S.I. No. 83/1996 - Health Insurance Act, 1994 (Minimum Benefit) Regulations, 1996
This is the act as published. Later amendments are not folded into the text below: each one is a separate act in this repository and an entry in this law's history.
3 amending acts · 2015-03-17, S.I. No. 96/2015 - Health Insurance Act 1994 (Minimum Benefit) (Amendment) Regulations 2015
S.I. No. 83 of 1996.
HEALTH INSURANCE ACT, 1994 (MINIMUM BENEFIT) REGULATIONS, 1996
The Minister for Health in exercise of the powers conferred on him by sections 3 and 10 of the Health Insurance Act, 1994 (No. 16 of 1994) hereby makes the following Regulations—
PART 1 GENERAL
1.
These Regulations may be cited as the Health Insurance Act, 1994 (Minimum Benefit) Regulations, 1996.
2.
These Regulations shall come into operation on the 28th day of March, 1996.
3.
In these Regulations—
"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;
"benefit year" means a period of a year from—
- (a) the commencement of a health insurance contract, or
- (b) the anniversary of the commencement of a health insurance contract;
"day-patient day" means a day, including a day upon which an inpatient stay commences and ceases, during the course of which a fully insured person is maintained in private hospital accommodation for the purpose of receiving day-patient services;
"day-patient services" means health services provided in, or by persons attached to, a hospital where the patient is admitted on an elective basis for care and/or treatment which does not require the use of a hospital bed overnight and is discharged as scheduled;
"dependent person" has the meaning assigned to it by section 1 of the Health (Nursing Homes) Act, 1990 ;
"excess" means an amount by which in specified circumstances a payment shall be reduced provided that such amount shall never be greater than the payment before any such reduction;
"fully insured person" means an insured person named in a health insurance contract other than a contract which relates solely to one or both of the following—
- (a) ancillary health services; or
- (b) public hospital daily in-patient charges made under Regulations pursuant to Section 53 of the Health Act, 1970 ;
"health services provider" means a publicly- funded hospital, private hospital, registered nursing home or hospital consultant, as appropriate;
"hospital consultant" means a registered medical practitioner who holds a current full registration with the Irish Medical Council and is engaged in hospital practice and who, by reason of his or her training, skill and experience in a designated speciality, is consulted by other registered medical practitioners and undertakes full clinical responsibility for patients in his or her care, or that aspect of care on which he or she has been consulted, without supervision in professional matters by any other person;
"initial waiting period" has the meaning assigned to it in the Health Insurance Act, 1994 (Open Enrolment) Regulations, 1996 ( S.I. No. 81 of 1996 );
"in-patient day" means a day during an in-patient stay where the day on which that 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;
"in-patient services" means in-patient services within the meaning of the Health Act, 1970 , but excluding day-patient services;
"in-patient stay" means a continuous period during which a fully insured person is maintained in private hospital accommodation for the purpose of receiving in-patient services, such period—
- (a) to commence on the later of the occurrence of the following events—
- (i) the most recent admission or transfer of that person to private hospital accommodation; or
- (ii) the cessation of the most recent previous in-patient stay in respect of that person; and
- (b) to cease on the occurrence of the earlier of the following events—
- (i) the next subsequent discharge or transfer of that person from private hospital accommodation;
- (ii) the death of that person; or
- (iii) a designation of the cessation of that period by the registered undertaking which effected the health insurance contract under which that person is named
provided that the effect of a designation under sub-paragraph (iii) shall not be to cause such a period to comprise less than five in-patient days or a day-patient day;
"insured person" means a person named in a health insurance contract as an insured person or an infant born to a person named in a health insurance contract provided that in the case of an infant the person who effected the health insurance contract requests that the health insurance contract be altered to name such infant as an insured person, and pays the appropriate premium in respect of such infant, within 13 weeks of the date of birth of the infant;
"nursing home" has the meaning assigned to it in section 2 of the Health (Nursing Homes) Act, 1990 ;
"pathological procedure" has the meaning assigned to it in Schedule C of these Regulations;
"pre-existing condition waiting period" has the meaning assigned to it in the Health Insurance Act, 1994 (Open Enrolment) Regulations, 1996 ( S.I. No. 81 of 1996 );
"prescribed health services" means—
- (a) in-patient services
- (b) day-patient services
- (c) out-patient services
- (d) health services provided by a hospital consultant whether in a hospital setting or otherwise which are appropriate health services and 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 and any form of assisted reproduction;
- (ii) dental, orosurgical or orthodontic treatment or consultation with a dental practitioner, other than those services prescribed in Schedule C of these Regulations;
