps you to pay the surgeon's and anaesthetist's fees and even an assistant surgeon, if required.

DOCTORS' VISIT
Doctor's office visit
In accordance with your health plan, Blue Cross of Jamaica Limited as the health plan administrator will pay a set amount of $500 for one visit to the doctor's office per day. You will be required to pay the difference according to the doctor's fee.

Doctor's hospital visit
The conditions are similar to those that exist for the doctor's office visit. However, the benefit is payable when you are seen by a doctor at the hospital.

Doctor's home visit
This benefit should be utilized only in emergency medical situations. Blue Cross®, the administrator will pay a set fee of $500 no matter what the doctor charges. The difference must be paid by you.

CONSULTANT'S FEE
When you visit a consultant, Blue Cross® will pay up to a maximum of $1,000 per visit. For payment of the consultant fee, you must be referred by a doctor.

DIAGNOSTIC SERVICES
Diagnostic services include x-rays, laboratory services, ultrasounds, MRIs and ECGs. The maximum amount payable for diagnostic services is $3,000 per contract year.

PRESCRIPTION DRUGS
The plan allows for the payment for prescription drugs, whether they are prescribed in the hospital or during an office visit. The maximum amount payable for the contract year is $4,000.

On the presentation of the NI Gold health card at a Blue Cross® Participating Pharmacy, you will be required to pay 10% of the cost of all prescriptions received. The balance of 90% up to the stated amount of $4,000 will be paid directly to the pharmacy by Blue Cross® on presentation of a claim. You will be required to sign the claim form indicating that you have received the drugs and made payment for 10% of the cost of the drug. If you do not show your NI Gold health card, you will be required to pay in full for the drugs and submit a claim to Blue Cross® for reimbursement.

DENTAL AND OPTICAL BENEFITS
Your total benefit amount for dental and optical care for the year is $2,000. You have the option of sharing this amount for both services or using it for only one of these services. Blue Cross® will pay 90% of the cost up to this amount, you will co-pay 10% to the participating provider.

Optical Care
Optical providers will call Blue Cross® to determine eligibility before providing optical services. The following guidelines apply for coverage of optical services:
Frame One allowed every 24 months
Lens One allowed every 12 months
Eye Examination One allowed every 12 months

WHEN YOU NEED TO MAKE A CLAIM
In the absence of your NI Gold membership card, the provider will charge you the full cost for service. In that case, you will need to send itemized bills or receipts along with a completed claim form to Blue Cross®, and you will be reimbursed in accordance with the NI Gold health policy and schedule of fees.

If you visit a non-participating health care provider, you will be required to pay in full and submit a claim along with original receipts for service to Blue Cross of Jamaica Limited. You must request that the provider completes his/her portion of the appropriate claim form.

Getting Your Claims Paid in 15 Working Days

Enter policy number and or your NIS pension number on all correspondence/claims.
Always enter your current mailing address and contact information on all claim forms.
Ensure that your health care provider enters the following information where applicable:

• diagnosis(es)
• the type of treatment received (i.e. surgery or otherwise)
• details of laboratory services received. If x-rayed, state what area.
• the name and cost of prescription drugs.
• For consultation, the name of referring doctor must be entered on claim form by the specialist.

Ensure that claim forms are signed by the health care provider and yourself or your officially appointed agent.
Original receipts should be submitted properly attached to related claim form.
Claims must be submitted within ninety (90) days of service.

To avoid your claim being delayed or returned ensure that all relevant information is completed.

PRECAUTION
When you visit a Blue Cross® health care provider, please ensure that you sign the provider claim book only after service and treatment are received from the provider. Additionally, you must ensure that the service or treatment indicated are those that you have received during your visit. Do not sign a blank claim form.

WHEN YOU HAVE ADDITIONAL HEALTH INSURANCE COVERAGE

Coordination of Benefits

The government of Jamaica has recently introduced the National Health Fund (NHF) that provides prescription drugs benefits for Jamaicans with specific chronic conditions.

It is important to advise us if you are enrolled on the National Health Fund or if have additional health care coverage, other than the NI Gold health plan. This will help to ensure that you get the maximum benefits available under all your health insurance policies.

Coordination of benefits also ensures that your insurers' combined payments do not add up to more than what we would have paid had we been your only insurance carrier.
Coordinating your benefits is one important way to keep health care costs down.

For example: Let us say you have coverage with Blue Cross of Jamaica Limited under the NI Gold health plan and you are covered with another health insurance company. Blue Cross® will co-ordinate benefits payment along with the other insurance company to make sure you receive the maximum amount to which you are entitled.

Coordination of benefits also apply if you have more than one health plan with the same insurance company.