Healthcare benefits: frequently asked questions About healthcare benefits What is private medical insurance? Private medical insurance (PMI) is a scheme designed to meet the cost of private medical treatment if you suffer from an illness, disease or injury that is likely to respond quickly to treatment. These are referred to as acute conditions. PMI provides cover where treatment is expected to lead to a full recovery or a return to the state of health you were in immediately before suffering from the condition. Some PMI schemes also provide some cover for certain longer-term ( chronic ) conditions. You should refer to your PMI scheme booklet for full details. What is a health cash plan? A health cash plan is a form of insurance that helps to cover the cost of day-to-day healthcare. This could include visits to your GP, doctor or optician, as well as NHS prescription charges and hospital surgery. Health cash plans are designed to pay back some or all of the cost of qualifying healthcare treatments, but provide less comprehensive cover than PMI schemes. What is critical illness insurance? Critical illness insurance provides a tax-free lump sum payment if you are diagnosed with a specified illness or condition of a certain severity. These typically include some cancers, stroke and heart attack. Critical illness is not formally classed as a healthcare benefit, as you may use the lump sum as you wish. This may (or may not) include paying for medical treatment. Healthcare benefits: frequently asked questions 1
Private medical insurance (PMI) FAQs How does PMI work? PMI schemes vary and you should check the details in your scheme booklet. However, typically, the process is: you visit your GP your GP refers you for specialist treatment you call your PMI provider to check you are covered before arranging any private treatment you visit the specialist if required, your hospital treatment starts If your claim is eligible, it will normally begin after your GP refers you to a specialist and you first contact your PMI provider to check your treatment is covered. However, you must remember to stay in contact with your PMI provider at every stage of the process and should always check whether the hospital, consultant or practitioner you intend to use is fully covered. Do I have a choice in the level of cover? This will depend on the scheme offered by your employer. You may, for example, have the option to extend cover to your spouse/partner and children. Who is covered? Who could be covered? What age are children covered to? If your scheme allows you to extend cover to others, only a dependent spouse or children of the main member who reside at the same address can be included. This depends on the provider so you should check policy terms and conditions. For UK plans, children are usually covered to age 21 with PruHealth, 24 with Bupa and 25 with AXA. Healthcare benefits: frequently asked questions 2
What is covered? What is or is not covered? PMI is designed to cover acute conditions, which are curable, short-term illnesses or injuries. Long-term chronic illnesses are not normally covered, although most insurers do provide cover for some types of cancer albeit at different levels. You should check your scheme booklet for full details of the types of illness and treatment that are covered within your policy. However, the summary below may help: GP or Accident & Emergency visit & outpatient drugs/dressings Inpatient tests & inpatient/day patient surgery Outpatient tests, consultations & specialist treatments Hospital accommodation Cash payment for receiving NHS inpatient treatment Physiotherapy, complementary therapy etc Normal pregnancy Complications with pregnancy Routine dental treatment Travel costs Overseas treatment (with a UK plan) Cosmetic & reconstructive treatments Usually included? It is vital you check with your insurer before starting any treatment, as you do not have unconstrained choice over where you are treated or by whom. Insurers use a schedule of fees that sets out the maximum they will pay specialists for a given procedure. If you choose, or require, a specialist whose charges exceed this maximum, you will need to make up the shortfall in cost. Some insurers have networks of recognised consultants who have already agreed not to charge more than the schedule fees. Will I be covered for pre-existing conditions? Many workplace PMI schemes do provide cover for pre-existing conditions, i.e. illnesses or injuries that you have had in the past or are currently suffering from. However, you should check this in your scheme s terms and conditions as this is not always the case. Healthcare benefits: frequently asked questions 3
What is covered? (continued) What if I have a disability? Is routine maternity covered? A disability is usually treated by PMI insurers in the same way as a pre-existing condition. They may not provide cover for treatments relating to the disability you have at the time you join the scheme. UK plan: Only certain complications of pregnancy are covered. Routine maternity is not normally covered. International plan: Routine maternity is covered as well as pregnancy complications, if included in the benefits of your particular scheme. Can I opt to have treatment in the private wing of an NHS hospital? Yes, provided the hospital is listed on your scheme s chosen hospital list. Joining the plan Do I need to give details about my health? Will I need a medical? Will the information I provide remain confidential? What does CPME mean? Can I transfer membership from another policy? This will depend on the basis on which your employer has established the PMI scheme in particular, how it is underwritten. You may be asked to complete a questionnaire