- (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 other than such care provided in the course or consequence of the provision of in-patient, day-patient or out-patient services;
- (viii) health services received overseas;
- (ix) health services provided other than
- (I) as a result of the insured person having been referred to the health services provider by a registered medical practitioner; or
- (II) in an emergency; or
- (III) in connection with an obstetric condition;
- (x) health services necessitated directly or indirectly by war or civil disturbance;
"prescribed minimum payment" means an amount determined in accordance with article 5 and shall not in any event exceed the amount of the fee or charge made in respect of the relevant prescribed health services;
"private hospital" means a hospital, other than a nursing home, which
- (a) provides prescribed health services, and
- (b) is not a publicly-funded hospital;
"private hospital accommodation" means accommodation in a private hospital or accommodation in a publicly- funded hospital which is designated by the Minister for Health as private or semi-private accommodation;
"private psychiatric hospital" means a facility registered pursuant to the Mental Treatment Act, 1945 ;
"publicly-funded hospital" means a hospital, other than a nursing home, which provides services to a person pursuant to his or her entitlements under Chapter II of Part IV of the Health Act, 1970 ;
"radiological procedure" has the meaning assigned to it in Schedule C of these Regulations;
"registered medical practitioner" means a person whose name appears in the General Register of Medical Practitioners maintained under the Medical Practitioners Acts, 1978 and 1993;
"registered nursing home" means a nursing home registered pursuant to the Health (Nursing Homes) Act, 1990 ;
"screening" means a medical examination or test that is not reasonably required for the management of the medical condition of the patient;
"single room" means a hospital bedroom designed for and accommodating only one patient;
"special procedures" mean the procedures which are listed in Schedule B of these Regulations;
"surgical procedure" has the meaning assigned to it in Schedule C of these Regulations;
"third party recovery" means a payment to a registered undertaking as a result of the acceptance by a third party of full or partial liability for fees or charges arising from the provision of prescribed health services to an insured person.
4.
In these Regulations a reference to an article means a reference to an article of these Regulations and a reference to a subarticle means a reference to a subarticle in the article to which it is referred.
PART II PRESCRIBED MINIMUM PAYMENTS
5.
(1) A health insurance contract effected by a registered undertaking (other than such a contract relating solely to ancillary health services and/or solely to the public hospital daily in-patient charges made under Regulations, pursuant to Section 53 of the Health Act, 1970 ) shall provide for the payment by that undertaking, in respect of the provision of prescribed health services to an insured person by a health services provider, of amounts that are not less than the amounts provided for in these Regulations (herein referred to as the "prescribed minimum payments").
- (2) Prescribed minimum payments shall be determined in accordance with Schedule A (payments in respect of hospital charges (in-patient and day patient services)), Schedule B (payments in respect of hospital charges relating to special procedures), Schedule C (payments in respect of consultants' fees (in-patient and day-patient services)), or Schedule D (payments in respect of hospital charges and consultants' fees (out-patient services)), as appropriate and as amended from time to time.
- (3) If all registered undertakings combined have been required to make prescribed minimum payments in relation to in-patient services provided to an insured person in respect of any psychiatric condition other than a condition described in subarticle (4) for a total of 100 in-patient days in a calendar year then notwithstanding the provisions of subarticles (1) and (2) a registered undertaking shall not be required to make any further such payments in respect of the same calendar year.
- (4) If all registered undertakings combined have been required to make prescribed minimum payments in relation to in-patient services provided to an insured person constituting treatment for alcoholism, drug or other substance abuse for a total of 91 in-patient days in any continuous period of 5 years then notwithstanding the provisions of subarticles (1), (2) and (3) a registered undertaking shall not be required to make any further such payments in respect of that 5 year period.
- (5) A registered undertaking shall not be required to make any prescribed minimum payments in respect of prescribed health services provided by a registered nursing home unless—
- (i) such prescribed health services are provided to an insured person immediately following the provision of in-patient services to such insured person; and
- (ii) the registered undertaking has received and approved, prior to the admission of the insured person to the registered nursing home, a certificate from the hospital consultant responsible for the treatment of the insured person, in such form as may be specified by the undertaking, to the effect that the prescribed health services to be provided by the registered nursing home are appropriate health services.
