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S.I. No. 83/1996 - Health Insurance Act, 1994 (Minimum Benefit) Regulations, 1996

Type Statutory Instrument
Publication 1996-03-28
Last updated 2015-03-17
State In force superseded text
Text As published
Source Irish Statute Book
articles 15

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

Reform history JSON API

TABLE C.3
Code Radiological Procedure Procedure Benefit IR£ Procedure Benefit IR£
Radiological Anaesthetic
ALIMENTARY TRACT
6000 Plain film, abdomen 11
6001 Plain film abdomen complete, including decubitus and/or erect views 22
SINGLE CONTRAST STUDIES(BARIUM OR WATER SOLUBLE)
6005 Ba. enema 33
6015 Ba. meal 22
6020 Ba. meal and follow through or small bowel study 33
6025 Ba. swallow 22
6060 Small bowel enema 46
6066 Defaecating proctogram 64
DOUBLE CONTRAST STUDIES
6010 Ba. enema, double contrast 46
6011 Ba. enema, therapeutic forreduction of intussusception 64
6021 Ba. meal (double contrast) 33
6030 Ba. swallow and meal 33
6035 Cholecystogram 22
6040 Screening crosbie capsule 22
6045 Screening diaphragm 22
6070 T - tube cholangiogram 22
6055 IV cholangiogram 33
CHEST
6075 Chest and ribs 11
6079 Chest, PA and lateral 11
6080 Chest, PA and lateral with flouroscopy 22
6085 Chest, PA lateral and apical- 11
6086 Chest, complete, minimum of four views 22
6090 Larynx 11
6095 Sternum and chest 11
6100 Thoracic inlet 11
C.T. SCANS
6102 Brain, without contrast 64 42
6103 Brain, with contrast material 100 42
6104 Orbit, sella or outer, middle, or inner ear, without contrast (except if done at same time as 6102 or 6103) 64 42
6106 Orbit, sella or outer, middle, or inner ear: with contrast material (except if done at same time as 6102 or 6103) 100 42
6107 Maxillofacial area, without contrast material (except if done at same time as 6102 or 6103) 64 42
6108 Maxillofacial area, with contrast material (except if done at same time as 6102 or 6103) 100 42
6109 Thorax, without contrast material 64 42
6112 Thorax, with contrast material 100 42
6111 CAT scanning for biopsy or drainage 100 42
6113 High resolution, lungs 100 42
6114 Abdomen, without contrast material 64 42
6116 Abdomen, with contrast material 100 42
6117 I.V. dynamic sequential scanning 100 42
6118 I.V. dynamic non-incremental scanning 100 42
SKELETAL
6224 C.T. of spine with contrast material 100 42
6226 Long bones 48 42
6227 Joints 64 42
6228 Spine 64 42
6229 Feet/Hands 64 42
JOINTS AND LONG BONES
6115 Ankle 11
6119 Ankle, complete, minimum of three views including inversion/eversion 22
6121 Acromioclavicular joints,bilateral, with or without weight distraction 22
6122 Knee, complete, including oblique(s), and tunnel, and/or patellar and/or standing views 22
--- --- --- ---
Code Radiological Procedure Procedure Benefit IR£ Procedure Benefit IR£
Radiological Anaesthetic
6120 Bone age 22
6125 Calcaneum 11
6130 Clavicle 11
6135 Elbow 11
6140 Femur 11
6145 Finger/toe 11
6150 Foot 11
6155 Hand 11
6160 Hip 11
6165 Humerus 11
6170 Knee 11
6175 Limb length/orthopaedicmeasurement 22
6180 Pelvis (inc. hips) 11
6185 Radius and ulna 11
6190 Sacro-lliac joints 11
6195 Scaphoid 11
6200 Scapula 11
6205 Scoliosis series 11
6210 Shoulder 11
6215 Sternoclavicular joint 11
6220 Tibia and fibula 11
6225 Wrist 11
MAGNETIC RESONANCE IMAGING (M.R.I.)
6230 Magnetic resonance imaging 73 42
