1. These Regulations may be cited as the Health Insurance Act 1994 (Information Returns) Regulations 2009.

2. (1) In these Regulations—

F1[“Act of 1994" means the Health Insurance Act 1994 (No. 16 of 1994);]

“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;

“cell” or “specified cell” means a group of insured persons who belong to both a common gender and a common prescribed age band;

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

“cell claim value” means the sum of all in-patient and day-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;

F2["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;]

F3["cell returned benefits" means the sum of all returned benefits 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 paid which have been taken into account under a previous settled claim;]

F2["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;]

“claim” means an application by, or on behalf of, an insured person to a registered undertaking for the discharge or reimbursement, under the terms of a health insurance contract, of all or part of the fees or charges due to a health services provider in respect of the provision of prescribed health services during a hospital stay or stays;

“covered persons”, in relation to a registered undertaking, means—

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

(b) persons not already included under subparagraph (a) who, during the same specified period as in that subparagraph, were named in a health insurance contract effected by the registered undertaking and who, but for the cessation of their health insurance contract, would have belonged to a specified cell or combination of cells on the last day of that specified period, or

(c) persons not already included under subparagraph (a) or (b) and—

(i) in respect of whom there was a settled claim during the same specified period as in subparagraph (a), and

(ii) who were formally named in a health insurance contract effected by the registered undertaking and who, but for the cessation of their health insurance contract, would have belonged to a specified cell or combination of cells on the last day of that specified period;

“corrective payment” means a payment made to, or an amount recovered from, a health service provider or an insured person in respect of prescribed health services for which an incorrect payment, other than one arising from a systematic error in the method of processing claims, was made;

F1[“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 F4[…] 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;]

“data adjustment” has the meaning assigned to it by Regulation 5(9);

“dependent person” has the meaning assigned to it by section 1 of the Health (Nursing Homes) Act 1990 (No. 23 of 1990);

“fixed price procedure” means any prescribed health service, the benefit for which is payable by an undertaking to a publicly funded hospital or a private hospital, on behalf of an insured person by reference to a specified monetary amount agreed between the undertaking and the hospital as representing full settlement of all charges and fees arising;

F5["Fund" and "high cost claim credit" have the meanings assigned to them by section 6A(1) of the Act of 2004;]

“gross provider payment”, in relation to a settled claim, means a payment or payments, based on proper and correct accounts, due, or nominally due, from a registered undertaking to a health services provider or in respect of services rendered by that provider, disregarding the effect of—

(a) any third party recoveries in respect of that claim,

(b) any corrective payments in respect of that claim,

(c) any discounts, overall limits or like reductions or bonuses or other additional compensation which may have been agreed between that provider and that undertaking, and

(d) any reinsurance recoveries in respect of that claim;

“health services provider” means a publicly-funded hospital, private hospital, registered nursing home or hospital, private psychiatric hospital or hospital consultant, as appropriate;

“hospital consultant” means a registered medical or dental practitioner who by reason of his or her training, skill and experience in a designated speciality, is consulted by other registered medical practitioners and who has a continuing clinical and professional responsibility for patients under his or her care, or that aspect of care on which he or she has been consulted;

“hospital stay” means an in-patient stay or a day-patient day or any attendance at a hospital during the provision of services described in item 1 of the table to Article 1 of Schedule 1 while the insured person was maintained in accommodation other than private hospital accommodation;

“in-patient day” means a day during an in-patient stay where the day on which the 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;

F6[…]

F2["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 F4[…] 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;]

“initial waiting period” shall be construed in accordance with the Health Insurance Act 2001 (Open Enrolment) Regulations 2005 (S.I. No. 332 of 2005);

“insured person” means—

(a) a person named in a health insurance contract as an insured person, and

(b) from date of birth, any infant born to any person named in a health insurance contract, provided that the person who effected the said contract requests that it be altered to name any such infant as an insured person, and pays the appropriate premium, if any, in that respect, within 13 weeks of the infant’s date of birth,

but does not include—

(i) any person named in a health insurance contract which does not relate to inpatient indemnity services,

(ii) any person named in a health insurance contract which relates solely to public hospital daily in-patient charges under Regulations made pursuant to section 53 of the Health Act 1970 (No. 1 of 1970), or

(iii) any person who has not completed an initial waiting period;

“medical condition” means any disease, illness or injury;

F5["member number" means an identifiable unique number corresponding to an insured person and all consecutive or continuous contracts held by the said insured person;]

“net provider payment” has the meaning assigned to it by Regulation 4(2);

F5["notifiable claim" means an amount or amounts discharged or reimbursed on application by, or on behalf of, an insured person to a registered undertaking, under the terms of a health insurance contract where such amount exceeds €10,000 for that contract;]

