Health Insurance Act, 1994 (Minimum Benefit) Regulations, 1996

• Jurisdiction: Ireland
• Citation: IR SI 83/1996
• Year: 1996

S.I. No. 83 of 1996.
HEALTH INSURANCE ACT, 1994 (MINIMUM BENEFIT) REGULATIONS, 1996
The Minister for Health in exercise of the powers conferred on him by sections 3 and 10 of the Health Insurance Act, 1994 (No. 16 of 1994) hereby makes the following Regulations—
PART 1 GENERAL
	1. These Regulations may be cited as the Health Insurance Act, 1994 (Minimum Benefit) Regulations, 1996.
	2. These Regulations shall come into operation on the 28th day of March, 1996.
	3. In these Regulations—
"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;
"benefit year" means a period of a year from—
(a) the commencement of a health insurance contract, or
(b) the anniversary of the commencement of a health insurance contract;
"day-patient day" means a day, including a day upon which an inpatient stay commences and ceases, during the course of which a fully insured person is maintained in private hospital accommodation for the purpose of receiving day-patient services;
"day-patient services" means health services provided in, or by persons attached to, a hospital where the patient is admitted on an elective basis for care and/or treatment which does not require the use of a hospital bed overnight and is discharged as scheduled;
"dependent person" has the meaning assigned to it by section 1 of the Health (Nursing Homes) Act, 1990 ;
"excess" means an amount by which in specified circumstances a payment shall be reduced provided that such amount shall never be greater than the payment before any such reduction;
"fully insured person" means an insured person named in a health insurance contract other than a contract which relates solely to one or both of the following—
(a) ancillary health services; or
(b) public hospital daily in-patient charges made under Regulations pursuant to Section 53 of the Health Act, 1970 ;
"health services provider" means a publicly- funded hospital, private hospital, registered nursing home or hospital consultant, as appropriate;
"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;
"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 );
"in-patient day" means a day during an in-patient stay where the day on which that 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 services" means in-patient services within the meaning of the Health Act, 1970 , but excluding day-patient services;
"in-patient stay" means a continuous period during which a fully insured person is maintained in private hospital accommodation for the purpose of receiving in-patient services, such period—
(a) to commence on the later of the occurrence 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 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) a designation of the cessation of that period by the registered undertaking which effected the health insurance contract under which that person is named
provided that the effect of a designation under sub-paragraph (iii) shall not be to cause such a period to comprise less than five in-patient days or a day-patient day;
"insured person" means a person named in a health insurance contract as an insured person or an infant born to a person named in a health insurance contract provided that in the case of an infant the person who effected the health insurance contract requests that the health insurance contract be altered to name such infant as an insured person, and pays the appropriate premium in respect of such infant, within 13 weeks of the date of birth of the infant;
"nursing home" has the meaning assigned to it in section 2 of the Health (Nursing Homes) Act, 1990 ;
"pathological procedure" has the meaning assigned to it in Schedule C of these Regulations;
"pre-existing condition waiting period" has the meaning assigned to it in the Health Insurance Act, 1994 (Open Enrolment) Regulations, 1996 ( S.I. No. 81 of 1996 );
"prescribed health services" means—
(a) in-patient services
(b) day-patient services
(c) out-patient services
(d) health services provided by a hospital consultant whether in a hospital setting or otherwise which are appropriate health services and 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 and any form of assisted reproduction;
(ii) dental, orosurgical or orthodontic treatment or consultation with a dental practitioner, other than those services prescribed in Schedule C of these Regulations;
(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 other than such care provided in the course or consequence of the provision of in-patient, day-patient or out-patient services;
(viii) health services received overseas;
(ix) health services provided other than
(I) as a result of the insured person 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;
(x) health services necessitated directly or indirectly by war or civil disturbance;
"prescribed minimum payment" means an amount determined in accordance with article 5 and shall not in any event exceed the amount of the fee or charge made in respect of the relevant prescribed health services;
"private hospital" means a hospital, other than a nursing home, which
(a) provides prescribed health services, and
(b) is not a publicly-funded hospital;
"private hospital accommodation" means accommodation in a private hospital or accommodation in a publicly- funded hospital which is designated by the Minister for Health as private or semi-private accommodation;
"private psychiatric hospital" means a facility registered pursuant to the Mental Treatment Act, 1945 ;
"publicly-funded hospital" means a hospital, other than a nursing home, which provides services to a person pursuant to his or her entitlements under Chapter II of Part IV of the Health Act, 1970 ;
"radiological procedure" has the meaning assigned to it in Schedule C of these Regulations;
"registered medical practitioner" means a person whose name appears in the General Register of Medical Practitioners maintained under the Medical Practitioners Acts, 1978 and 1993;
"registered nursing home" means a nursing home registered pursuant to the Health (Nursing Homes) Act, 1990 ;
"screening" means a medical examination or test that is not reasonably required for the management of the medical condition of the patient;
"single room" means a hospital bedroom designed for and accommodating only one patient;
"special procedures" mean the procedures which are listed in Schedule B of these Regulations;
"surgical procedure" has the meaning assigned to it in Schedule C of these Regulations;
"third party recovery" means a payment to a registered undertaking as a result of the acceptance by a third party of full or partial liability for fees or charges arising from the provision of prescribed health services to an insured person.
	4. In these Regulations a reference to an article means a reference to an article of these Regulations and a reference to a subarticle means a reference to a subarticle in the article to which it is referred.
PART II PRESCRIBED MINIMUM PAYMENTS
	5. (1) A health insurance contract effected by a registered undertaking (other than such a contract relating solely to ancillary health services and/or solely to the public hospital daily in-patient charges made under Regulations, pursuant to Section 53 of the Health Act, 1970 ) shall provide for the payment by that undertaking, in respect of the provision of prescribed health services to an insured person by a health services provider, of amounts that are not less than the amounts provided for in these Regulations (herein referred to as the "prescribed minimum payments").
(2) Prescribed minimum payments shall be determined in accordance with Schedule A (payments in respect of hospital charges (in-patient and day patient services)), Schedule B (payments in respect of hospital charges relating to...