- (6) If all registered undertakings combined have been required to make prescribed minimum payments in respect of in-patient and day patient services provided to an insured person for a total of 180 days (in-patient and day-patient days combined) in a calendar year then notwithstanding the provisions of subarticles (1), (2), (3) and (4), a registered undertaking shall not be required to make any further prescribed minimum payments in respect of in-patient or day-patient services provided to such insured person.
- (7) This article applies subject to article 9.
PART III LIMITATION ON TYPE OF HEALTH SERVICES FOR WHICH PAYMENT MUST BE MADE
6.
(1) A registered undertaking shall not be required to make the prescribed minimum payments specified in sub-paragraphs (1), (2), (3) or (6) of paragraph 1 of Schedule A in respect of in-patient services if, on receipt of appropriate medical advice, the undertaking determines that the health services provided to the insured person could have been provided as day-patient services or out-patient services rather than in-patient services. In such circumstances if the undertaking determines that—
( a ) the relevant health services should have been day-patient services, the prescribed minimum payments may be the amounts specified in sub-paragraphs (4) or (5) of paragraph 1 of Schedule A, as appropriate; or
( b ) the relevant health services should have been out-patient services and if the relevant health services were provided in a private hospital, the prescribed minimum payments may be the amounts specified in Tables D.1 and D.2 of Schedule D, as appropriate.
- (2) A registered undertaking shall not be required to make the prescribed minimum payments specified in sub-paragraphs (4) or (5) of paragraph 1 of Schedule A in respect of day-patient services if, on receipt of appropriate medical advice, the undertaking determines that the health services provided to the insured person could have been provided as out-patient services rather than day-patient services. In such circumstances, and if the relevant health services were provided in a private hospital, the undertaking may make the prescribed minimum payments specified in Tables D.1 and D.2 of Schedule D.
- (3) If the health services provided to an insured person were not prescribed health services, a registered undertaking shall not be required to make any payment.
- (4) This article applies subject to article 9.
PART IV LIMITATIONS ON PRESCRIBED MINIMUM PAYMENTS IN RESPECT OF OUT-PATIENT SERVICES
7.
Notwithstanding articles 5 and 6, the total amount which must be paid by a registered undertaking in respect of out-patient services listed in Table D.1 of Schedule D (and all in-patient services and day-patient services in respect of which the prescribed minimum payment is, in accordance with subarticle 1(b) or subarticle (2) of article 6, determined by reference to Table D.1 of Schedule D) provided to all insured persons named in a health insurance contract in a benefit year shall be the total of the prescribed minimum payments determined by reference to Table D.1 of Schedule D provided that in the case where the health insurance contract—
( a ) relates to only one insured person that total amount shall be subject to a maximum of £650 and shall also be subject to an excess of £150, and
( b ) relates to more than one insured person that total amount shall be subject to a maximum of £1,300 and shall also be subject to an excess of £300.
PART V HEALTH SERVICES PROVIDED DURING THE PRESCRIBED WAITING PERIODS
8.
(1) Notwithstanding articles 5 and 6, a registered undertaking shall not be required to make a prescribed minimum payment in respect of prescribed health services provided to an insured person during the initial waiting period applicable to such a person, except where such prescribed health services are provided as a result of accident or injury to the insured person which occurred while that person was an insured person.
- (2) Notwithstanding articles 5 and 6, a registered undertaking shall not be required to make a prescribed minimum payment in respect of prescribed health services provided to an insured person during a pre-existing condition waiting period except where such prescribed health services do not relate to the condition which gave rise to that waiting period.
PART VI HEALTH SERVICES PROVIDED BY A PARTICULAR HEALTH SERVICE PROVIDER
9.
Where:
( a ) the provision of specified prescribed health services by a health service provider is not covered under the terms of a contract; and
( b ) the specified prescribed health services concerned could have been provided by a health service provider who is specified in that contract,
then notwithstanding articles 5 and 6, a registered undertaking shall not be required to make a prescribed minimum payment in respect of those prescribed health services.
PART VII MISCELLANEOUS PROVISIONS
10.
Notwithstanding articles 5 and 6, the total amount of prescribed minimum benefits payable by a registered undertaking in respect of the provision of prescribed health services to an insured person may be reduced by any corresponding third party recoveries which that registered undertaking has made in respect of those services.
