Health Insurance (Amendment) Act, 2001
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Risk equalisation schemes. |
9.—The following sections are substituted for section 12 of the Principal Act: | |
“12.—(1) The Minister may prescribe a scheme or schemes of risk equalisation (which or each of which shall be known as a risk equalisation scheme and is referred to in this Act as ‘a scheme’). | ||
(2) (a) Subject to paragraphs (b) and (c), a scheme shall apply to each registered undertaking and each such undertaking shall comply with the terms and conditions of the scheme. | ||
(b) A scheme may include a provision specifying that the scheme shall not, at any time on and from the service on the Minister of the notice hereafter referred to, apply to a restricted membership undertaking which— | ||
(i) was carrying on business in the State before the commencement of section 9 of the Health Insurance (Amendment) Act, 2001, and | ||
(ii) was, on 1 May 2000, a registered undertaking, | ||
if, before a date specified for the purposes of this subsection by the Minister, the undertaking serves a notice on the Minister stating that it does not wish any scheme to apply to it. | ||
(c) A scheme may include a provision specifying that the scheme shall not apply to so much of the activities of a registered undertaking as consist of effecting health insurance contracts that solely provide for the making of payments for the reimbursement or discharge in whole or in part of fees or charges in respect of the provision of relevant health services. | ||
(3) (a) A scheme shall include a provision requiring each registered undertaking to make returns (each of which is referred to in this Act as a ‘return’) to the Authority in relation to such matters concerning its health insurance business as may be prescribed. | ||
(b) The provision referred to in paragraph (a) shall require a return to be made— | ||
(i) in the case of the first return, in respect of such period as may be prescribed, | ||
(ii) in the case of the second or any subsequent return, in respect of each period of— | ||
(I) 3 months, or | ||
(II) such greater duration as may be prescribed, | ||
and to be so made not later than such number of days after the end of the period to which it relates as may be prescribed. | ||
(4) (a) A scheme shall include a provision requiring— | ||
(i) the making of payments by registered undertakings to the Authority of such amounts as may be determined by the Authority in such manner and by reference to such matters as may be specified in the scheme (including the nature and distribution of insured risks amongst the undertakings), | ||
(ii) the making of payments by the Authority of such amounts as may be determined by the Authority to such registered undertakings as may be so determined in such manner and by reference to such matters as may be specified in the scheme (including the nature and distribution of insured risks amongst the undertakings). | ||
(b) The provision referred to in paragraph (a) shall provide that the requirements of the provision shall not have effect until such day as the Minister determines and appoints for that purpose in accordance with the provision of the scheme referred to in paragraph (c). | ||
(c) A scheme shall include a provision— | ||
(i) requiring the Authority to— | ||
(I) evaluate and analyse each return made to it (and such an evaluation and analysis shall be made by reference to the matters that are specified in the scheme for the purposes of the provision referred to in paragraph (a)), | ||
(II) prepare and furnish to the Minister, at such intervals as may be prescribed, a report in relation to— | ||
(A) such an evaluation and analysis in so far as it relates to returns made to it in a prescribed period, and | ||
(B) matters concerning the carrying on of health insurance business and developments in relation to health insurance generally that the Authority considers ought to be included in the report as a result of that evaluation and analysis, | ||
(III) if it appears to the Authority from such an evaluation and analysis that conditions specified in the scheme related to the nature and distribution of insured risks amongst the registered undertakings are fulfilled, include in that report a recommendation by it that the Minister ought or ought not (as it considers appropriate having regard to the best overall interests of health insurance consumers) to exercise the power hereafter mentioned in this subsection, | ||
(ii) providing that the Minister shall consider any such report made to him or her under the provision and— | ||
(I) if the report includes a recommendation by the Authority that the Minister ought to exercise the power referred to in this subparagraph, may, or | ||
(II) if it appears to the Minister that conditions specified in the scheme related to the nature and distribution of insured risks amongst the registered undertakings are fulfilled, shall (unless it appears to the Minister, having consulted with the Authority in relation to the best overall interests of health insurance consumers, that there are good reasons for not doing so), determine that the requirements of the provision referred to in paragraph (a) shall have effect on and from a specified day and appoint a day for that purpose accordingly. | ||
(5) The provision of a scheme referred to in subsection (4)(c) shall require the Authority, if it appears to the Authority that a recommendation of the kind referred to in that provision is required to be included in a report under that provision, to— | ||
(a) give notice to each registered undertaking of the fact that it proposes to include such a recommendation in the report, the nature of that proposed recommendation and the reasons therefor, | ||
