S.I. No. 185 of 2005

SOCIAL WELFARE (CONSOLIDATED PAYMENTS PROVISIONS) (AMENDMENT) (No. 1) (TREATMENT BENEFIT) REGULATIONS 2005

S.I. No. 185 of 2005

SOCIAL WELFARE (CONSOLIDATED PAYMENTS PROVISIONS) (AMENDMENT) (No.1) (TREATMENT BENEFIT) REGULATIONS 2005

The Minister for Social and Family Affairs, in exercise of the powers conferred on him by sections 4 (as amended by section 12 of the Social Welfare (Miscellaneous Provisions) Act, 2002 ( No. 8 of 2002 )) and 117 of the Social Welfare (Consolidation) Act, 1993 (No. 27 of 1993), hereby makes the following Regulations:

Citation and construction.

1.  (1)  These Regulations may be cited as the Social Welfare (Consolidated Payments Provisions) (Amendment) (No.1) (Treatment Benefit) Regulations 2005.

(2)  These Regulations and the Social Welfare (Consolidated Payments Provisions) Regulations, 1994 to 2005 shall be construed together as one and may be cited as the Social Welfare (Consolidated Payments Provisions) Regulations 1994 to 2005.

Definitions.

2.  In these Regulations “the Principal Regulations” means the Social Welfare (Consolidated Payments Provisions) Regulations 1994 ( S.I. No. 417 of 1994 ).

Treatment benefit.

3.  Part II of the Principal Regulations is hereby amended by the substitution for Chapter 9 (amended by the Social Welfare (Consolidated Payments Provisions) (Amendment) (No.13) (Treatment Benefit) Regulations 1997 ( S.I. No. 530 of 1997 )) of the following Chapter:

“CHAPTER 9

Treatment Benefit

Interpretation.

67A.  In this Chapter

‘afocal goggles’ means goggles containing lenses with no optical power;

‘afocal sunglasses’ means sunglasses with no optical power;

‘appliance’ means an appliance -

(a)  provided as benefit under these Regulations including the repair thereof, and

(b)  which complies with Council Directive 93/42/EEC of 14 June 1993 concerning medical devices ;

‘audiologist’ means -

(a)  a member of the Irish Society of Hearing Aid Audiologists, or

(b)  a member of the British Society of Hearing Aid Audiology, or

(c)  a member of the British Society of Audiology Technicians Group having passed the B.A.A.A.T. examinations Parts 1 and 2, or

(d)  a member of the International Hearing Society having passed the National Board for Certification in Hearing Instrument Sciences (NBC-HIS) National Competency Examinations in the United States, or

(e)  a person who has an equivalent recognised qualification in Hearing Aid Audiology, or

(f)   a company being a body corporate employing a person with one of the above qualifications;

‘claimant’ means a person who has made a claim for dental benefit, optical benefit or medical appliance benefit, as the case may be;

‘dental treatment’ means the performance of any dental operation and any examination, treatment, advice, opinion or attendance usually performed or given by a dentist, including the fitting, insertion or fixing of dentures, which is included in the Schedule of Treatments for the time being fixed by the Minister;

‘dentist’ means

(a)  a person registered, or

(b)  a person entitled to be registered

in the Register of Dentists in Ireland;

‘dependent spouse’ means

(a)  a spouse who is a qualified adult as defined in section 2(2) and by article 6 of the Principal Regulations (as substituted by article 3 of the Social Welfare (Consolidated Payments Provisions) (Amendment) Regulations 1996 ( S.I. No. 95 of 1996 )); or

(b)  a spouse who is not a qualified adult as so defined in subparagraph (a) by virtue of being engaged in insurable employment and who immediately prior to taking up such employment was a dependent spouse entitled to treatment benefit; or

(c)  a spouse who would be a qualified adult as so defined, but for the receipt by that spouse of carer's benefit under Chapter 11A of Part II, old age (non contributory) pension under Chapter 4 of Part III or carer's allowance under Chapter 10 of Part III in his or her own right;