6231 Magnetic resonance imaging with contrast enhancement 100 42
NUCLEAR MEDICINE IMAGING
MUSCULO SKELETAL SYSTEM
6270 Limited joint scan 22
6275 Multiple joint scan 33
6280 Sacro-iliac joint uptake 22
6290 Partial body bone scan 22
6295 Whole body bone scan 33
6300 3—Phase bone scan 33
6305 SPECT (tomo) bone scan 46
6340 Gallium scan 33
CENTRAL NERVOUS SYSTEM
6310 Static brain 22
6315 Dynamic brain scan 33
6320 SPECT brain (CBF, ceretec, ECD, blood pool) 46
6325 Static - planar cysternogram 45
6330 SPECT cysternogram 64
CARDIOVASCULAR SYSTEM
6260 Aortogram 22
6265 Arteriogram 22
6360 Angiocardiogram (1st pass) 33
6365 Blood pool scan (MUGA) 46
6370 Exercise blood pool scan (EX. MUGA) 73
6375 Dipyridamole thallium 73
6380 Exercise thallium 73
6385 P.Y.P. infarct scan 33
6390 Anti-myosin scan 33
6395 SPECT anti-myosin scan 46
6400 SPECT thallium 73
6570 Venogram, unilateral 33
6575 Venogram, bilateral 46
GENITOURINARY SYSTEM
6415 Renogram 33
6420 Combined renogram/GFR 46
6425 Captopril renogram 46
6430 Diuretic renogram 46
--- --- --- ---
Code Radiological Procedure Procedure Benefit IR£ Procedure Benefit IR£
Radiological Anaesthetic
6435 DMSA renal scan 33
6440 Micturating cystogram 46
6445 SPECT DMSA renal scan 46
6550 Testicular scan 33
GASTROINTESTINAL SYSTEM
6285 Abdominal scan (Meckel's) 22
6335 Duodenal/gastric reflux 22
6345 Gastric emptying 33
6350 G.I. bleed 33
6355 G.F.R. (Tc-99m DTPA, Cr-51 EDTA) 22
6525 Oesophageal motility study 33
6450 Colloid liver scan 33
6455 HIDA liver scan 33
6460 SPECT liver scan 46
6465 Hepatic (liver) blood flow 33
6540 Salivary scan 22
6545 Spleen scan 22
RESPIRATORY SYSTEM
6470 Aerosol lung scan 33
6475 Gallium lung scan 33
6480 Lung perfusion scan 33
6485 Lung ventilation scan 33
6490 SPECT lung scan 46
6495 Ventilation/perfusion lung scan 64
ENDOCRINE SYSTEM
6410 Whole body iodine scan 33
6520 MIBG scan 46
6530 Parathyroid scan 33
6555 Technetium scan of thyroid 22
6560 Iodine scan of thyroid 22
6565 Thallium scan of thyroid 22
OTHER SCANS
6255 Cholesterol scan 33
6285 Bile salt malabsorption scan 33
6500 Lymphoscintigram 33
6505 Marrow scan 46
6240 White blood cell scan (WBC) 33
6510 Monoclonal antibody scan-SPECT 46
6515 Monoclonal antibody scan - static 33
6535 Platelet scan 33
NUCLEAR MEDICINE IN-VIVO NON-IMAGING TESTS
GENERAL TESTS
6566 Bile salt absorption (ScHCAT) 22
6567 Bile salt breath test 11
6568 Exchangeable body sodium 22
6569 1—131 Uptake (thyroid uptake) 22
6571 1—131 Therapy (thyroid therapy) 33
6572 Oestrogen receptor assay 11
6573 Red cell survival 22
6574 Red cell mass 11
6576 Schilling test (urine) 22
6577 Schilling test (whole body monitor) 22
6578 Total body water 22
6579 Total body potassium 22
OBSTETRIC
6580 Abdomen 11
6585 Pelvimetry 22
SKULL
6590 Facial bones 11
6595 Foramina optic 11
--- --- --- ---
Code Radiological Procedure Procedure Benefit IR£ Procedure Benefit IR£
Radiological Anaesthetic
6600 Internal auditory canals 11
6605 Mandible 11
6610 Mastoid 11
6615 Maxilla 11
6620 Nasal bones 11
6625 Nasal sinuses 11
6630 Orbital views 11
6635 Parotid gland 11
6640 Pituitary fossa 11
6645 Skull 11
6650 Temporomandibular joint 22
SOFT TISSUES
6655 F.B. in eye and localisation 22
6660 Mammogram 33
6665 Soft tissue neck 11
SPECIAL PROCEDURES