(b) invite, by means of that notice, the undertaking to make, within 21 days from the date of the service of the notice on the undertaking, representations to the Authority in relation to the nature of the recommendation that, in the undertaking's opinion, ought to be included in the report, and | ||
(c) take into account any such representations made to it within that period before finally deciding what the nature of the said recommendation ought to be. | ||
(6) The provision of a scheme referred to in subsection (4)(c) shall require the Minister, if he or she proposes to make a determination of the kind referred to in subparagraph (ii) of that subsection, to— | ||
(a) give notice to each registered undertaking of the fact that he or she proposes to make such a determination (and the day proposed to be appointed under that provision accordingly) and the reasons for that proposed determination, | ||
(b) invite, by means of that notice, the undertaking to make, within 21 days from the date of the service of the notice on the undertaking, representations to the Minister as to why, in the undertaking's opinion, the said determination ought not to be made, and | ||
(c) shall take into account any such representations made to him or her within that period before finally deciding whether to make the said determination. | ||
(7) A scheme may provide— | ||
(a) that a registered undertaking which has made a return shall, on request being made of it to do so by the Authority, furnish to the Authority such information or documents in its possession or capable of being procured by it and forming the basis of that return as is or are specified in the request and that the undertaking shall comply with such a request not later than 7 days from the date the request is made, | ||
(b) that a report referred to in subsection (4)(c)(i)(II) shall be in such form, and contain such particulars in relation to the evaluation and analysis concerned, as the Minister determines. | ||
(8) A scheme may provide that a registered undertaking which has made representations under the provision of the scheme referred to in subparagraph (i) or (ii) of subsection (4)(c) to the Authority or, as the case may be, the Minister shall, on request being made of it to do so by the Authority or the Minister, as appropriate, furnish to the Authority or the Minister such information or documents in its possession or capable of being procured by it and forming the basis of those representations as is or are specified in the request and that the undertaking shall comply with such a request not later than 7 days from the date the request is made. | ||
(9) A scheme may provide— | ||
(a) for the establishment and maintenance by the Authority of a fund into which all moneys paid to the Authority under the scheme shall be paid and out of which all moneys paid by the Authority under the scheme shall be paid, and | ||
(b) for the keeping by the Authority of specified accounts in relation to the scheme and the furnishing of copies of those accounts, as audited by the Comptroller and Auditor General, and copies of the reports of the Comptroller and Auditor General thereon to the Minister at specified times. | ||
(10) (a) A reference in this section to— | ||
(i) a health insurance consumer is a reference to a person, other than the registered undertaking, who is party to, or named in, a health insurance contract or likely to be interested in being such a party or being so named, | ||
(ii) insured risks among registered undertakings is a reference to the risks that have been respectively insured by the undertakings under health insurance contracts, and | ||
(iii) the best overall interests of health insurance consumers includes a reference to the need to maintain the application of community rating across the market for health insurance and to facilitate competition between undertakings. | ||
(b) The conditions specified in a scheme for the purposes of the provision of the scheme referred to in subsection (4)(c)(i)(III) may be different from the conditions specified in the scheme for the purposes of the provision of the scheme referred to in subsection (4)(c)(ii)(II). | ||
(c) The nature and distribution of insured risks amongst registered undertakings to which conditions as aforesaid relate may be expressed in the scheme concerned by reference to the amounts that would fall to be paid to or by a particular registered undertaking or undertakings under the provision of the scheme referred to in subsection (4)(a) if the requirements of that provision had effect at the time of the making of the evaluation and analysis to which the report concerned referred to in subsection (4)(c)(i)(II) relates. | ||
12A.—(1) The contents of returns shall, in so far as they can be related to individual undertakings, be disclosed only where necessary for the functions of the Authority or the Minister. | ||
(2) Subject to subsection (1), the Authority may, where it considers it appropriate to do so, disclose aggregate data derived from returns (other than returns made to the Authority during the period lastly referred to in section 12B(1) by an undertaking that has served a notice under and in accordance with that section). | ||
(3) The Minister may engage a person whom he or she considers to be competent and qualified to do so to advise him or her and to consult with him or her in relation to the functions of the Minister under a scheme. | ||
(4) A payment due by a registered undertaking to the Authority under a scheme may be recovered by the Authority from the undertaking as a simple contract debt in any court of competent jurisdiction.”. |