‘dispensing optician’ means -

(a)  a person registered, or

(b)  a person entitled to be registered

in the Register of Dispensing Opticians in Ireland;

‘ophthalmologist’ means -

(a)  (i)    a person registered, or

(ii)   a person entitled to be registered

in the Ophthalmology Specialists Register of the Irish Medical Council, or

(b)  a person with a recognised qualification in ophthalmology from the College of Ophthalmologists Ireland, or

(c)  a person who has an equivalent recognised qualification in ophthalmology;

‘optometrist’ means -

(a)  a person registered, or

(b)  a person entitled to be registered

in the Register of Optometrists in Ireland;

‘ready made reading spectacles’ means spectacles that have two single vision lenses each of which has the same positive spherical power not exceeding four dioptres and the purpose of which is to relieve the condition known as presbyopia;

‘Register of Dentists in Ireland’ means a register established under Part III of the Dentists Act 1985 (No. 9 of 1985);

‘Register of Optometrists in Ireland’ means a register established under Part III of the Opticians Act 1956 (No. 17 of 1956) as amended;

‘Register of Dispensing Opticians in Ireland’ means a register established under Part IV of the Opticians Act 1956 (No. 17 of 1956) as amended;

‘the Regulations of 1996’ means the Social Welfare (Consolidated Contributions and Insurability) Regulations, 1996 ( S.I. No. 312 of 1996 );

‘relevant contribution year’ means the second last complete contribution year before the beginning of the benefit year in which the relevant date occurs or, where the claimant has attained pensionable age, either the second or third last complete contribution year before the relevant date;

‘relevant date’ means the date on which benefit is claimed or, where the claimant is over pensionable age, the date on which he or she attained pensionable age;

‘scale of charges’ means, as respects any benefit, the scale of fees or charges appropriate to such benefit for the time being fixed by the Minister;

‘spectacles’ means corrective single vision, bifocal or varifocal lenses and associated frames and includes contact lenses whether afocal or focal lenses but does not include -

(a)    afocal goggles or similar articles,

(b)    afocal sunglasses or similar articles, or

(c)    ready made reading spectacles;

‘treatment benefit’ means, dental benefit, optical benefit or medical appliance benefit, as the case may require.

Benefit to be provided.

67B.  The treatment benefit to be provided under section 117 shall be

(a)    dental benefit,

(b)    optical benefit, and

(c)    medical appliance benefit.

Entitlement to treatment benefit.

67C.  Subject to this Chapter, a person shall be entitled to treatment benefit if he or she satisfies the contribution conditions in articles 67D or 67E.

Contribution conditions for entitlement.

67D.  (1)  Subject to this Chapter, the contribution conditions for entitlement to treatment benefit shall be

(a)    in the case of a claimant who is under the age of 21 years that he or she has qualifying contributions in respect of not less than 39 contribution weeks between the date of his or her entry into insurance and the relevant date, or

(b)    in the case of a claimant who is of or over the age of 21 years and under the age of 25 years that he or she -

(i)   has qualifying contributions in respect of not less than 39 contribution weeks between the date of his or her entry into insurance and the relevant date, and

(ii)  (I)    subject to sub-paragraph (II), has qualifying contributions or credited contributions in respect of not less than 39 contribution weeks, of which at least 13 must be qualifying contributions, in the relevant contribution year, or

(II)   in the case of a person to whom sub-article (5) applies, has qualifying contributions or credited contributions in respect of not less than 39 contribution weeks in the relevant contribution year,

or

(c)    in the case of a claimant who is of or over the age of 25 years that he or she

(i)   has qualifying contributions in respect of not less than 260 contribution weeks between the date of his or her entry into insurance and the relevant date, and

(ii)  (I)    subject to sub-paragraph (II), has qualifying contributions or credited contributions in respect of not less than 39 contribution weeks, of which at least 13 must be qualifying contributions, in the relevant contribution year, or

(II)   in the case of a person to whom sub-article (5) applies, has qualifying contributions or credited contributions in respect of not less than 39 contribution weeks in the relevant contribution year .