11.
The prescribed minimum benefit which a registered undertaking is required to make under sub-paragraphs (3), (5) and (6) of paragraph 1 of Schedule A may be reduced to take into account the effect of any discount, overall limit or like reduction which has been agreed between that registered undertaking and the private hospital concerned.
12.
If a person to whom prescribed health services are provided is an insured person under more than one health insurance contract (other than any such contract which relates solely to ancillary health services and/or solely to the public hospital daily in-patient charges made under Regulations pursuant to Section 53 of the Health Act, 1970 ) the prescribed minimum payment to be made under each such health insurance contract in respect of such prescribed health services shall be the prescribed minimum payment determined in accordance with articles 5 to 11 divided by the total number of such health insurance contracts.
13.
The prescribed minimum payment may be made by the registered undertaking either to the health services provider or to the person who effected the health insurance contract under which the recipient of the prescribed health services is an insured person, depending upon the terms of the contract, and subject always to the requirements of section 15 of the Finance Act, 1987 .
14.
Notwithstanding articles 5 and 6, in the case of a restricted membership undertaking lawfully carrying on health insurance business in the State on the 30th day of June 1994 and covering less than 1,500 insured persons at that date, the prescribed minimum payments (and where relevant the total periods over which such payments are required to be made) for the prescribed health services specified under the said articles shall be subject to a maximum of the lowest level of cover provided for those services under the rules of that undertaking at the date on which these regulations shall come into operation.
15.
Notwithstanding sub-articles (3) and (4) of article 5, in the case of a restricted membership undertaking lawfully carrying on health insurance business in the State on the 30th day of June 1994 and covering 1,500 or more insured persons at that date, the prescribed minimum payments (and where relevant the total periods over which such payments are required to be made) for the prescribed health services specified under the said sub-articles shall be subject to a maximum of the lowest level of cover provided for those services under the rules of that undertaking at the date on which these regulations shall come into operation.
Schedule A
-Hospital Charges (In-patient and Day-patient Services)
The prescribed minimum payments in this Schedule relate to prescribed health services (other than those special procedures listed in Table B.1 of Schedule B of these Regulations) provided by a private hospital, and prescribed health services provided by a publicly-funded hospital or a registered nursing home, to an insured person as in-patient services or day-patient services. Prescribed minimum payments shall be determined as follows
| In respect of: | In respect of: | Prescribed Minimum Payment | Prescribed Minimum Payment | Prescribed Minimum Payment |
| 1. | Prescribed health services which are in-patient services provided by a publicly-funded hospital while the insured person was maintained in accommodation other than private hospital accommodation. | The public hospital daily in-patient charges made under regulations pursuant to Section 53 of the Health Act, 1970 . | The public hospital daily in-patient charges made under regulations pursuant to Section 53 of the Health Act, 1970 . | The public hospital daily in-patient charges made under regulations pursuant to Section 53 of the Health Act, 1970 . |
| 2. | Prescribed health services which are in-patient services provided by a publicly-funded hospital while the insured person was maintained in private hospital accommodation. | The amount of the charge payable under Section 55 of the Health Act 1970 , reduced by 40 in the case of charges arising in respect of a period or periods during which the insured person was accommodated in a single room, plus the amount of the public hospital daily in-patient charges made under regulations pursuant to %Section 53 of the Health Act, 1970 . | The amount of the charge payable under Section 55 of the Health Act 1970 , reduced by 40 in the case of charges arising in respect of a period or periods during which the insured person was accommodated in a single room, plus the amount of the public hospital daily in-patient charges made under regulations pursuant to %Section 53 of the Health Act, 1970 . | The amount of the charge payable under Section 55 of the Health Act 1970 , reduced by 40 in the case of charges arising in respect of a period or periods during which the insured person was accommodated in a single room, plus the amount of the public hospital daily in-patient charges made under regulations pursuant to %Section 53 of the Health Act, 1970 . |
