Risk Equalisation Scheme, 2003

• Statutory Instrument No.: 261/2003
• Date: 26 June 2003

I, Micheál Martin, Minister for Health and Children, in exercise of the powers conferred on me by sections 3 and 12 of the Health Insurance Act, 1994 (No. 16 of 1994) as amended and substituted by sections 9 , 10 and 13 of the Health Insurance (Amendment) Act, 2001 (No. 17 of 2001) and section 5 of the Health Insurance (Amendment) Act, 2003 (No. 11 of 2003) hereby make and prescribe the following Scheme-

PART I GENERAL 1. This Scheme may be cited as the Risk Equalisation Scheme, 2003. 2. Articles 1 to 10, 13 and 14 of this Scheme shall come into operation on the 1st day of July, 2003.

Articles 11 and 12 shall come into operation on a day determined in accordance with Article 13. 3. In this Scheme —

“Act” means the Health Insurance Act, 1994 , (No. 16 of 1994) as amended by the Health Insurance (Amendment) Act, 2001 , (No. 17 of 2001) and the Health Insurance (Amendment) Act, 2003 (No. 11 of 2003);

“Authority” means The Health Insurance Authority established under Part IV of the Act;

“appropriate health services” means health services in relation to the diagnosis or treatment of the illness or injury of a patient which would be accepted generally by the medical profession as appropriate and necessary, having regard to good standards of medical practice and to the nature and cost of any alternative forms of treatment as well as to all of the circumstances relevant to the patient;

“calculation error” means an error on the part of the Authority or its agents in the calculation of payments under section 12 (4) (a) of the Act;

“cell” or “specified cell” means a group of insured persons who belong to both a common gender and a common prescribed age band;

“cell equalised benefits” has the meaning assigned to it in the Second Schedule;

“cell claim value” has the meaning assigned to it in the Second Schedule;

“claim” means an application by, or on behalf of, an insured person to a registered undertaking for the discharge or reimbursement, under the terms of a health insurance contract, of all or part of the fees or charges due to a health services provider in respect of the provision of prescribed health services during a hospital stay or stays;

“corrective payment” means a payment made to, or an amount recovered from a health services provider or an insured person in respect of prescribed health services for which an incorrect payment, other than one arising from a systematic error in the method of processing claims, was made;

“day-patient day” means a day, including a day upon which an in-patient stay commences and ceases, during the course of which an insured person is maintained in private hospital accommodation for the purpose of receiving day-patient services:

“data adjustment” has the meaning assigned to it in Article 9 of this Scheme;

“day-patient services” has the meaning assigned to it in section 2 of the Act;

“dependent person” has the meaning assigned to it in section 1 of the Health (Nursing Homes) Act, 1990 , (No. 23 of 1990);

“equalisation contribution” has the meaning assigned to it in the Second Schedule;

“fixed price procedure” means any prescribed health service, the benefit for which is payable by an undertaking to a publicly funded hospital or a private hospital, on behalf of an insured person by reference to a specified monetary amount agreed between the undertaking and the hospital as representing full settlement of all charges and fees arising;

“gross provider payment” means, in respect of a settled claim, a payment or payments, based on proper and correct accounts, due, or nominally due, from a registered undertaking to a health services provider or in respect of services rendered by that provider, disregarding the effect of:

(a) any third party recoveries made in respect of that claim,

(b) any corrective payments in respect of that claim, and

(c) any discounts, overall limits or like reductions or bonuses or other additional compensation which may have been agreed between that provider and that undertaking;

“health insurance business” has the meaning assigned to it in section 2 of the Act;

“health insurance contract” has the meaning assigned to it in section 2 of the Act;

“health services provider” means a publicly-funded hospital, private hospital registered nursing home or hospital, private psychiatric hospital or hospital consultant, as appropriate;

“health status weight” has the meaning assigned to it in the Second Schedule;

“hospital consultant” means a registered medical practitioner who holds a current full registration with the Irish Medical Council and is engaged in hospital practice and who, by reason of his or her training, skill and experience in a designated speciality, is consulted by other registered medical practitioners and undertakes full clinical responsibility for patients in his or her care, or that aspect of care on which he or she has been consulted, without supervision in professional matters by any other person;