(2)  In the case of a person who would be entitled to treatment benefit but for the fact that he or she does not satisfy the condition of having qualifying contributions in respect of at least 13 contribution weeks in the relevant contribution year, that person shall be entitled to treatment benefit -

(a)    in the case of a person who has attained pensionable age, if he or she has qualifying contributions in respect of at least 13 contribution weeks in the contribution year preceding the relevant contribution year, and

(b)    in any other case, if he or she has qualifying contributions in respect of at least 13 contribution weeks in either of the two contribution years preceding the relevant contribution year or in a subsequent contribution year.

(3)  The contribution conditions contained in sub article 1(c)(ii) shall not apply in the case of a person who has attained pensionable age before the 6th day of July, 1992.

(4)  The contribution conditions contained in sub articles (1)(c)(i) and (1)(c)(ii) requiring the claimant to have qualifying contributions in respect of at least 260 contribution weeks between the date of his or her entry into insurance and the relevant date and qualifying or credited contributions in respect of not less than 39 contribution weeks in the relevant contribution year shall -

(a)    in respect of a person who has attained pensionable age before the 1st day of October, 1987, have effect as if ‘156 contribution weeks’ were substituted for ‘260 contribution weeks’, and ‘26 contribution weeks’ were substituted for ‘39 contribution weeks’, and

(b)    in respect of a person who has attained pensionable age before the 6th day of July, 1992, have effect as if ‘208 contribution weeks’ were substituted for ‘260 contribution weeks’.

(5)  The contribution condition contained in sub article (1)(b)(ii)(II) and (1)(c)(ii)(II) shall apply in the case of a person who -

(a)    is in receipt of

(i)     disability benefit under Chapter 7 of Part II for a period of not less than 312 days in respect of any period of interruption of employment,

(ii)    carer's benefit under Chapter 11A of Part II,

(iii)   retirement pension under Chapter 13 of Part II,

(iv)   invalidity pension under Chapter 15 of Part II,

(v)    unemployment assistance under Chapter 2 of Part III and is a person to whom section 121 (1)(a) (as amended by section 22 of the Social Welfare Act, 1996 ) applies,

(vi)   pre retirement allowance under Chapter 3 of Part III, or

(vii)  carer's allowance under Chapter 10 of Part III, or

(b)    not being in receipt of any benefit under Part II or assistance under Part III, is of or over the age of 55 years and is entitled to employment contributions credited under the provisions of article 58 of the Regulations of 1996 in respect of proved unemployment.

Contribution conditions for development workers.

67E.  The contribution conditions to be satisfied by a volunteer development worker for treatment benefit in respect of any claim made in the benefit year in which he or she returns to the State from a developing country or in the next succeeding benefit year shall be -

(a)    that he or she has qualifying contributions paid in respect of not less than 26 contribution weeks in the period from his or her entry into insurance to the relevant date, and

(b)    that he or she has qualifying contributions or credited contributions in respect of not less than 26 contribution weeks in the relevant contribution year.

Treatment benefit for dependent spouse.

67F.  A dependent spouse shall be entitled to treatment benefit where the contribution conditions specified in article 67D or 67E, as the case may be, are satisfied by his or her spouse.

Continued benefit to dependent spouse after the death of an insured person.

67G.  On the death of an insured person whose dependent spouse, at the date of the death, was or would have been entitled to treatment benefit under article 67F, the dependent spouse shall continue to be entitled to treatment benefit for as long as that person remains a widow or widower, as the case may be.

Continued entitlement after attaining age 60.

67H.  Where an insured person, on attaining the age of 60 years, is or would be entitled to treatment benefit under this Chapter he or she shall thereafter continue throughout his or her life to be so entitled.

