Groups of 4-25 employees require 100% participation. All employees are required to have the same benefit coverage unless there are benefits tied to their salaries. Where dental and vision is offered, 100% of the group must be covered. Groups of 26+employees require a minimum participation of 75%. 100% of eligible employees is preferred.
Clients with Individual Coverage
Yes, a claim form is required when submitting for reimbursement. The Reimbursement Claim Form can be found on our Forms page. (link the reimbursement claim form)
Clients with Group Coverage
You can login to your member portal at www.bhpulseportal.com and submit and e-Claim using Claim Submission.
Payment in full is only required when meeting your annual deductible, accessing out of network care, or for reimbursable benefits such as airfare, lodging, and transportation. Otherwise, please present your BahamaHealth card at the time of service to utilize copayment and coinsurance benefits specified by your plan.
Note: Reimbursement is governed by the provisions of the policy.
BahamaHealth recommends that you consult with your primary care physician to obtain the necessary medical records prior to consultation with a specialist physician.
The right of a Member to obtain a second medical opinion relative to a particular condition is limited to those conditions requiring services that are Covered Services. A referral letter is not required for second opinions rendered overseas; however, approval is required by the Company.
Clients with Individual Coverage:
You must complete an Advice of Change form (https://bahamahealth.com/wp-content/uploads/2020/08/BH-Individual-Advice-Of-Change-FILLABLE-2020.pdf) and submit to Client Care via BHClient.Relations@familyguardian.com or via E-Services where applicable.
You can downgrade your plan at any time. You can upgrade during your renewal month (the anniversary month of your policy) only.
Clients with Group Coverage:
Please contact your Group Administrator for assistance as your employer decides on the benefit coverage offered to the employees.
Payments can be made:
Clients with Individual Coverage
Submissions should be directed to the Claims Department via email at bhclaimsubmission@familyguardian.com
Clients with Group Coverage
You can login to your member portal at www.bhpulseportal.com and submit and e-Claim using Claim Submission.
Clients with Individual Coverage:
You must complete a Client Update form (https://bahamahealth.com/wp-content/uploads/2020/08/BH-Client-Update-Form-FILLABLE-Updated-Aug-6-1.pdf) and submit to Client Care via BHClient.Relations@familyguardian.com or via E-Services where applicable.
Clients with Group Coverage:
You can login to your member portal at www.bhpulseportal.com and click on My Profile to update your contact information.
Dependent child refers to each unmarried child less than 19 years of age. “Child” includes an Employee’s
1) Natural child;
2) Legally adopted child;
3) Child under legal guardianship (proof of legal guardianship must be provided to the Company); or
4) Stepchild.
BahamaHealth policies cover each unmarried child between the ages of 19 and 25, but only if such child is a full-time student enrolled in an accredited educational institution, such as a college, university, junior college or trade school, and is not employed on a full-time basis. Proof of full-time registration from the educational institution must be provided to the Company upon request.
A mentally or physically handicapped child who regardless of age, continues to be handicapped, is not capable of self-support and is mainly dependent on the Employee for support can remain on your insurance indefinitely. (Proof must be provided which may take the form of Affidavit).
Where applicable, the Company or its designee must receive written notice of a claim or any resubmission within one hundred eighty (180) days after the date of service occurs. The Company or its designee will not deny or reduce a claim if it is shown not to have been reasonably possible to give written notice within 180 days of the date of service. However, the Company has no obligation to pay claims or any resubmission that have been filed with the Company or its designee beyond 180 days from the date of service.
There is no waiting period for preventive care services.
Subject to your group enrollment conditions, a pre-existing limitation of twelve (12) months may apply from your effective date of coverage.
There is no waiting period for preventive care services.
A pre-existing limitation of twelve (12) months is applied from your effective date of coverage, inclusive of a 12-month maternity waiting period.
Required premium payments to the Company are subject to a thirty-one (31) day period following the premium due date called the grace period, during which time premium payments may be made to the Company without a lapse of the coverage. If premium payments are not received by the Company by the end of the grace period, coverage may be cancelled at the option of the Company. The first monthly premium is due and payable on the Effective Date. Subsequent monthly premiums are payable in advance of or on the 1st day of each month.
Once you have paid your out of pocket responsibilities (deductible, co-payment, or coinsurance) for the service(s) rendered by a participating provider contracted with BahamaHealth, you should not incur a balance bill.
BahamaHealth individual medical insurance provides coverage for persons ages 0-99. Applications are accepted through age 69.