about your medical history. Based on the information you provide, your scheme insurer may then ask your GP for more information but it is extremely unlikely that they will request a medical. The insurer is more likely to simply exclude an existing condition from the cover. Yes. All PMI insurers must meet the requirements laid down in the Data Protection Act 1998. This means they must treat sensitive and personal information, particularly those relating to medical matters, as confidential. CPME stands for continued personal medical exclusions and is relevant when your employer changes the provider of your PMI scheme. It means that the new provider will apply the same exclusions as the previous provider at the time the policy transferred. This is normally only possible when you hold individual cover with the same insurer that your employer is using to provide their group PMI scheme. Please refer to your scheme contact for further guidance. If you have an existing PMI policy, the key thing to consider is whether changing provider now will mean you lose cover for any illnesses or injuries you either have currently or have suffered from since taking out your original policy. Healthcare benefits: frequently asked questions 4
Making a claim Are there any waiting periods? This will depend on the way your employer has established the scheme and any rules applied by your specific insurer. Where a scheme is medically underwritten, it is usual to have 10 month waiting periods for benefits such as psychiatric and maternity. However, if your scheme has been established on a medical history disregarded (MHD) basis these waiting periods are usually waived. You should check your policy booklet for more details. Is a GP referral required before I can claim? Can I see any GP? UK plan: Yes, a GP referral must always be obtained before a claim can be made. International plan: No, you can be seen by a specialist without the need for a GP referral. UK plan: No, you are usually required to visit the GP you are registered with. International plan: You are typically allowed to see any GP, private or otherwise. However, the cost is ordinarily only covered up to a certain monetary limit, specified in the policy terms and conditions. Does the referral have to come from an NHS GP or could it come from a private GP? What treatments require pre-approval? What treatments can be reimbursed? Is the excess applied per policy year or per claim? UK plan: A referral can come from either an NHS or private GP. However, private GP costs are not covered. International plan: A referral can come from any GP (private, NHS or otherwise) and the cost will be covered if included within the benefit limits of your particular scheme. For UK plans, most inpatient treatment requires pre-approval, as do a select number of outpatient treatments. However, we suggest you always check with your insurer that all costs will be covered before starting treatment, as hospital and consultant networks do vary. In an international plan, most outpatient and day patient treatments can be reimbursed if there is no need for an overnight stay. This will depend on your particular scheme. However, the majority of providers apply a per person, per policy year excess payment. Healthcare benefits: frequently asked questions 5
Cost How much is this going to cost? This depends on how your employer has established the PMI scheme and, potentially, your personal circumstances. Your HR/benefits team will be able to tell you how much the scheme will cost you, as employers often meet some or all of the cost on your behalf. If your employer does pay all or part of the cost of providing your PMI benefit, you may need to pay a tax charge (see below). One distinct benefit of a group scheme is that it normally provides access to private healthcare at a lower cost than if you had taken out a comparable individual policy. What is the tax charge and what is P11D? PMI is classed as a benefit in kind by HMRC and is taxable if your employer meets all or part of the cost. The value of any benefits in kind you receive are included on a form called a P11D, which is sent by your employer to HMRC at the end of each tax year (your employer must also provide you with a copy of this information). For most people, the tax due is then collected through PAYE via an adjustment to your tax code. Please see Orb s guide Healthcare benefits: personal tax explained for more details. Will the cost increase over time? This will depend on your employer and their scheme. However, the cost of PMI does typically increase over time, often at a rate higher than general inflation. The are various reasons for this, including: advances in technology introduction of new drugs and treatments improvements in our ability to diagnose conditions increasing age both as an individual and in the general population. If you have any further questions about your healthcare benefits, the Orb team will be pleased to help. You can contact us: By phone: 0845 013 8709 By email: info@orb-eb.co.uk Via our website: www.orb-eb.co.uk By post: Orb Employee Benefits, 1st Floor, Block A, Rosemount House, West Byfleet, Surrey, KT14 6LB The information provided in this guide is based on our understanding of current legislation, taxation law and HM Revenue & Customs (HMRC) practice, which may change in the future. Nothing in this guide constitutes individual advice. Orb Employee Benefits is a trading name of Orb Financial Services Limited which is authorised and regulated by the Financial Conduct Authority FCA No. 573629 Registered office: Dawes Court House, Dawes Court, Esher, KT10 9QD Registered in England and Wales No. 6367377 Healthcare benefits: frequently asked questions 6 Orb Employee Benefits 2014