| 3. | Prescribed health services (other than special procedures listed in Table B.1 of Schedule B) which are in-patient services provided by a private hospital, other than a private psychiatric hospital. | The lesser of: (a) £135 for each in-patient day; or (b) 60% of (i) the charge made by the private hospital; less (ii) £40 for each day during which the insured person was accommodated in a single room | The lesser of: (a) £135 for each in-patient day; or (b) 60% of (i) the charge made by the private hospital; less (ii) £40 for each day during which the insured person was accommodated in a single room | The lesser of: (a) £135 for each in-patient day; or (b) 60% of (i) the charge made by the private hospital; less (ii) £40 for each day during which the insured person was accommodated in a single room |
| 4. | Prescribed health services which are day-patient services provided by a publicly-funded hospital while the insured person was maintained in private hospital accommodation. | The amount of the charge payable under Section 55 of the Health Act, 1970 . | The amount of the charge payable under Section 55 of the Health Act, 1970 . | The amount of the charge payable under Section 55 of the Health Act, 1970 . |
| 5. | Prescribed health services which are day-patient services provided by a private hospital, other than a private psychiatric hospital. | The lesser of: (a) £135 for each day patient day; or (b) 60% of (i)the charge made by the private hospital; less(ii) £40 for each day during which the insured person was accommodated in a single room. | The lesser of: (a) £135 for each day patient day; or (b) 60% of (i)the charge made by the private hospital; less(ii) £40 for each day during which the insured person was accommodated in a single room. | The lesser of: (a) £135 for each day patient day; or (b) 60% of (i)the charge made by the private hospital; less(ii) £40 for each day during which the insured person was accommodated in a single room. |
| 6. | Prescribed health services which are in-patient services provided by a private psychiatric hospital. | The lesser of: (a) £65 for each in-patient day; or (b) 60% of the charge made by that hospital; | The lesser of: (a) £65 for each in-patient day; or (b) 60% of the charge made by that hospital; | The lesser of: (a) £65 for each in-patient day; or (b) 60% of the charge made by that hospital; |
| 7. | Prescribed health services which are in-patient services provided by a registered nursing home. | £20 per day, subject to a maximum of £280 respect of any particular continuous period during which an insured person was in receipt of such prescribed health services. | £20 per day, subject to a maximum of £280 respect of any particular continuous period during which an insured person was in receipt of such prescribed health services. | £20 per day, subject to a maximum of £280 respect of any particular continuous period during which an insured person was in receipt of such prescribed health services. |
The amount determined under paragraph I in respect of hospital charges relating to childbirth by means of a normal vaginal delivery shall be £300.
Schedule B
— Special Procedures
The prescribed minimum payments in this Schedule relate to prescribed health services which are the special procedures listed herein and which are provided by a private hospital to an insured person while that person is maintained in private hospital accommodation for in-patient services orday-patient services.
The prescribed minimum payment shall be 35% of the procedure benefit derived from Table B.1 of this Schedule.
TABLE B.1
| Procedure | Procedure Description | Procedure |
| Code | Benefit | |
| (£) | ||
| 5801 | Exploration of mediastinum | 940 |
| 5802 | Endoscopic extirpation of lesion of mediastinum | 940 |
| 5803 | Diagnostic endoscopic examination of mediastinum | 940 |
| 6675 | Angiogram (direct puncture, single vessel study, brachial, femoral) | 1,238 |
| 5945 | Cardiac catheterisation with digital subtraction angiography | 1,270 |
| 5080 | Cardiac catheterisation (left, right or both sides) | 1,306 |
| 5085 | Cardiac angiography (left, right or both sides) | 1,306 |
| 5090 | Cardiac catheterisation and cardiac angiography combined | 1,306 |
| 2676 | Vitroctomy | 2,354 |
| 5520 | Valve shunt (hydrocephalus) - (Brain and Meninges) | 2,756 |
| 5730 | Cervical disc, partial excision of or fusion | 2,866 |
| 5862 | Cardiac Pacemaker System introduced through vein (Single Chamber) | 3,032 |
| 5067 | Cardiac Pacemaker System introduced through vein (Dual Chamber) | 3,032 |
| 5068 | Insertion of antitachycardia pacemaker | 3,032 |
