S.I. No. 294/2009 - Health Insurance Act 1994 (Information Returns) Regulations 2009

1. The maximum limit of net provider payments for prescribed health services provided by a publicly-funded hospital or a private hospital to an insured person, which are not fixed price procedures, are as set out in the following table

TABLE

Payments in respect of:(Column 1)

Maximum Limit:(Column 2)

Item 1

Prescribed health services which are hospital in-patient services provided by a publicly-funded hospital while the insured person was maintained in accommodation other than private hospital accommodation.

Limit for Item 1

The public hospital daily in-patient charges under Regulations made pursuant to

section 53

of the

Health Act 1970

, and any other charges that may be payable under that Act as in force from time to time.

Item 2

Prescribed health services which are hospital in-patient services provided by a publicly-funded hospital while the insured person was maintained in private hospital accommodation.

Limit for Item 2

The amount of the charge payable under

section 55

of the

Health Act 1970

plus the amount of the public hospital daily in-patient charges under Regulations made pursuant to section 53 of that Act.

Item 3

Prescribed health services which are hospital in-patient services provided by a private hospital other than a private psychiatric hospital.

Limit for Item 3

The lesser of

€550 for each in-patient day;or100% of the charge made by the private hospital less €100 for each day during which the insured person was accommodated in a single room.

Item 4

Prescribed health services which are day-patient services provided by a publicly-funded hospital while the insured person was maintained in private hospital accommodation.

Limit for Item 4

The amount of the charge payable under

section 55

of the

Health Act 1970

plus the amount of the public hospital daily in-patient charges under Regulations made pursuant to section 53 of that Act.

Item 5

Prescribed health services which are day-patient services provided by a private hospital other than a private psychiatric hospital.

Limit for Item 5

The lesser of:€550 for each day-patient day;or100% of the charge made by the private hospital.

Item 6

Prescribed health services which are hospital in-patient services provided by a private psychiatric hospital.

Limit for Item 6

€220 for each in-patient day.

2. The amount determined under this Schedule in respect of hospital charges relating to childbirth by means of a normal delivery shall not exceed €1,000.

3. In respect of fixed price procedures, the maximum limit of net provider payments shall be the lesser of, the amount paid or 90% of that specified in an agreement between the undertaking and the hospital as representing full settlement of all fees and charges payable for the particular services concerned.

4. The maximum limit of net provider payments in respect of prescribed health services provided by a hospital consultant shall be the amount paid by the undertaking for the particular services concerned.

5. In respect of prescribed health services provided outside of the State, the maximum limit of net provider payments shall be the lesser of, the maximum limit of net provider payments in accordance with the other provisions of this Schedule, or the amount paid by the undertaking for the particular services concerned in accordance with a health insurance contract.

SCHEDULE 2

Form No. 1

Return to the Health Insurance Authority pursuant to Section 7D of the

Health Insurance Act 1994

Return for the Period Ending

PART 1 OF RETURN

Data for First Quarter of Period

Gender: Female

Returning undertaking:....................................

Cell

Number of insured persons on first day of the first month of that quarter

Number of insured persons on first day of the second month of that quarter

Number of insured persons on first day of the third month of that quarter

Cell prescribed benefits for that quarter (€000s)

Cell claim value for that quarter

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

Form No. 1

PART 1 OF RETURN (Continued)

Data for First Quarter of Period

Gender: Male

Returning undertaking:....................................

Cell

Number of insured persons on first day of the first month of that quarter

Number of insured persons on first day of the second month of that quarter

Number of insured persons on first day of the third month of that quarter

Cell prescribed benefits for that quarter (€000s)

Cell claim value for that quarter

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

Form No. 1

PART 2 OF RETURN

Data for Second Quarter of Period

Gender: Female

Returning undertaking:....................................

Cell

Number of insured persons on first day of the first month of that quarter

Number of insured persons on first day of the second month of that quarter

Number of insured persons on first day of the third month of that quarter

Number of insured persons on first day of the next following period

Cell prescribed benefits for that quarter (€000s)

Cell claim value for that quarter

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

Form No. 1

PART 2 OF RETURN (Continued)

Data for Second Quarter of Period

Gender: Male

Returning undertaking:....................................

Cell

Number of insured persons on first day of the first month of that quarter

Number of insured persons on first day of the second month of that quarter

Number of insured persons on first day of the third month of that quarter

Number of insured persons on first day of the next following period

Cell prescribed benefits for that quarter (€000s)

Cell claim value for that quarter

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

Form No. 1

Return for the Period Ending .................................. as confirmed by

Name: ....................................................Name

*Position: ..............................................Position

Signature: ..............................................Signature

Date: ......................................................Date

*One of the signatories must be the managing director, the chief executive officer, or the company secretary, of the returning undertaking, or a member of the Board of the returning undertaking, or a person of similar status in relation to the returning undertaking.

GIVEN under my Official Seal,

29 July 2009.

MARY HARNEY,

Minister for Health and Children.

EXPLANATORY NOTE

(This note is not part of the Instrument and does not purport to be a legal interpretation.)

This statutory instrument sets out the format and content of the information returns specified in Section 7D of the Health Insurance Acts. The purpose of the information returns is to enable the Authority to report to the Minister as set out in Section 7E of the Acts and in particular to recommend any changes in the levy and tax credits having considered the need to support the principal objective as specified in the Acts.

6. Paragraphs (1), (3), (4), (5), (6), (8) and (9) of Regulation 5 are hereby declared to each be a penal Regulation for the purposes of subsection (1)(

b

) of section 4 of the Act of 1994.

SCHEDULE 1

MAXIMUM LIMITS OF NET PROVIDER PAYMENTS

Notice of the making of this Statutory Instrument was published in

“Iris Oifigiúil” of

31

st July

, 2009.

I, MARY HARNEY, Minister for Health and Children, in exercise of the powers conferred on me by sections 3(1) (as amended by

section 13

(

b

) of the

Health Insurance (Amendment) Act 2001

(No. 17 of 2001) and

section 5

of the

Health Insurance (Miscellaneous Provisions) Act 2009

(No. 24 of 2009)) and 7D(1) (as inserted by

section 9

of the

Health Insurance (Miscellaneous Provisions) Act 2009

(No. 24 of 2009)) of the

Health Insurance Act 1994

(No. 16 of 1994), hereby make the following Regulations

PART 1 GENERAL