Reckoning of contributions paid under National Health Insurance Acts.

67I.  (1)  For the purposes of this article an ‘existing contributor’ means a person whose insurance as an employed contributor or a voluntary contributor under the National Health Insurance Acts was effective immediately before the 5th day of January, 1953.

(2)  In determining for the purposes of satisfying the contribution condition for treatment benefit contained in subparagraph (i) of article 67D(1)(c), every two contributions paid by or in respect of an existing contributor under the National Health Insurance Acts shall be reckoned as three qualifying contributions paid under the Principal Act, and any odd contribution paid under the said Acts shall be reckoned as two qualifying contributions paid under the Principal Act.

Claim for treatment benefit.

67J.  A claim for treatment benefit shall be made in the form and in such manner for the time being approved by the Minister.

Limitation on benefit for a claimant who is a member of the Defence Forces.

67K.  Subject to article 67D, a claimant to whom article 87 of the Regulations of 1996 applies shall be entitled to dental benefit and optical benefit to the extent specified in articles 67Q and 67W and to medical appliance benefit under article 67T and to no other treatment benefit.

Cost of medical certificates.

67L.  A claimant for treatment benefit may be granted the cost of any medical certificate required by the Minister and necessarily incurred for the purposes of the claim.

Time limit for obtaining treatment benefit.

67M.  (1)  The time within which any treatment, service or appliance is to be obtained is 3 months.

(2)  The Minister may, if he or she is satisfied that there are good grounds for so doing, extend the time within which any treatment, service or appliance is to be obtained.

(3)  A grant of treatment benefit which is not obtained within the time as fixed or extended by the Minister shall lapse to the extent which the benefit has not been obtained.

(4)  The Minister may renew a grant of treatment benefit which has lapsed.

Decisions on claims for treatment benefit.

67N.  (1)  The Minister shall cause notification of the decision on a claim for treatment benefit to be given to the claimant and of the procedure to be complied with by him or her for the purpose of obtaining such benefit.

(2)  The claimant shall be advised where he or she is required to pay any sum towards the cost of the treatment benefit and of the amount of such sum, if known.

Payment by the Minister.

67O.  (1)  The Minister shall -

(a)      on being informed in writing by the claimant that he or she has received to his or her satisfaction the treatment, service or appliance in respect of which he or she is entitled to treatment benefit (not being benefit received in a case falling within paragraph (2)), and

(b)      the audiologist, dentist, dispensing optician, ophthalmologist or optometrist, as the case may be, has entered into an agreement with the Minister in respect of the provision of dental, optical or medical appliance treatment and that agreement is for the time being in force,

pay the sum which the Minister is liable to pay in respect of this benefit.

(2)  The Minister shall, on being informed in writing by the claimant that he or she has received to his or her satisfaction the treatment, service or appliance in another Member State in respect of which he or she is entitled to treatment benefit, pay the sum which the Minister is liable to pay in respect of this benefit.

Panels.

67P.  The Minister may, for the purposes of information from time to time, prepare and publish a list of -

(a)      dentists, for the purposes of dental benefit,

(b)      dispensing opticians, ophthalmologists or optometrists for the purposes of optical benefit and medical appliance benefit, and

(c)      audiologists, for the purposes of medical appliance benefit,

with whom agreements, in accordance with this Chapter, have been made by the Minister and which shall be known as the Dental Panel, the Optical Panel or the Hearing Aid Panel, as the case may be.

Limitation on dental benefit for a claimant who is a member of the Defence Forces.

67Q.  The dental benefit to which a claimant, to whom article 87 of the Regulations of 1996 applies, shall be entitled, shall be the provision of dentures and repairs, additions and alterations thereto and remodelling thereof.

Amount of payment by the Minister and the claimant in respect of dental benefit.

