Billing for Health Services

Are there any regulations about what a doctor can charge for visits?

Bermuda’s health system does not regulate what private healthcare providers can charge or what insurers must pay for most non-hospital treatment. When there is no regulation, each party may set their rates.

Physician and other health professionals’ fees vary from practice to practice, so you can shop around and find a provider whose charges are better suited to your budget. A helpful tool for this is our Healthcare Directory. It lists all known healthcare providers by specialty to help you find the care that’s right for you.

The fees that are regulated in Bermuda are: all local hospital charges, any local hospital-based service delivered by a private physician or dentist, and some diagnostic and home medical services.


Do I have to pay a doctor’s bill that is months or years old?

If the service took place before 1st August 2012, and less than six years old, yes. The Limitations Act 1984 allows a provider to seek payment for a bill up to six years from the date of the transaction.

However, if the service took place after 1st August 2012, the provider should submit the bill directly to insurers within 30 days. After a year the claim expires.

Some exemptions apply to this rule. If the provider is given permission or an exemption from the regulations by the Bermuda Health Council or if you require a medical device such as glasses or a crown, you may be charged immediately for the service.

I have insurance that will cover glasses, but my optician charged me for them. I thought they had to bill my insurer?

The Health Insurance (Health Service Providers) (Claims) Regulations 2012 prohibit charging insured patients for the insured portion of a health bill at the time of service (upfront payment).

However, medical appliances, devices and products, like glasses, crowns, etc., which may be covered by health insurance are excluded from the Regulations because they have to be ordered custom-made for each patient.

What do I have to pay when I visit a healthcare professional?

If you are insured, in most cases you will be responsible only for your co-payment or the portion of your bill not covered by your insurance as per the Health Insurance (Health Service Providers and Insurers) (Claims) Regulations 2012. So if the visit cost $150 and the insurer covers $100, you must pay $50 at the visit.

However, if the health service provider has an exempt status from BHeC as per the Claims Regulations or you require medical appliances (e.g. glasses, crowns etc.) you will be responsible for the fees.

Uninsured patients are responsible for the entirety of their healthcare visit bill.

What is a co-payment?

A co-payment is the portion of your bill not covered by your health insurance. So if the visit costs $150 and the insurer covers $100, you must pay $50 at the visit.

If you are uninsured, you are required to pay the full cost of a healthcare visit.

Employers' Health Insurance Obligations

Am I covered by health insurance when I leave my employment?

If an employee willfully leaves their employment or is terminated, the employer is required under the Health Insurance (Cover) Regulations 1971 to continue to provide the Standard Health Benefit (SHB) coverage for a period of approximately four weeks depending on your last day of employment.

Does my employer have to provide me with health insurance?

According to the Health Insurance Act 1970, all employers must provide the mandated minimum health insurance package – Standard Health Benefit (SHB) – for employees and the employees’ non-employed spouses. Self-employed persons must also have the minimum health insurance coverage. Health insurance products in Bermuda are generally not just SHB, but will include supplemental benefits. Failure to provide health insurance can result in a $500 fine and/or imprisonment (see Questions 4 for more information).

What can my employer deduct from my pay cheque to cover health insurance?

Employers must pay the Standard Premium to the insurer on behalf of the employee and the non-employed spouse, but may deduct half of it from the employee’s salary. The Standard Premium is the price of the SHB, which is set by Government annually.

Making deductions greater than allowed can result in a fine of $1,000 (Section 23 of the Health Insurance Act 1970) and making deductions and not submitting the deductions to insurers can result in a $500 or imprisonment for 12 months (Section 25 (1) of the Health Insurance Act 1970).

Once hired, the employer must give the employee a written statement with the name of their health insurer, the date it came into effect and the policy number. Failure to provide a written statement can result in a fine between $500-$1,000 or imprisonment for six months as per Section 24A of the Health Insurance Act 1970.

An employee, however, must keep their employer informed of all facts related to their spouse and changes to their non-employed status (Section 24 of the Health Insurance Act 1970).

What do I do if I find that my employer has made deductions but I have no insurance?

If you confirm that you have no health insurance coverage, but deductions have been made, you should liaise with your employer to seek a resolution. If you are not able to resolve the matter, you should contact the Bermuda Health Council to advise us.

