S.I. No. 522/2013 - Health Insurance Act 1994 (Information Returns) (Amendment) Regulations 2013.

Notice of the making of this Statutory Instrument was published in

“Iris Oifigiúil” of 3rd January, 2014.

I, JAMES REILLY, Minister for Health, in exercise of the powers conferred on me by sections 3 and 7D of the Health Insurance Act 1994 (No. 16 of 1994), hereby make the following regulations:

1. These Regulations may be cited as the Health Insurance Act 1994 (Information Returns) (Amendment) Regulations 2013.

2. In these Regulations “Principal Regulations” means the Health Insurance Act 1994 (Information Returns) Regulations 2009 ( S.I. No. 294 of 2009 ).

3. Regulation 2(1) of the Principal Regulations is amended—

(a) by substituting the following definition for the definition of “Act of 1994”:

“ ‘Act of 1994’ means the Health Insurance Act 1994 (No. 16 of 1994);”,

(b) by inserting the following definition after the definition of “cell claim value”:

“ ‘cell claim value (overnight stays)’ means the sum of all in-patient days, in respect of settled claims which acquired that status during the quarter concerned, in respect of covered persons but disregarding any such hospital stays which have been taken into account under a previous settled claim;”,

(c) by inserting the following definitions after the definition of “cell returned benefits”:

“ ‘cell returned benefits (hospital consultants)’ means the sum of all returned benefits (hospital consultants) paid, in respect of settled claims which acquired that status during the quarter concerned, to or on behalf of covered persons but disregarding any returned benefits (hospital consultants) paid which have been taken into account under a previous settled claim;

‘cell returned benefits (private hospitals)’ means the sum of all returned benefits (private hospitals) paid, in respect of settled claims which acquired that status during the quarter concerned, to or on behalf of covered persons but disregarding any returned benefits (private hospitals) paid which have been taken into account under a previous settled claim;

‘cell returned benefits (publicly-funded hospitals)’ means the sum of all returned benefits (publicly-funded hospitals) paid, in respect of settled claims which acquired that status during the quarter concerned, to or on behalf of covered persons but disregarding any returned benefits (publicly-funded hospitals) paid which have been taken into account under a previous settled claim;”,

(d) by substituting the following definition for the definition of “day-patient day”:

“ ‘day-patient day’ means—

(a) 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, or

(b) 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 a hospital bed in a publicly-funded hospital where a charge is payable under section 55 of the Health Act 1970 (No.1 of 1970) for such a stay for the purpose of receiving day-patient services;”,

(e) by deleting the definition of “in-patient stay”,

(f) by inserting the following definitions immediately before the definition of “initial waiting period”:

“ ‘in-patient stay’ means—

(a) an in-patient stay (private hospital), or

(b) an in-patient stay (publicly-funded hospital);

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

(a) to commence on the occurrence of the later of—

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

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

and

(b) to cease on the occurrence of the earlier of—

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

(ii) the death of that person, or

(iii) 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;

‘ in-patient stay(publicly-funded hospital)’ means a continuous period during which an insured person stays overnight in a hospital bed in a publicly-funded hospital where a charge is payable under section 55 of the Health Act 1970 for such a stay for the purpose of receiving hospital in-patient services, such period—

(a) to commence on the occurrence of the later of—

(i) the most recent admission or transfer of that person to the hospital bed, 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—

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

(ii) the death of that person, or

(iii) 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;”,

and

(g) by inserting the following definitions after the definition of “returned benefits”:

“ ‘returned benefits (hospital consultants)’ in respect of each settled claim, means the sum of the net provider payments under that claim paid to hospital consultants;

‘ returned benefits (private hospitals)’ in respect of each settled claim, means the sum of the net provider payments under that claim paid to private hospitals;

‘ returned benefits (publicly-funded hospitals)’ in respect of each settled claim, means the sum of the net provider payments under that claim paid to publicly funded hospitals:”.

4. Regulation 5 of the Principal Regulations is amended by substituting the following paragraph for paragraph (3):

“(3) A returning undertaking shall ensure that each of its information returns contains the following:

(a) for each quarter within the relevant period to which the return relates and for each type of cover, the details specified herein in respect of each cell by gender and related aggregate details:

(i) the number of insured persons on the first day of each month of the quarter;

(ii) the cell returned benefits for the quarter;

(iii) the cell returned benefits (publicly funded hospitals) for the quarter;

(iv) the cell returned benefits (private hospitals) for the quarter;

(v) the cell returned benefits (hospital consultants) for the quarter;

(vi) the cell prescribed benefits for the quarter;

(vii) the cell claim value for the quarter;

(viii) the cell claim value (overnight stays) for the quarter;

(ix) the aggregate details in respect of clauses (i) to (viii) for the gender concerned; and

(x) the aggregate details corresponding to clauses (i) to (viii) for all cells for both genders combined;

and

(b) where the quarter is the second quarter of the relevant period, in respect of each type of cover, the number of insured persons on the first day of the first month of the first quarter of the immediately succeeding relevant period in respect of each cell by gender.”.

6. The Principal Regulations are amended by substituting the following Schedule for Schedule 2:

“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 ..

(NOTE: Where the returned benefits payable under a type of cover to which this form relates have materially changed, then the undertaking concerned shall make separate returns of this form in respect of each material level of returned benefit. Also, the undertaking concerned shall make separate returns of this form in respect of the sum of all types of cover to which this form relates.)

PART 1 OF RETURN

Data for First Quarter of Period:

Gender: Female

Type of cover: ...

Returning undertaking: .

PART 1 OF RETURN (Continued)

Data for First Quarter of Period:

Gender: Male

Type of cover: ...

Returning undertaking: .

PART 2 OF RETURN

Data for Second Quarter of Period:

Gender: Female

Type of cover: ...

Returning undertaking: .

PART 2 OF RETURN

Data for Second Quarter of Period:

Gender: Male

Type of cover: ...

Returning undertaking: .

Return for the Period Ending ..as confirmed by:

* One of the signatories must be 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,

19 December 2013.

JAMES REILLY,

Minister for Health.

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 contents of the information returns specified in Section 7D of the Health Insurance Acts, as amended by the Health Insurance (Amendment) Act, No 45 of 2012, to include additional information that the Health Insurance Authority has previously obtained as a result of information requests.

In addition to the data currently provided in relation to all in-patients stays, information returns will now provide a breakdown of returned benefits into that relating to publicly funded hospitals, private hospitals and to hospital consultants. A breakdown of Cell Claim Value into that relating to overnight stays is provided as well as a breakdown of overnight stays where a charge is payable under Section 55 of the Health Act, 1970 for such period. 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 make its recommendations to the Minister on any changes in the risk equalisation credits and corresponding stamp duty levy required to fund the credits.