6675 Angiogram (direct puncture, single vessel study, branchial, femoral) includes introduction of needles or catheter injection of contrast media and necessary pre and post injection care specifically related to the injection procedure 73
6680 Angiogram (selective catheter,single/multiple vessel study,coeliac, mesenteric, renal, subclavian etc) includes introduction of needles/catheter injection of contrast media and necessary pre and post injection care specifically related to injection procedure 100
6681 Single selective carotid angiography and/or vertebral study 107
6682 Bilateral carotid angiography study 185
6683 Bilateral carotid angiography and vertebral study 278
6685 Aortogram (arch/TLA, etc.) 73
6690 Cavernosogram 73
6705 Facet arthrogram (single level) 46
6706 Hepatic needle puncture/ catheterisation for biliary procedures 100
6710 Portogram 64
6720 Orbital venogram 64
6721 Spinal arteriogram 334
6725 Splenoportogram 64
6730 Venous sampling - adrenal, parathyroid, renal, etc. 100
6735 Venogram, peripheral, single limb 46
6740 Venography (selective, catheter, single vessel study and/or venous sampling, I.V.C., S.V.C., adrenal, renal, hepatic) 100
SPINE
6745 Cervical 11
6750 Coccyx 11
6755 Complete spine 22
6760 Dorsal (thoracic) 11
6765 Lumbar 11
6770 Sacrum 11
6775 Scoliosis views 22
6780 Skeletal survey 33
TEETH
6785 Occlusal (Intra-Oral) 11
6790 Pantomogram 22
6795 Tooth single 11
6800 Total Lower and Lower Jaw 22
ULTRASOUND
6805 Biliary 22
6810 Breast 22
6811 Chest 33
6825 Doppler (carotid, cerebral, peripheral, abdominal, renal, etc.) 46
6835 Eye 22
6840 Hip 33
6841 Knee 33
--- --- --- ---
Code Radiological Procedure Procedure Benefit IR£ Procedure Benefit IR£
Radiological Anaesthetic
6845 Obstetrical 22
6846 Obstetrical (with full foetal assessment) 46
6850 Paediatric cranial 46
6855 Pelvic 33
6856 Parotid gland 33
6857 Pleural space (for localisation) 33
6860 Prostate - transrectal 46
6865 Renal (kidneys) 33
6870 Shoulder 33
6875 Testicular 33
6880 Transvaginal 46
6885 Thyroid 22
6890 Upper abdominal (includes liver, pancreas, aorta and kidneys) 46
6895 Ultrasound guidance during investigations or therapeutic procedure 64
URINARY TRACT
6905 Cystogram 22
6910 I.V.P. 33
6915 Micturating cystogram 33
6920 Straight renal tract (KUB) 11
6925 Urethrogram 33
6930 Vesiculogram 33
OTHERS
6950 Antegrade pyelogram 46
6955 Arthrogram 46
6960 Bronchial brushing 73
6965 Bronchogram 46
6970 Dacrocystogram 33
6975 Discogram 64
6985 Hysterosalpingogram 33
6990 Laryngogram 33
6995 Lymphangiogram 100
7000 Myelogram 64
7005 Myelogram (direct lateral puncture, thoracic or cervical) 100
7010 Needle biopsy (trans-thoracic, bone, abdominal) 64
7011 Nephrostogram 46
7020 Percutaneous transhepaticcholangiogram 64
7025 Per-operative cholangiogram 33
7034 Imaging supervision, interpretation and report for injection procedures during cardiac catheterisation; ventricular and/or atrial angiography 27
7036 Radiological guidance during investigations or therapeutic procedure (use code 7034 for cardiology procedures) 64
7037 Radiological guidance for mammographic wire guided biopsy 27
7040 Retrograde pyelogram 33
7051 Sialgram, Parotid 33
7052 Sialogram, Submandibular 33
7055 Sinogram 22
7065 Tomograms (+ area films) 22
7070 Ventriculogram 64
THERAPEUTIC/INVASIVE PROCEDURES
Please note that therapeutic/invasive procedures are listed in Table C.2