| 5069 | Insertion of automatic implantation cardioverter/defibrillator | 3,032 |
| 5525 | Valve shunt revision - (Brain & Meninges) | 3,032 |
| 5660 | Craniotomy | 3,721 |
| 3595 | Spinal fusion anterior & posterior | 4,410 |
| 3596 | Spinal fusion, in scoliosis spine, anterior and posterior | 4,410 |
| 3601 | Spinal fusion with instrumentation | 4,410 |
| 5101 | Angioplasty (Coronary) | 4,410 |
| 5962 | Plastic repair of aorta (Coarctation/Interrupted Aortic Arch) | 5,181 |
| 5957 | Revision repair of coarctation of aorta | 5,181 |
| 5893 | Open Operations on pulmonary artery | 5,209 |
| 5735 | Cervical spondylosis, laminectomy, etc. | 5,435 |
| 5480 | Posterior fossa tumours, removal of | 5,512 |
| 5470 | Pituitary gland, hypophysectomy | 5,677 |
| 5075 | Blalock Operation | 5,788 |
| 5870 | Myocardial aneurysmyotomy | 5,788 |
| 5811 | Atrial inversion for transposition of great vessels | 5,788 |
| 5812 | Other correction of transposition of great vessels | 5,788 |
| 5814 | Closure of defect of atrioventricular septum using dual prosthetic patch | 5,788 |
| 5817 | Closure of defect of interventricular septum | 5,788 |
| 5818 | Planned repair of post infraction ventricular septal defect | 5,788 |
| 5819 | Emergency repair of post infraction ventricular septal defect | 5,788 |
| 5958 | Revision closure of defect of intra-ventricular septum | 5,788 |
| 5813 | Correction of total anomalous pulmonary venous connection | 5,788 |
| 5872 | Excision of pericardium | 5,788 |
| 5809 | Correction of tetralogy of fallot | 5,788 |
| 5871 | Open correction of patent ductus arteriosus | 5,788 |
| 5882 | Closed correction of patent ductus arteriosus | 5,788 |
| 5875 | Shoulder replacement prosthesis | 6,107 |
| 5555 | Acoustic neuroma, removal of | 6,173 |
| 1246 | Arterial bypass, popliteal artery | 6,284 |
| 5865 | Repair of ascending aortic aneurysm | 6,284 |
| 3300 | Arthroplasty (Forearm & Elbow) | 7,186 |
| 5942 | Lobectomy of Lung (including excision of segment) | 7,717 |
| 5831 | Plastic repair of mitral valve | 8,268 |
| 5833 | Replacement of tricuspid valve (includes valvuloplasty) | 8,268 |
| 5855 | Annuloplasty | 8,268 |
| 5839 | Double valves | 8,268 |
| 5842 | Triple valves | 8,268 |
| 5843 | Valve and grafts | 8,268 |
| 5959 | Revision of valve surgery | 8,268 |
| 5816 | Closure of defect of interatrial septum | 8,599 |
| 5821 | Other open operations on the septum of the heart | 8,599 |
| 5824 | Refashioning of atrium (Ebstein's) | 8,599 |
| 5826 | Operations on wall of atrium | 8,599 |
| 5832 | Replacement of aortic valve (includes valvuloplasty) | 9,922 |
| 5836 | Open Valvotomy | 9,922 |
| 5055 | Aortic endarterectomy | 9,922 |
| 5829 | Replacement of mitral valve (includes valvuloplasty) | 9,922 |
| 5844 | Saphenous vein graft bypass for coronary artery(ies) | 9,922 |
| 5846 | Autograft bypass for coronary artery(ies) | 9,922 |
| 5847 | Allograft bypass for coronary artery(ies) | 9,922 |
| 5848 | Prosthetic bypass for coronary artery(ies) | 9,922 |
| 5849 | Connection of mammary artery(ies) to coronary artery(ies) | 9,922 |
| 5851 | Connection of other thoracic artery(ies) to coronary artery(ies) | 9,922 |
| 5852 | Correction of anomalous coronary arteries | 9,922 |
| 5853 | Other open operation(s) on coronary artery(ies) | 9,922 |
| 5904 | Revision of prosthesis of aorta | 9,922 |
| 5956 | Revision coronary artery surgery | 9,922 |
| 5099 | Coronary artery bypass grafts and angiogram | 10,970 |
| 4283 | Allogeneic bone marrow transplantation, (complete procedure) | 27,560 |
| 4284 | Autologous bone marrow transplantation (complete procedure) | 27,560 |
Schedule C
— Consultants' Fees (In-Patient and Day-Patient Services)
Definitions
"consultant anaesthetist" means a hospital consultant whose designated speciality is anaesthesia;
"consultant pathologist" means a hospital consultant whose designated speciality is pathology;
"consultant radiologist" means a hospital consultant whose designated speciality is radiology;
"in-patient attendance" means a period during which a hospital consultant is responsible for the care of an insured person;
"linked procedure" means a linked surgical procedure, or a radiological procedure, which is carried out in conjunction with other radiological procedures;
"linked surgical procedure" means a surgical procedure which is performed in conjunction with other surgical procedures during the same theatre session;
"pathological procedure" means a service, treatment or procedure listed in Table C.4 of this Schedule;
"radiological procedure" means a service, treatment or procedure listed in Table C.3 of this Schedule and therapeutic/invasive procedures listed in Table C.2 of this Schedule;
"surgical procedure" means a service, treatment or procedure listed in Table C.2 of this Schedule.