The group should consist of not less than 4 eligible employees working a minimum of 30 hours per week. 100% of eligible employees is required for groups with less than 25 or less employees and a minimum of 75% for groups with more than 25 lives. In cases where coverage is offered by classification same applies i.e. Management and non-management employees
The first monthly premium is due and payable on the Effective Date. Subsequent monthly premiums are payable in advance of or on the 1st day of each month. Required premium payments to the Company are subject to a thirty-one (31) day period following the premium due date called the grace period, during which time premium payments may be made to the Company without a lapse of the coverage. If premium payments are not received by the Company by the end of the grace period, coverage may be cancelled at the option of the Company.
For Group Clients: Please contact your Group Adminstrator(s) for assistance.
For Individual Clients: Please contact your Agent, Broker, or Customer Service at 242-396-1311.
Those fees negotiated and agreed to between the Company, or its designee, and participating providers or, in the absence of such agreement, those charges determined by the Company to be usual, customary and reasonable.
Completed application form (https://bahamahealth.com/wp-content/uploads/2020/11/BH-INDIVIDUAL-APPLICATION-FORM-FINAL-FILLABLE.pdf), $90 application fee, 1st month’s premium inclusive of VAT charges, copy of government issued, verified, valid ID, copy of NIB card.
A pre-existing condition is an illness or injury for which symptoms have been present or for which a member has received medical care, treatment or advice at any time during the twelve (12) months before coverage begins under this policy. The Company will not cover eligible expenses for covered services for pre-existing conditions during the first twelve (12) months of continuous coverage under this policy.
The period beginning with the Effective Date of the policy to the first Policy Anniversary is the first policy year. Thereafter, any period of 12 months commencing on a policy Anniversary is a Policy Year.
A deductible is the fixed dollar amount of eligible expenses specified in the Schedule of Benefits that a member must pay each Calendar Year before the Company starts to make payments for Covered Services. Once each of two (2) Members from the same family have met the deductible in a Calendar Year, the Deductible will be considered as having been met for other family members for that Calendar Year. If in any Calendar Year a Member does not meet the Deductible, Eligible Charges for Covered Services received during October, November or December of that year will count towards that Member’s Deductible for the next year.
An Out-Of-Pocket Maximum or Maximum Out-Of-Pocket is the limit of Co-Payments, Deductible and Co-Insurance that must be paid by a Member in a Calendar Year. Once the applicable Out-Of-Pocket Maximum has been met, Eligible Charges will be paid at 100% thereafter. Charges in excess of the Eligible Charges or non-Covered Services or supplies do not apply to the Out-Of-Pocket maximum.
Co-payments are payments that must be paid by a member as a condition for receiving certain covered services.
Coinsurance is that percentage of eligible charges that is the financial responsibility of the member.
Reimbursement claims are processed within 5-10 working days.
In-Network providers are those Participating providers that have entered into a contractual agreement with the Company or its designee to provide Hospital and Medical Services to a Member at pre-negotiated fees.
Out-of-Network providers are individuals or facilities with which the Company or its designee has made no arrangements to provide services to Members and which, therefore, are not bound by a contractual obligation to refrain from billing Members directly for services rendered.
Pre-certification is approval in advance by the Company, or its designee, for Medically Necessary Covered Services, subject to Eligible Charges.
The following eligible expenses where they relate to non-emergency events must be pre-authorized by the Insurer 48 hours in advance of incurral, in order to receive maximum reimbursement under your Policy:
1. Hospitalizations
2. Outpatient surgical procedures, whether provided at a Hospital, Ambulatory Surgical Centre or in a Physical office.
3. MRI/CAT/ PET Scans.
4. Rehabilitation / Skilled Nursing Facility confinements.
5. Home Health Care.
6. Organ Transplants.
7. Inpatient Treatment of Mental and Nervous Disorders.
8. Air transportation, whether by Air Ambulance or Commercial Airline.
9. Pharmaceutical drugs or supplies with a cost of $1,500 or more.
10. Durable Medical Equipment.
The Insured is responsible for ensuring that the necessary information required by the Insurer is furnished. If Pre-Authorization for non-emergencies is not obtained or notification within 72 hours for emergencies is not made, all benefits will have 40% coinsurance and no maximum annual out of pocket limit will apply.
You may contact the Healthcare Coordination Center at 242-396-1303 for further assistance.
Premium payment notices are issued on the 15th of every month and Pending Suspension notices are sent on the 25th of every month.