TABLE C.4
Code Pathological Investigation Procedure Benefit IR£
8900 CATEGORY 1 13
HAEMATOLOGY
APTT, PT+INR, Blood Gp+uncomplicated crossmatch. Cold Aggluts,
FBC without film, HbH, (in)/direct Coomb's test. Monospot.
BIOCHEMISTRY
Single analytes
IMMUNOLOGY
a-1—AT, C3, C4, lgs, RA Screen, Thyroid Abs
MICROBIOLOGY
Pregnancy test. Stool O/B
CATEGORY 1(A) 13
HAEMATOLOGY
9230 Coag. Factor Assay
8930 Ferritin
8910 Fibrinogen
8935 Iron
9220 RBC autohaemolysis
9215 RBC osm frag.
9225 Platelet Aggregation
8920 Protein C
BIOCHEMISTRY
9185 All nuclear medicine in-vitro investigations(except for those investigations listed in category 5)
All Profiles:
Biochemical Investigations of,
9000 -Renal (one or more)
9005 -Hepatic (one or more)
9010 -Cardiac (one or more)
9015 -Thyroid (one or more)
9020 -Bone(not PTH) (one or more)
9025 -Lipids (one or more)
9310 Biochemistry of hypertension
9165 GTT
9165 HbA1C
9166 Drug levels (including RIA)
9167 HPLC
IMMUNOLOGY
9285 Allurgens
9168 Caeruloplasmin
9169 CRP
9171 Cryoglobulins
9275 IgE
9172 PFB
8945 Streptolysin
8936 Transferrin
ENDICRINOLOGY
8937 Hormone Levels (except for those investigations listed in Category 5)
CATEGORY 3 5
HAEMATOLOGY
8905 FBC + manual film ± eosinophil count
9040 Kliehauer
8915 LAP
9035 Reticulocyte count
MICROBIOLOGY
8970 MSU + culture
9045 Stool O+P
BIOCHEMISTRY
9030 Sweat investigation
IMMUNOLOGY
9050 IF - single antibody e.g. ANF (except if this investigation gives rise to the investigations listed in Categories 4 or 5)
CATEGORY 4 10
BIOCHEMISTRY
9160 All electrophoresis|serum, lipoprotein, urine
9175 CSF including oligoclonal bands
9180 Myeloma Screen including electrophoresis
9181 Trace metals
9182 Vits A & E
HAEMATOLOGY
9205 Ab indentification (transfusion)
9200 Bleeding time
8925 HbA2
9210 Hb electrophoresis
9226 Thrombophilia screen -this consists of three or more of the following items:
Antithrombin 3, protein C, protein S. factor 7, factor 12, platelet aggregation (spontaneous, second wave of aggregation with weak ADP, and response to dilutions of epinephrine)
8940 U. haemosiderin
9507 Flow cytometry
MICROBIOLOGY
9100 Interpretive review of culture result from wounds, joint fluids, sputum, intestine and other body sites including TB Culture
9385 Interpretative review of viral, bacterial or fungal sarology or viral culture
9202 Antibiotic assay }
9203 MBC } maximum payable, any combination, three
9204 MIC } per claim
9206 Cidal levels
9207 Toxin levels
IMMUNOLOGY
9221 ANCA-for single antibody
9222 AGBM-for single antibody
9280 Gel electrophoresis
9223 HIV, VD or Hepatitis screen
9224 Teicoic acid
9228 Cardiolipin
9227 CH50— functional assay
ALL DISCIPLINES
9694 Gene rearrangement studies
CATEGORY 5 (A) 20
BIOCHEMISTRY
9301 ·Diabetic KA/hyperosmolar coma
9302 ·Acute Renal failure
9303 · Acute hepatic failure
9306 ·Porphyria investigation
9308 ·Diabetes insipidus
ENDOCRINOLOGY
9304 ·Dynamic endocrine function tests (IST. Synact, TRH, Dex supp)
9307 ·Full endocrinological investigation of infertility
9309 ·Full investigations for inborn errors of metabolism in paediatric patients.
Benefit is only payable once per patient at time of initial investigation(diagnosis).
CATEGORY 5 (B) 20
HISTOPATHOLOGY
9360 Small (1-2 blocks) include cytology and neuropathology
MICROBIOLOGY
9381 Interpretive review of culture of CSF, blood
IMMUNOLOGY
9391 Infertility screen
9270 Paraprotein typing
9392 IF - autoantibody screen and/or DNA Abs and/or subtyping
9605 Immune complex assays (except for those investigations listed in Category 1)
All DISCIPLINES
9393 Polymerase chain reaction
CATEGORY 6 31
HAEMATOLOGY
9501 Marrow aspirate (except immunocytochemistry)
9502 Marrow trephine
HISTOPATHOLOGY
9530 Medium (e.g. description + 3—5 blocks)
9540 Colonoscopic series
9550 Clinical (i.e. non screening cytology (not including smear + section)
9535 Lymph node
9545 Parathyroid
IMMUNOLOGY
9503 HLA typing
MICROBIOLOGY
9504 Immunofluorescence
9506 Electron microscopy
CATEGORY 7 56
HISTOPATHOLOGY
9601 Liver, renal biopsies including special stains
9602 Fine needle aspiration biopsy, cell block and smear done together
9650 Large (5 + blocks and all major dissections)
9651 Breast screening, localisation segments with review of radiographs
HAEMATOLOGY
9603 Marrow aspirate and trephine done together
IMMUNOLOGY
9670 IF - frozen section direct or indirect
9610 WBC function tests
CATEGORY 8 (A) 73
HISTOPATHOLOGY
9693 Frozen section or rapid intraoperative diagnosis
9691 Immunohistology (include fluorescence)
CATEGORY 8 (B) 73
HAEMATOLOGY
9505 Immunocytochemistry
CATEGORY 9 30
9700 All tests associated with Obstetrics, including normal delivery, caesarean section and miscarriage

