Health Insurance (Amendment) Act 2021

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Amendment of section 6A of Principal Act

2. Section 6A of the Principal Act is amended, in subsection (1)—

(a) in the definition of “risk equalisation credits”—

(i) in paragraph (a), by—

(I) the deletion of “and” after subparagraph (i), and

(II) the insertion of the following subparagraph after subparagraph (i):

“(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”,

and

(ii) in paragraph (b), by—

(I) the deletion of “and” after subparagraph (i), and

(II) the insertion of the following subparagraph after subparagraph (i):

“(ia) the amount of the high cost claim credits (if any) referred to in paragraph (a)(ia), and”,

(b) by the insertion of the following definitions:

“ ‘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;”,

and

(c) in paragraph (a) of the definition of “relevant amount”, by the insertion of “, but only if that number of nights’ or days’ accommodation were paid under the health insurance contract concerned” after “private hospital accommodation which fall within the hospital stay concerned referred to in that definition”.