The prescribed minimum payments in this Schedule relate to prescribed health services which are provided by a hospital consultant to an insured person for in-patient services or day-patient services while that person is maintained in private hospital accommodation or in a recognised intensive care unit.
The prescribed minimum payment in respect of the participation by a consultant anaesthetist in a surgical or radiological procedure, that procedure not being an integral part of another more serious procedure performed at the same time, shall be the anaesthetic procedure benefit as set out in Tables C.2 or C.3 respectively of this Schedule except that if that procedure is a linked procedure the prescribed minimum payment shall be that anaesthetic procedure benefit multiplied by a value derived from the following table
| Value | |
| For the linked procedure which has the greatest anaesthetic procedure benefit of all related linked procedures | 1.00 |
| For all other linked procedures | 0.00 |
The prescribed minimum payment in respect of a period of in-patient attendance by a consultant anaesthetist on an insured person in a recognised intensive care unit shall be—
- (a) determined in accordance with Table C.1 of this Schedule if that attendance arises in other than a post surgical context; and
- (b) £45 if that attendance arises in a post surgical context provided that this payment shall only fall due for care on or after the third post operative day.
The prescribed minimum payment in respect of in-patient attendance by a hospital consultant, other than a consultant anaesthetist, shall be the in-patient attendance benefit determined in accordance with Table C.1 of this Schedule except that no payment shall fall due if that attendance arises:—
- (a) in conjunction with a surgical procedure performed by that hospital consultant other than as provided under paragraph 7; or
- (b) during a stay in a private psychiatric hospital.
The prescribed minimum payment in respect of an in-patient consultation is £33 and falls due when the admitting hospital consultant responsible for the care of an insured person refers that person to another hospital consultant for an opinion, other than where such a referral is a routine matter of policy, and shall be payable once only, irrespective of the number of examinations or visits required to form an opinion.
The prescribed minimum payment in respect of a surgical procedure performed by a hospital consultant, other than a consultant anaesthetist, that procedure not being an integral part of another procedure performed at the same time, shall be the surgical procedure benefit as set out in Table C.2 of this Schedule except that—
- (a) where that procedure is a linked surgical procedure the prescribed minimum payment shall be that surgical procedure benefit multiplied by a value derived from the following table—
| Value | |
| For the linked surgical procedure which has the greatest surgical procedure benefit of all related linked surgical procedures | 1.00 |
| For the linked surgical procedure which has the second greatest surgical procedure benefit of all related linked surgical procedures | 0.50 |
| For the linked surgical procedure which has the third greatest surgical procedure benefit of all related linked surgical procedures | 0.25 |
| For all other linked surgical procedures | 0.00 |
- (b) notwithstanding subsection (a) herein where that procedure is designated as "I.P." and is a linked surgical procedure no prescribed minimum payment shall fall due;
- (c) where that procedure is designated "Diagnostic" the prescribed minimum payment shall be—
- (i) if the insured person is maintained in private hospital accommodation for a period of three in-patient days or less, the greater of the surgical procedure benefit and the in-patient attendance benefit for that period determined in accordance with Table C.1; and
- (ii) if the insured person is maintained in private hospital accommodation for a period of more than three in-patient days, the sum of the surgical procedure benefit and the in-patient attendance benefit for that period.
