Statutory Instruments

The Health Insurance Act 1994 (Risk Equalisation Scheme) Regulations 2013

The Health Insurance (Amendment) Act, 2012 introduced a permanent Risk Equalisation Scheme (RES) in the private health insurance market, with effect from 1 January, 2013. Risk equalisation is a process that aims to neutralise, in an equitable manner, differences in health insurers costs that arise due to variations in the health status of their members.

The Act provides for the payment of risk equalisation credits in respect of private health insurance premiums paid under contracts renewed or entered into on or after 1 January 2013. These credits are payable from a new Risk Equalisation Fund administered by the Health Insurance Authority and are paid to registered undertakings in respect of:-

— the payment of private health insurance premiums by insured persons aged 50 years and over, based on age,   gender and type of insurance  cover

— €75 payment per night for each hospital stay involving an overnight stay in a hospital bed in private hospital accommodation (including designated   private hospital accommodation in a public hospital).

These Regulations set out the structures for submitting annual claims and returns by registered undertakings and the validation of those claims by the Health Insurance Authority. The regulations also allow for interim claims to be made by authorised registered undertakings (normally monthly).

In addition, the regulations require registered undertakings to keep sufficient records and make them available to the Health Insurance Authority, to allow them to validate claims.

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