Section 25 of the Health Insurance Act 1970 entitles individuals to recover the benefits lost from your employer as a civil debt before a court. To do so, we would first need to verify through inspection of records the amount owed.

Healthcare Professionals' Registration

How do I know if my physician is registered to practice in Bermuda?

The register for each professional group is gazetted annually and we maintain the most recent registers for each professional group on our Professional Bodies’ page.

How do I register to practice as a health professional in Bermuda?

Healthcare professionals must be licensed or registered by a statutory council or board dedicated to their profession; i.e. if you are a nurse, you must register with the Nursing Council before practicing. Councils or Boards (there are 8) are required by law to re-register healthcare professionals every two years, though there are a few exceptions.

Each council or board has unique practice standards and entry-to-practice criteria; a list of councils can be found at Professional Bodies.

Insurance Coverage Basics

What are youth, senior and indigent subsidies?

In Bermuda’s context, subsidies refer to government paying for hospital (SHB) costs of these populations. If a child uses SHB services at the local hospital, the hospital bill is sent to the Government’s Health Insurance Department (HID).

If a senior aged 65 – 74 years uses SHB services at the hospital, whether they have insurance or not, HID will get 70% of the bill and the senior or their insurer will get 30% of the hospital bill. If the senior is 75 or older, the government pays 80%.

And for indigent persons, the government picks up the full SHB bill at the hospital. This is why the subsidies are more accurately referred to as “patient subsidies”.

What is the difference between HIP and SHB?

The Standard Health Benefit is NOT the same as HIP. “HIP” is the Government’s Health Insurance Plan. It is an affordable package that includes SHB plus some supplemental benefits such as dental care.

What is the Standard Health Benefit?

Standard Health Benefit (SHB) is the minimum benefits package that must be included in any health insurance policy sold in Bermuda. SHB covers a majority of local hospital services and some diagnostic imaging procedures outside of the hospital. For general descriptions of benefits that fall under SHB refer to the Health Insurance (Standard Health Benefit) Regulations 1971.

Making a Complaint

How do I make a complaint about my employer failing to pay my health insurance?

If you have tried to resolve the problem with your employer, please contact the Bermuda Health Council (BHeC) and we will assist.

How do I make a complaint to BHeC?

BHeC handles complaints about health system matters such as health insurance coverage and illegal billing practices; we can also help patients access the right statutory body for complaints against health professionals. Complaints to BHeC should be in writing.

Filing your complaint with us does not prevent you from also addressing complaints through other channels such as the Consumer Affairs Board and statutory bodies. To contact BHeC with your concerns please email us or call 292-6420.

If I am concerned about the clinical practice of a health professional who should I contact?

The professional conduct of health professionals is overseen by the relevant statutory body. For example, if you are concerned with treatment by a physician, you should contact the Bermuda Medical Council. For statutory body information visit: Professional Bodies.

If I want to change my doctor, does my previous doctor have to forward my file?

Bermuda currently has no legislation on patient access to medical records. However, if a patient requests his or her medical records in writing, a physician and other healthcare providers should provide a copy or a summary of the record to the patient or to another physician, an attorney, or other person designated by the patient. Medical records should not be withheld from the patient because of an unpaid bill for medical services or for any other reason.

Screening Mammography

Are any other countries implementing these guidelines? The US is not always right.

Canada, Australia and England all have similar guidelines recommending screening from age 50. Other European countries do so also. The more progressive are considering abandoning some screening programmes that have not proven to improve health or reduce deaths. For example, a large Danish study found that two regions had similar drops in breast cancer mortality over the same period despite one having no screening programme at all. The mortality drops were due to improved treatment and access to it.

Do any oncologists support these guidelines?

Bermuda’s two oncologists support the recommendation. In addition, the ’50-plus’ guideline is supported by the Royal College of Physicians and Surgeons of Canada, the Canadian Medical Association, the Canadian Task Force on Preventive Health Care, the Canadian Cancer Society, the National Clinical Guidelines Centre (UK), the National Institute for Health and Care Excellence (UK), and various medical Royal Colleges. The guideline is also recommended by the Nordic Cochrane Centre, an independent research centre which has published more research on mammography screening than any other independent institution; you can see their leaflet at: www.cochrane.dk/screening/mammography-leaflet.pdf.

If I am under 50 and want to have a mammogram, will I have to pay for it myself?