SCHEDULE D

—Out-Patient Services

1.

The prescribed minimum payments in this Schedule relate to prescribed health services which are provided by a private hospital or a hospital consultant to an insured person while that person is in receipt of services other than in-patient services or day-patient services. Prescribed minimum payments shall be determined under Table D.1 and D.2 as follows:—

TABLE D.1
In respect of Prescribed Minimum Payment Prescribed Minimum Payment Prescribed Minimum Payment Prescribed Minimum Payment
Private Hospital Private Hospital Hospital Consultant's Hospital Consultant's
Charges Charges Fees Fees
(Column 1) (Column 1) (Column 2) (Column 2)
1 Procedures and services carried out when the insured person is in receipt of out-patient services only. In respect of each procedure or In respect of each procedure or Either: Either:
group of procedures which gives rise to a payment under Column 2 of this table either: (a) £15 for each procedure or group of associated procedures listed in Table C.4 of Schedule C;or
(a) £6 for each procedure or group of associated procedures listed in Table C.4 of Schedule C;or (b) determined in accordance with Table C.3 of Schedule C for the procedures listed therein.
(b) £15 for each procedure or group of associated procedures listed in Table C.3 plus £90 in respect of a Magnetic Resonance Imaging procedure and £60 in respect of a Computerised Tomography procedure
2. Services provided by a hospital consultant excluding those services described in sub-paragraph 1 of this Table or in Table D.2. Not applicable. Not applicable. £30 for each consultation. £30 for each consultation.

TABLE D.2
In respect of Prescribed Minimum Payment Prescribed Minimum Payment
Private Hospital Hospital Consultant's
Charges Fees
(Column 1) (Column 2)
Procedures and services carried out when the insured person is in receipt of out-patient services only. £15 for each procedure or group of associated procedures which results in a payment arising under Column 2 of this Table. Determined in accordance with Table C.2 of Schedule C for the procedures listed therein.

GIVEN under the Official Seal of the Minister for Health this 28th

day of March, 1996.

Michael Noonan

Minister for Health

EXPLANATORY NOTE

(This note is not part of the Instrument and does not purport to be a legal interpretation).

These Regulations prescribe a minimum level of cover to be provided under health insurance contracts. They set out payments and periods applicable to the minimum level of benefits as regards hospital in-patient, day-patient and out-patient services and medical consultants' fees. They also set out minimum benefits applicable to maternity, convalescence and treatment for substance abuse. Provision is made for insurance undertakings to determine whether benefits are appropriate for payment as in-patient, day-patient or out-patient services. There are also excesses specified in relation to payment of benefit in respect of out-patient services. The Regulations set out the conditions relating to the payment of minimum benefit during waiting periods relating to first entry to health insurance and to pre-existing conditions. They provide for registered undertakings to specify health service providers who will make available health services for the purposes of payment of benefits under the Regulations. There are also a number of miscellaneous provisions.

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