F25[6A. — (1)In this Part and Schedules 3 and 4—

"advanced cover" shall be construed in accordance with section 11E(4);

"age group" means age group as prescribed in regulations made under section 7D, and includes any age group, whether or not by reference to any one or more of the following:

(a) being less than a specified age;

(b) being of a specified age or over such age but under another specified age; or

(c) being of a specified age or over such age;

"age-related tax credit" has the same meaning as in section 470B(4) of the Taxes Consolidation Act 1997;

"approved accounting standards" means accounting standards which are in accordance with generally accepted accounting principles in the State;

"changed existing contract" has the meaning assigned to it by F26[section 7AB(2)];

"cumulative net financial impact", in relation to a registered undertaking or former registered undertaking which has furnished the Authority with information under section 7F(1) in respect of a period, means the difference between—

(a) the total amount of the age-related tax credits and risk equalisation credits recorded in accounts for that undertaking in respect of that period as extracted from that information by the undertaking in respect of that period, and

(b) the total amount of the stamp duty referred to in section 125A of the Stamp Duties Consolidation Act 1999 recorded in accounts for that undertaking in respect of that period as extracted from that information by the undertaking in respect of that period;

"draft report" has the meaning assigned to it by section 7F(7);

"Fund" means the Risk Equalisation Fund established under section 11D;

F27["high cost claim" means a claim, or more than one claim, arising in any period of 12 months prescribed for that purpose relating to an insured person under a health insurance contract or contracts effected by the same registered undertaking—

(a) the amount, or the cumulative amount, of which claim or claims, as the case may be, exceeds the high cost claim threshold, and

(b) which has or have been paid by the undertaking,

but does not include a claim for the cost of drugs that are not listed on the Reimbursement List established and published by the Health Service Executive under section 17 of the Health (Pricing and Supply of Medical Goods) Act 2013;

"high cost claim credit" means the amount that is equal to the high cost claim quota share multiplied by the amount by which the high cost claim exceeds the high cost claim threshold;

"high cost claim quota share" means the percentage that is specified in paragraph 2 of Schedule 5 as the high cost claim quota share, being the portion of a high cost claim in excess of the high cost claim threshold payable from the Fund as a high cost claim credit;

"high cost claim threshold", in relation to a high cost claim, means the sum of the following amounts:

(a) the amount that is specified in paragraph 1 of Schedule 5, and

(b) the amount (if any) of any other risk equalisation credits (other than high cost claim credits) claimed from the Fund relating to the insured person under a health insurance contract or contracts arising in the period of 12 months to which the high cost claim relates;]

F28["hospital utilisation credit" means the relevant amount payable from the Fund in respect of each hospital stay (whether on an overnight accommodation or day case basis) in private hospital accommodation, on or after 31 March 2013 if the stay is on an overnight accommodation basis and on or after 1 March 2016 if the stay is on an overnight accommodation or day case basis, by a person who is an insured person under a health insurance contract effected for any period commencing on or after the date concerned;]

"information return" means an information return referred to in section 7D(1);

"non-advanced cover" shall be construed in accordance with section 11E(4);

"positive", in relation to the cumulative net financial impact on a registered undertaking or former registered undertaking which has submitted one or more information returns to the Authority in respect of a period, means that, for that period and that undertaking, the amount specified in paragraph (a) of the definition of "cumulative net financial impact" in this subsection exceeds the amount specified in paragraph (b) of that definition;

F28[ "private hospital accommodation" means—

(a) accommodation in a private hospital, whether or not in a hospital bed, or

(b) accommodation in a publicly funded hospital where a charge is payable under section 55 of the Health Act 1970; ]

"relevant amount", in relation to the definition of F29["hospital utilisation credit"] in this section and an insured person referred to in that definition, means the lower of the following:

F28[(a) the amount concerned specified in Schedule 3 for the purposes of that definition multiplied by the number of nights on an overnight accommodation basis, or, as applicable, the number of days on a day case basis, that the insured person stayed in private hospital accommodation which fall within the hospital stay concerned referred to in that definition F27[but only if that number of nights’ or days’ accommodation were paid under the health insurance contract concerned];]

(b) the sum of all benefits paid under the health insurance contract concerned referred to in that definition in respect of hospital in-patient services provided during the hospital stay concerned referred to in that definition of the insured person;

"relevant contract" has the meaning assigned to it by section 125A(1) of the Stamp Duties Consolidation Act 1999;

"relevant contract (advanced cover)" means a relevant contract which is not a relevant contract (non-advanced cover);

"relevant contract (non-advanced cover)" means a relevant contract which falls within a type of relevant contract specified in regulations under section 11E as a type of relevant contract in respect of which the Authority is satisfied under that section that it does not provide for advanced cover;

"relevant financial provisions" means—

(a) the Risk Equalisation Scheme,

(b) section 125A of the Stamp Duties Consolidation Act 1999, or

(c) section 470B of the Taxes Consolidation Act 1997,

or any combination of any of the Risk Equalisation Scheme (including any constituent provision of the Scheme) and any section referred to in paragraph (b) or (c);

"relevant market sector", in relation to information returns made to the Authority for any period of 6 months referred to in section 7D(1), means all the registered undertakings or former registered undertakings which have made those returns;

"relevant period" has the meaning assigned to it by section 7D(1)(b);

"risk equalisation credits"—

(a) in relation to an individual insured under a health insurance contract effected by a registered undertaking for any period commencing on or after 1 January 2013, means—

(i) the payment from the Fund to the undertaking on behalf of the individual of any F29[hospital utilisation credits] which the individual is entitled to have so paid, F30[…]

F27[(ia) the payment from the Fund to the undertaking on behalf of the individual of any high cost claim credits which the individual is entitled to have so paid, and]

(ii) the payment from the Fund of the part (if any) of the premium payable under the contract which the individual is entitled to have so paid by virtue of section 11C(1),

and

(b) in relation to such undertaking and such contract, means—

(i) the amount of the F29[hospital utilisation credit] (if any) referred to in paragraph (a)(i), F30[…]

F27[(ia) the amount of the high cost claim credits (if any) referred to in paragraph (a)(ia), and]

(ii) the amount of the part (if any) of the premium payable referred to in paragraph (a)(ii) that it has not collected from the policy holder by virtue of section 11C(1);

"type of cover" means a specific health insurance contract which provides for the payment of prescribed benefits where either—

(a) the particulars relating to the contract are contained in The Register of Health Insurance Contracts, or

(b) the particulars relating to the contract were once contained in that Register but, notwithstanding that such particulars are no longer contained in that Register, prescribed benefits are still payable under the contract.

(2) F31[…]]]