S.I. No. 84/1996 - Health Insurance Act (Risk Equalisation Scheme), 1996

1. The period (referred to in this Schedule as the "specified period") in respect of which the calculations specified in this Schedule are to be carried out shall be a period determined in accordance with article 7 of this Scheme.

2. General Definitions

"claim group" means in respect of a settled hospital claim any previous claim which is either

(a) a linked claim of that claim; or

(b) is a constituent of or gave rise to a previous claim group which includes a claim which is so linked provided that no claim may be included in a claim group more than once;

"covered persons" means in relation to a scheme undertaking

(a) fully insured persons who on the last day of a specified period were named in a health insurance contract effected by that scheme undertaking and who belonged on that day to a specified cell or combination of cells, or

(b) fully insured persons not already included under paragraph (a) of this definition who were formerly named in a health insurance contract effected by that scheme undertaking and who, but for the cessation of their health insurance contract, would have belonged to that cell or those cells on the last day of that period;

"current claim" has the meaning assigned to it under the definition of linked claim;

"first day" means in relation to a settled hospital claim either, as appropriate,

(a) the day upon which the hospital stay to which a settled accommodation claim relates commenced; or

(b) the day of the provision of outpatient services to which a settled out-patient claim relates;

"last day" means in relation to a settled hospital claim either, as appropriate,

(a) the day upon which the hospital stay to which a settled accommodation claim relates ceased; or

(b) the day of the provision of outpatient services to which a settled outpatient claim relates;

"linked claim" means 'in respect of a settled hospital claim (referred to in this Schedule as the "current claim") a previous settled hospital claim relating to the same fully insured person (referred to in this Schedule as the "previous claim") which satisfies one or more of the following conditions

(a) that the first day of the previous claim

(i) is after or coincides with the first day of the current claim; and

(ii) is before or not more than seven days after the last day of the current claim; or

(b) that the last day of the previous claim

(i) is before or coincides with the last day of the current claim; and

(ii) is after or not more than seven days before the first day of the current claim; or

(c) that the first day of the previous claim is before the first day of the current claim and the last day of the previous claim is after the last day of the current claim.

"weighted claim value" means, for a settled hospital claim

(a) if that claim is a settled accommodation claim

(i) a value determined in accordance with the following table

Total number of in-patient days in respect of the hospital stay to which that claim relates

Value

1

0.20

2

0.30

3

0.40

4

0.50

5 or more

1.00

or as appropriate

(ii) a value calculated in accordance with the following formula

0.20 x Y

where Y is the total number of day- patient days in respect of the hospital stay to which that claim relates,

(b) if that claim is a settled out-patient claim 0.10

(c) the value determined in accordance with paragraphs (a) or (b) as appropriate in respect of that claim shall be reduced by an amount calculated in accordance with the following formula

Z - 1

where Z is the greater of

(i) one; and

(ii) the sum of

(A) the value determined in accordance with paragraphs (a) or (b) as appropriate; and

(B) the sum of the weighted claim values for the claim group associated with the claim;

"specified period" has the meaning assigned to it by paragraph 1 of this Schedule;

"previous claim" has the meaning assigned to it under the definition of linked claim;

"previous claim group" means a claim group given rise to by a previous claim.

3. Cell Definitions (with respect to a specified period, a specified scheme undertaking and a specified cell)

"cell day-patient days" means the sum of all day-patient days in respect of settled accommodation claims which acquired that status during that period in respect of covered persons;

"cell insured population" and "CIP" means the sum of

(a) the total number of fully insured persons in that cell on the first day of that period, and

(b) the total number of fully insured persons in that cell on the first day of the next following period

with the result being divided by two;

"cell equalised benefits" and "CEB" means the sum of all prescribed equalised benefits paid, in respect of settled claims which acquired that status during that period, to or on behalf of covered persons;

"cell weighted claim value" and "CWCV" means the sum of all weighted claim values, in respect of settled hospital claims which acquired that status during that period, in respect of covered persons;

"cell equalised benefits average" and "CEBA" means an amount determined in accordance with the following formula

4. Scheme Undertaking Definitions (with respect to a specified period and a specified scheme undertaking)

"undertaking insured population" and "UIP" means the sum for all cells of

CIP

"undertaking equalised benefits" and "UEB" means the sum for all cells of

CEB

"undertaking adult lives" and "UAL" means the sum, for all cells other than the cell or cells which comprise, the prescribed age band "age 17 and under", of

CIP

"undertaking child lives" and "UCL" mean the value, for the cell or cells which comprise the prescribed age band "age 17 or under", of