“nursing home” or “registered nursing home” has the meaning assigned to it by section 2 of the Health (Nursing Homes) Act 1990 (No. 23 of 1990);

F7[“prescribed age band" means one of the following 91 age ranges:

(a) under one year of age at the start of a specified period;

(b) one year of age but under 2 years of age at the start of a specified period;

(c) for each year of age starting from 2 years of age up to and including 89 years of age such that—

(i) the first age range is 2 years of age but under 3 years of age at the start of a specified period, and

(ii) the last age range is 89 years of age but under 90 years of age at the start of a specified period;

(d) 90 years of age and over at the start of a specified period;]

“prescribed benefits” shall be construed in accordance with Regulation 4;

“prescribed health services” means—

(a) hospital in-patient services, including any day-patient service,

(b) health services provided by a hospital consultant in conjunction with a hospital stay, or

(c) in relation to health services received outside the State, services equivalent to those at subparagraph (a) or (b) provided in accordance with the terms of a health insurance contract,

where such services are provided—

(i) as a result of the patient having been referred to the health services provider by a registered medical practitioner,

(ii) in an emergency, or

(iii) in connection with an obstetric condition,

and are appropriate health services, 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 or any form of assisted reproduction,

(II) dental, orosurgical or orthodontic treatment or consultation with a dental practitioner,

(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, and

(VIII) health services necessitated directly or indirectly by war or civil disturbance;

“private hospital” means a hospital (including an approved centre within the meaning of section 63 of the Mental Health Act 2001 (No. 25 of 2001)) which—

(a) provides prescribed health services, and

(b) is not a publicly-funded hospital,

but excluding a nursing home, or a hospital which is outside the State;

F7[“private hospital accommodation" means—

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

(b) accommodation in a publicly-funded hospital F8[where a charge is payable under section 55 of the Health Act 1970;]]

“private psychiatric hospital” means a centre, within the meaning of section 62 of the Mental Health Act 2001 (No. 25 of 2001), registered pursuant to section 64 of that Act;

“publicly-funded hospital” means a hospital, other than a private hospital or nursing home, which provides services to a person pursuant to his or her entitlement under Chapter II of Part IV of the Health Act 1970 (No. 1 of 1970);

“quarter” has the meaning assigned to it by section 2(1) of the Act of 1994;

“relevant period” has the meaning assigned to it by section 7D(1)(b) of the Act of 1994;

F3["returned benefits", in respect of each settled claim, means the sum of the net provider payments under that claim;]

F2["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;]

“returning undertakings” means all registered undertakings or former registered undertakings required to make the information return concerned by virtue of section 7D(4) of the Act of 1994;

“screening” means a medical examination or test that is not reasonably required for the diagnosis of, or management of, the medical condition of an insured person;

“settled claim” means a claim in respect of which payments due have been made but excluding any claim in respect of a person who, at the time of the hospital stay or stays to which the claim relates, had not completed an initial waiting period;

“third party recovery” means a payment made to a registered undertaking as a result of payments made by a third party for fees or charges arising from the provision of prescribed health services to an insured person other than payments made in respect of a contract of F7[reinsurance;]

(2) The definitions of “quarter” and “relevant period” in paragraph (1) shall not be construed to prejudice the generality of the application of section 19 of the Interpretation Act 2005 (No. 23 of 2005) to the construction of these Regulations.

3. The Authority shall have all powers that are necessary for or incidental to the performance of its functions in relation to these Regulations.

4. (1) A returning undertaking shall calculate and record, in respect of each settled claim, the amount of prescribed benefits F9[and the amount of returned benefits] in accordance with the provisions of this Regulation and Schedules 1 and 2.

(2) In respect of each settled claim and for each health services provider, the returning undertaking shall determine an amount (to be known for the purposes of these Regulations as the “net provider payment”), being the gross provider payment in respect of that claim and that provider multiplied by an amount determined in accordance with the formula:

A

B

where, for the quarter in which that claim was settled—

A is the sum of:

(a) the total of actual amounts which that undertaking has paid, disregarding the effect of any corrective payments and third party recoveries, in respect of all settled claims which acquired that status during that quarter; and

(b) the net total of corrective payments relating to that undertaking during that quarter, provided that this amount shall be subject to an upper limit of 0.5% of B and be subject to a lower limit of –0.5% of B, reduced by the total of any third party recoveries made by that undertaking during that quarter; and

B is the sum of that undertaking’s gross provider payments under all settled claims which acquired that status during that quarter.

(3) The prescribed benefits in respect of each settled claim shall be the sum of the net provider payments under that claim, where each such net provider payment is subject to the maximum limits specified in Schedule 1 as regards the type of payments contained therein.