67R.  The payment to be made by the Minister in respect of dental benefit shall be so much of the cost of the dental treatment, subject to the maximum cost defined in accordance with the scale of charges as may from time to time be fixed by the Minister, and the remainder of the said cost, if any, shall be paid by the claimant.

Benefit provided in respect of medical appliances.

67S.  The appliances to be provided as benefit under articles 67T and 67U shall be contact lenses supplied for medical reason and hearing aids.

Amount of payment by the Minister and the claimant.

67T.  The payment to be made by the Minister in respect of medical appliance benefit under this article and article 67U shall be 50 per cent. of the cost of providing or repairing an appliance, subject to a maximum payment, and the remainder of the said cost shall be paid by the claimant.

Claims for and payment of medical appliance benefit.

67U.  (1)  Subject to sub article (2) a claimant for medical appliance benefit shall submit with the claim

(a)      a recommendation from the medical practitioner attending him or her, and

(b)      an estimate of the cost of appliances supply or repair.

(2)  The Minister may, if he or she thinks fit, dispense with the submission of a recommendation from the medical practitioner where the benefit claimed is in respect of the repair of an appliance.

(3)  When a claim for medical appliance benefit is granted, the Minister shall notify the claimant.

Claims for and payment of optical benefit.

67V.  (1)The Minister may require a certificate from an ophthalmic surgeon to be submitted with a claim for optical benefit.

(2)Where a claim for optical benefit is granted, the Minister may notify the claimant.

Limitation on optical benefit for claimant who is a member of the Defence Forces.

67W.  The optical benefit to which a claimant, to whom article 87 of the Regulations of 1996 applies, shall be entitled, shall be the provision of optical appliances and repairs thereto.

Amount of payment by the Minister and the claimant.

67X.  The payment to be made by the Minister in respect of optical benefit shall be so much of the cost of the optical treatment, subject to the maximum cost defined in accordance with the scale of charges as may from time to time be fixed by the Minister, and the remainder of the cost, if any, shall be paid by the claimant.

Sight tests.

67Y.  (1)  A person shall only be entitled to optical benefit, in respect of a sight test, once in any period of two years, save where the Minister is satisfied that there are good clinical reasons in a particular case for obtaining such tests more frequently.

(2)  Sight tests provided by way of optical benefit shall be undertaken at the optical practitioner's normal place of business.”

EXPLANATORY NOTE

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

These Regulations consolidate all existing provisions relating to Treatment Benefit as well as facilitating the extension of the current Treatment Benefit Scheme to provide for a reimbursement system to customers who receive treatment in another EU Member State.

Under the Treatment Benefit Scheme a person may qualify for:

-   Dental Benefit,

-   Optical Benefit (including Contact Lenses), and

-   Medical Appliance Benefit (i.e. Hearing Aids).

A person may qualify for these benefits if he/she:

(i)      satisfies the PRSI contribution conditions,

(ii)      is a spouse of an insured person, or

(iii)     is a widow/widower whose spouse at the time of death was qualified for Treatment Benefit.

Contributions paid at PRSI Classes A, E, H and P count towards qualifying for Treatment Benefit. Persons must have been in insurable employment and paid the appropriate rates of PRSI for a defined period of time. In addition, the PRSI contribution conditions relating to entitlement under the Treatment Benefit Scheme, vary depending on the age of the insured person:

-   Persons aged under 21 years of age must have at least 39 weeks PRSI paid since first starting work in order to qualify,

-   Persons aged from 21 to 24 years of age must have at least 39 weeks PRSI paid since first starting work and 39 weeks paid or credited in the relevant tax year of which a minimum of 13 weeks must be paid contributions, and

-   Persons aged from 25 to 65 years of age must have at least 260 weeks PRSI paid since first starting work and 39 weeks PRSI paid or credited in the relevant tax year of which a minimum of 13 weeks must be paid contributions.

-   In addition, there are a number of exceptions to the 13 week rule and these are specified in the Regulations.

The Regulations also include a number of technical amendments and corrections in the definitions and terms used.