“hospital in-patient services” has the meaning assigned to it in section 2 of the Act;

“hospital stay” means an in-patient stay or a day-patient day;

“in-patient day” means a day during an in-patient stay where the day on which the stay ceased is deemed a whole day and the day on which that stay commenced is disregarded, except that if that stay commenced and ceased on the same day then that day shall be deemed a day-patient day;

“in-patient stay” means a continuous period during which an insured person is maintained in private hospital accommodation for the purpose of receiving hospital in-patient services, such period

(a) to commence on occurrence of the later of the following events-

(i) the most recent admission or transfer of that person to private hospital accommodation, or

(ii) the cessation of the most recent previous hospital in-patient stay in respect of that person, and

(b) to cease on the occurrence of the earlier of the following events-

(i) the next subsequent discharge or transfer of that person from private hospital accommodation,

(ii) the death of that person, or

(iii) on the date designated as the cessation date of that period by the registered undertaking which effected the health insurance contract under which that person is named;

“initial waiting period” has the meaning assigned to it in the Health Insurance Act 1994 (Open Enrolment) Regulations, 1996, ( S.I. No. 81 of 1996 );

“insured person” means:

(a) a person named in a health insurance contract as an insured person, and

(b) from date of birth, any infant born to any person named in a health insurance contract, provided that the person who effected the said contract requests that it be altered to name any such infant as an insured person, and pays the appropriate premium, if any, in that respect, within 13 weeks of the infant's date of birth,

but does not include:

(i) any person named in a health insurance contract which relates solely to relevant health services, or

(ii) any person named in a health insurance contract which relates solely to public hospital daily in-patient charges made under Regulations pursuant to section 53 of the Health Act, 1970 , (No. 1 of 1970), or

(iii) any person who, for the time being, does not qualify for payments in respect of prescribed health services under a health insurance contract because he or she has not completed an initial waiting period;

“market equalisation percentage” has the meaning assigned to it in the Second Schedule;

“medical condition” means any disease, illness or injury;

“Minister” has the meaning assigned in the Act;

“net provider payment” has the meaning assigned to it in Article 8;

“nursing home” or “registered nursing home” has the meaning assigned to it in section 2 of the Health (Nursing Homes) Act, 1990 , (No. 23 of 1990);

“period” means two consecutive quarters ending on the 30th day of June and on the 31st day of December in any given year;

“prescribed age band” means one of the following age groupings, where age is attained age (in whole years) of the person at the start of a specified period:

(a) Age 17 and under (b) Age 18 to age 29 (c) Age 30 to age 39 (d) Age 40 to age 49 (e) Age 50 to age 59 (f) Age 60 to age 69 (g) Age 70 to age 79 (h) Age 80 and over;

“prescribed equalised benefits” has the meaning assigned to it in Article 8;

“prescribed health services” means:

(a) hospital in-patient services, including any day-patient service, or

(b) health services provided by a hospital consultant in conjunction with a hospital stay, or

(c) in relation to health services received outside the State, services equivalent to those at (a) and (b) provided in accordance with the terms of a health insurance contract;

where such services are provided-

(i) as a result of the patient having been referred to the health services provider by a registered medical practitioner, or

(ii) in an emergency, or

(iii) in connection with an obstetric condition,

and are appropriate health services, the sole purpose of which is the medical investigation, treatment, cure or alleviation of the symptoms, of illness or injury but excluding

(I) treatment directly or indirectly arising from, or required in connection with, male and female birth control, infertility or any form of assisted reproduction,

(II) dental, orosurgical or orthodontic treatment or consultation with a dental practitioner.

(III) cosmetic services or treatment except the correction of accidental disfigurement or significant congenital disfigurement,

(IV) health services relating to eating disorders or weight reduction,

(V) preventive health services such as check-ups or screenings,

(VI) health services provided by a nursing home other than a registered nursing home,

(VII) nursing care, whether provided in an institution or otherwise, to persons who are dependent persons,

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