5. F10[(1) Each returning undertaking shall make information returns to the Authority in accordance with section 7D of the Act of 1994 and the returns shall be electronically submitted such that the Authority can readily process the information contained in the returns.]

(2) F11[Notwithstanding paragraph (3)(c), Form No. 1] set out in Schedule 2 shall be the prescribed form of information return to be completed by each returning undertaking and submitted to the Authority.

F12[(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;

F11[(vii) the cell claim value for the quarter, with a breakdown of the sum of in-patient and day-patient days between publicly funded hospitals and private hospitals;

(viii) the cell claim value (overnight stays) for the quarter, with a breakdown of the sum of all in-patient days between publicly funded hospitals and private hospitals;]

(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 F11[by gender;]]

F13[(c) for all notifiable claims, the details specified herein, split by contract period and split monthly based on date of provision of services and date of payment, in the form specified by the Authority pursuant to section 11G of the Act of 2004:

(i) details of insured individual for each health insurance contract including membership number, age, gender, type of cover and whether the type of cover is specified as advanced cover by the Authority under section 11E of the Act of 1994;

(ii) details of risk equalisation credit claimed from the Fund under section 11C of the Act of 1994 excluding high cost claim credits.

(iii) breakdown of the notifiable claim amount into that relating to services rendered—

(I) in a publicly funded hospital,

(II) in a private hospital, and

(III) by a hospital consultant;

(iv) the total amount reimbursed for drugs which are not on the Reimbursement List established by the Health Service Executive under section 17 of the Health (Pricing and Supply of Medical Goods) Act 2013;

(v) the cell claim value (publicly funded hospitals);

(vi) the cell claim value (private hospitals);

(vii) the cell claim value (overnight stays) (publicly funded hospitals) and

(viii) the cell claim value (overnight stays) (private hospitals).]

(4) A returning undertaking shall ensure that each of its information returns is accompanied by an analysis, for each quarter within the relevant period to which the return relates, of the difference between—

(a) the following:

(i) the total number of persons (including such persons excluded from the definition of “insured person” by virtue of subparagraph (i), (ii) or (iii) of that definition) named in health insurance contracts effected by that registered undertaking that are in force on the first day of the quarter; and

(ii) the total number of insured persons on the first day of the quarter for all cells for both genders combined,

and

(b) the following:

(i) the total amount of payments made under health insurance contracts during the quarter; and

(ii) the total amount of the cell prescribed benefits for the quarter for all cells for both genders combined.

(5) A returning undertaking shall ensure that each of its information returns is accompanied by a statement setting out the details of the material assumptions (if any) used in preparing the return.

(6) A returning undertaking shall ensure that each of its information returns is accompanied by a report by an independent accountant stating whether or not, in the opinion of the independent accountant—

(a) the return has been prepared in accordance with these Regulations in all material respects,

(b) the material assumptions (if any) used in preparing the return are appropriate, consistently applied and adequately disclosed in the statement referred to in paragraph (5), and

(c) the return has been prepared in accordance with the underlying books and records of the undertaking.

(7) The independent accountant referred to in paragraph (6) shall set out in the report referred to in that paragraph the basis for his or her opinion referred to in that paragraph and include in the report such findings or qualifications as he or she considers ought to be included in the report in the circumstances of the case.

(8) A returning undertaking shall ensure that—

(a) each of its information returns is confirmed by being signed by 2 of its officers who are authorised to do so by the Board of that undertaking, and

(b) one of those signatories is the managing director, the chief executive officer, or the company secretary, of the undertaking, or a member of the Board of the undertaking, or a person of similar status in relation to the undertaking.

(9) If a returning undertaking detects or otherwise becomes aware of an error in an information return which it has made, it shall forthwith notify the Authority of such error and, within 7 days of becoming so aware, submit a corrected information return (to be known for the purposes of these Regulations as a “data adjustment”), together with a report setting out the reasons why the error occurred and the steps which have been taken to prevent a recurrence of any such error.

(10) If the Authority receives a data adjustment, it shall, if time permits, incorporate the data adjustment into its evaluation and analysis required under section 7E of the Act of 1994 to be carried out for the relevant period concerned. If a data adjustment is received when it is not possible to incorporate it into such evaluation and analysis or report required under section 7E of the Act of 1994 to be furnished to the Minister, and the Authority considers it to be a material data adjustment, the Authority shall advise the Minister of the impact that the data adjustment would have had on its evaluation and analysis and report as soon as is practicable after the receipt of the data adjustment. The Minister shall have regard to any such advice in making recommendations to the Minister for Finance pursuant to section 7E(2) of the Act of 1994.

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.