As with all medical interventions, you should discuss it with your medical doctor first. Together you’ll make a decision that is right for you. If your doctor does not see clinical reasons for you to have a screening mammogram, you could pay for it yourself, as you would for any medically unnecessary procedure. If your doctor sees merit in referring you, your insurance will cover it by law.

If the American College of Radiologists does not support these guidelines, why are we considering implementing them?

Most international bodies support the ‘50 plus’ guideline – some are more conservative. Organizations representing specialists have a perspective which reflects their unique experience. It’s better to be guided by independent agencies with no vested interests in a particular technology or modality.  These guidelines are supported by multiple specialities and experts whose focus is on prevention and on the wider perspective which balances risk of over-diagnosis with the benefits of a procedure.

Isn’t changing the age to 50 for screenings just the Government implementing a cost-saving measure?

This is not a cost-saving measure. The guideline was recommended by local medical leaders concerned with healthcare quality and the benefits and risks of medical interventions. In fact, data shows that too many women aged 50 to 74 are neglecting screening at present, and more effort has to be made to encourage this group. The Government will not see any material savings from the shift.

The US Congress has not even accepted these guidelines so why should we?

Medical recommendations based on scientific evidence are independent of political decisions. The guideline to screen over 50s may be under political scrutiny in the US, but it is widely accepted in Canada, Australia, England and other European countries. Be aware that the political realm can be strongly influenced by special-interest groups and lobbyists whose primary concern is not the health of the population.  Bermuda needn’t be restrained by political decisions in the US. It is better that we be guided by the scientific evidence. Anyone can read the evidence, for example, at: www.uspreventiveservicestaskforce.org/Page/Document/final-evidence-summary9/breast-cancer-screening

What harm can mammograms really do? My mom has been having them since she was 40 without any signs of problems.

It exposes women to low levels of radiation which, over time, can be a greater risk in itself. In addition, intensive screening results in finding a multitude of minor and innocuous abnormalities that are then investigated and treated more invasively, though they were never going to become serious. This is known as over-diagnosis, and it can cause harm to women, as well as contribute to unnecessary psychological distress.

Who is the task force that reviewed these guidelines? Do any of them have expertise in cancer care or breast cancer screening?

The U.S. Preventive Services Task Force is comprised of scientists and medical experts on prevention. Task Force scientific analyses and interpretations were conducted on research conducted by various experts, including cancer researchers. The Task Force is made up of 16 independent members who are nationally recognized experts in prevention, evidence-based medicine, and primary care, with expertise including family medicine, internal medicine, obstetrics and gynaecology. Locally the guidelines were recommended by physician leaders: the then President of the Bermuda Medical Doctors’ Association (BMDA), the Chief of Staff of the Bermuda Hospitals Board (BHB), and the Chief Medical Officer.

Why wouldn’t you screen earlier? I thought if you screened earlier you would catch it sooner and save money and lives by reducing the need for invasive medical interventions.

Early detection is great when it’s picking up real problems. The trouble with overly-intensive screening is that it largely detects things that are not problematic or risky. We know they are not because the largest studies available show that detecting such small anomalies does not result in reduced deaths. It is better to properly screen populations at risk, than to over-diagnose groups with no known risks.

With the high incidence of breast cancers in Bermuda, and a population very different from that in the US, when will we as a country start allowing local health statistics to drive our local health policy?

It’s hard for small populations to produce large enough samples to yield scientifically valid results. There were less than 70 breast cancers diagnosed in Bermuda in 2014.  We cannot make scientifically accurate recommendations from a sample size this small. However, the studies available on cancer in African Americans have not found statistical evidence that earlier screening reduces mortality. Despite similar screening rates, black women are less likely to be diagnosed with breast cancer than white women; yet are more likely to die of breast cancer. The reasons are believed to be access to treatment and the types of cancer. It is important to understand that earlier diagnosis has not been shown to result in a reduction in mortality from breast cancer. The improvements in survival rates for breast cancer have been attributed primarily to improvements in treatment modalities.

The only large-scale cancer study publicly available in Bermuda is at: http://bhec.bm/wp-content/uploads/resources/documents/CancerinBermuda2004.pdf. However, in the coming years, efforts will continue to track local trends, the prior history and outcomes of our small population of cancer patients.  This will help to shed more light on the local situation. In the meantime, we must rely on the findings and recommendations from larger jurisdictions whose studies have scientific and statistical validity.