CIP

"undertaking equivalent adult lives" and "UEAL" means a value determined in accordance with the formula

"undertaking equivalent adult ratio" and "UEAR" means a value determined in accordance with the formula

5. Market Specific Definitions (with respect to a specified period)

"market insured population(cell)" and "MIP(Cell)" means the sum, for all scheme undertakings for a specified cell, of

CIP

"market insured population(total)" and "MIP(Total)" means, the sum, for all cells, of

MIP(Cell)

"market equalised benefits(cell)" and "MEB(Cell)" means the sum, for all scheme undertakings for a specified cell, of

CEB

"market equalised benefit(total)" and "MEB(Total)" means the sum, for all cells, of

MEB(Cell)

"market weighted claim value" and "MWCV(Cell)" means the sum, for all scheme undertakings for a specified cell, of

CWCV

"market equalised benefits average" and "MEBA(Cell)" mean an amount, for a specified cell, calculated in accordance with the formula

"market utilisation" and "MU(Cell)" means a value, for a specified cell, calculated in accordance with the formula

"market proportion" and "MP(Cell)" means a value calculated in accordance with the formula

"market equivalent adult lives" and "MEAL" means, the sum for all scheme undertakings of

UEAL

"market equivalent adult ratio" and "MEAR" means a value determined in accordance with the formula

6. With respect to a specified period, a specified scheme undertaking and a specified cell

"cell standardised benefits" and "CSB" mean an amount calculated in accordance with the formula

CEBA x MP(Cell) x MU(Cell) x UIP

provided that if for that cell the CWCV is less than 10, CSB instead shall be calculated in accordance with the formula

MEBA(Cell) x MP(Cell) x MU(Cell) x UIP

7. With respect to a specified period and a specified scheme undertaking

"undertaking standardised benefits - first calculation" and "USB1" means the sum for all cells of

CSB

"undertaking standardised benefits - second calculation" and "USB2" means a value determined in accordance with the formula

8. With respect to a specified period

"market standardised benefits" and "MSB" means the sum, for all scheme undertakings, of

USB2

9. With respect to a specified period and a specified scheme undertaking

"undertaking standardised benefits" and "USB" means an amount determined in accordance with the formula

10. The contribution (to be known for the purposes of this Scheme as the "equalisation contribution") for a specified period for a scheme undertaking shall be determined in accordance with the formula

USB - UEB

SCHEDULE E

Quarter ending ......................... Gender ............. Scheme Undertaking....................

Cell

Number of fully insured persons on first day of that quarter

Number of fully insured persons on first day of the next following quarter

Cell equalised benefits for that quarter

Cell weighted claim value for that quarter

Cell day-patient days for that quarter

Number of settled out-patient claims in respect of covered persons for that quarter

Number of settled in-patient claims in respect of covered persons for that quarter

Total

Which relate to one in-patient day only

Which relate to two in-patient days only

Which relate to three in-patient days only

Which relate to four in-patient days only

Which relate to five in-patient days only

Which relate to six in-patient days only

Which relate to six in-patient days only

Which relate to six in-patient days only

Which relate to seven in-patient days only

Which relate to eight in-patient days only

Which relate to nine in-patient days only

Which relate to ten in-patient days only

Which relate to not less than eleven and not more than fifteen in-patient days

Which relate to not less than sixteen and not more than twenty in-patient days

Which relate to not less than twenty one and not more than thirty in-patient days

Which relate to thirty one or more in-patient days

Age 17 and under

Age 18 to age 29

Age 30 to age 39

Age 40 to age 49

Age 50 to age 59

Age 60 to age 69

Age 70 to age 79

Age 80 and over

All cells for that gender combined

All cells for both genders combined

Confirmed by

NAME

..................

NAME

..................

Position

..................

Position

..................

SIGNATURE

..................

SIGNATURE

..................

Date

..................

Date

..................

GIVEN under the Official Seal of the Minister for Health this 28th day of March, 1996.

Michael Noonan

________________

Minister for Health

EXPLANATORY NOTE

These Regulations provide for the implementation of a scheme of risk equalisation. They set out the details for operation of the scheme, including the conditions which will give rise to the introduction of risk equalisation, the establishment of a risk equalisation fund and other arrangements. They provide for registered undertakings to make statistical returns relating to risk equalisation.

S.I. No. 84 of 1996.

HEALTH INSURANCE ACT (RISK EQUALISATION SCHEME), 1996

The Minister for Health in exercise of the powers conferred on him by

sections 3

and

12

of the

Health Insurance Act, 1994

(No. 16 of 1994) hereby makes the following Scheme—

PART I GENERAL