- (d) Notwithstanding subsection (a) herein where that procedure is designated as "*" and other surgical procedures so designated are carried out during the same in-patient stay or day-patient day the prescribed minimum payment shall be that surgical procedure benefit multiplied by a value derived from the following table:
| Value | |
| For the surgical procedure which has the greatest surgical procedure benefit of all such designated surgical procedures. | 1.00 |
| For all other such designated surgical procedures | 0.00 |
The prescribed minimum payment in respect of a radiological procedure performed by a consultant radiologist, that procedure not being an integral part of another more serious procedure performed at the same time, shall be the radiological procedure benefit as set out in Table C.3 of this Schedule or the surgical procedure benefit set out in Table C.2 of this Schedule as appropriate, except that no payment for Magnetic Resonance Imaging shall fall due other than in respect of the following clinical indications:-
| Suspected Multiple Sclerosis after appropriate clinical screening | Suspected Multiple Sclerosis after appropriate clinical screening | Suspected Multiple Sclerosis after appropriate clinical screening |
| Suspect leukodystrophies | Suspect leukodystrophies | Suspect leukodystrophies |
| Vascular malformations | Vascular malformations | Vascular malformations |
| Epilepsy - Temporal lobe type | Epilepsy - Temporal lobe type | Epilepsy - Temporal lobe type |
| Suspect posterior fossa tumours | Suspect posterior fossa tumours | Suspect posterior fossa tumours |
| IAMS - suspect acoustic neuromas with audiology screening | IAMS - suspect acoustic neuromas with audiology screening | IAMS - suspect acoustic neuromas with audiology screening |
| Pituitary - after Computerised Tomography screen | Pituitary - after Computerised Tomography screen | Pituitary - after Computerised Tomography screen |
| Lower cranial nerve palsies, i.e. meningeal processes | Lower cranial nerve palsies, i.e. meningeal processes | Lower cranial nerve palsies, i.e. meningeal processes |
| Encephalitis | Encephalitis | Encephalitis |
| Spine | - | Post-operative failed back |
| - | Spinal cord compression (acute) | |
| - | Cervical radiculopathy with | |
| neurological signs | ||
| - | Spinal dysraphism and | |
| associated abnormalities | ||
| - | Patients having had previous | |
| Computerised Tomography or | ||
| myelogram which was in | ||
| conflict with the patient's | ||
| symptoms/signs | ||
| - | Intrinsic spinal cord disease | |
| including cervical myelopathy | ||
| Bone Tumours | - | Staging of primary malignant |
| bone tumours | ||
| - | Soft tissue tumours for dialnosis | |
| and staging | ||
| Shoulder Joint | - | Rotator cuff tears |
| Knee Joint | - | Assessment of menisceal tears, |
| cruciate ligament injuries and | ||
| losse bodies (but only when | ||
| clinically indicated in | ||
| preference to an arthroscopy) | ||
| Abdomen | - | Possible assessment of patients |
| with known liver tumours for | ||
| resection (previous dynamic | ||
| Computerised Tomography and ultrasound scans will have to have been performed) | ||
| Assessment of the inferior vena cave in patients with known solid renal tumours |
The prescribed minimum payment in respect of a pathological procedure performed by a consultant pathologist shall be the procedure benefit as set out in Table C.4 of this Schedule, except that for each hospital admission a payment shall be due only once for any of the procedures comprising a designated group. A designated group is any of the following groups of pathological procedures:
- (a) Category 1 and 1(A) combined
- (b) Category 5(A)
- (c) Category 8(A)
- (d) Category 9
In respect of each episode of radiotherapy the prescribed minimum payment to a consultant anaesthetist shall be £69 and the prescribed minimum payment to a hospital consultant, other than a consultant anaesthetist, shall be £50.
In respect of surgical procedures coded from 1636 to 1639 on Table C.2 of this Schedule only an in-patient attendance benefit determined in accordance with Table C.1 of this Schedule shall be payable if these are performed other than while an insured person is in receipt of day-patient services.
Table C.1
| Period of Attendance | In Patient Attendance Benefit |
| 1 day | £ 50 |
| 2 days | £ 50 |
| 3 days | £ 50 |
| 4 days | £ 50 |
| 5 days | £ 50 |
| 6 days | £ 50 |
| 7 days | £ 59 |
| 8 days | £ 67 |
| 9 days | £ 75 |
| 10 days | £ 84 |
| 11 days | £ 92 |
| 12 days | £ 100 |
| 13 days | £ 109 |
| 14 days | £ 117 |
| 15 days | £125 |
| Periods in excess of 15 days | £8 for each day in excess of 15 days |
| plus £125 |
TABLE C.2
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