Treatment Benefit - Operational Guidelines


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PART 1 - DESCRIPTION OF SCHEME

            Information Leaflet/Guide
            Legislation
            Administration
            Qualifying Conditions in Summary
            Income qualification

QUALIFYING CONDITIONS IN DETAIL

            PRSI conditions
            Periods in another EU/EEA Member State
            Dependency condition. 

SPECIAL CATEGORIES

A.     Age 66 or over.
B.     Qualified at age 60.
C.     Widows/widowers
D.     Qualified Adults
E.     State Pension (Non-Contributory) or Carers Allowance.
F.     Volunteer Development Workers (VDW).
G.     Members of the Permanent Defence Forces.

BENEFIT STRUCTURE

Optical Benefit Scheme:

    Panellists
    Patient Fees
    Contact Lenses

  Dental Benefit Scheme
    
   
Dental Panel
   Patient Fees

  Medical Appliance Scheme

    Suppliers
    Grant

MEDICAL CERTIFICATES

 

PART 2: CLAIMS, INVESTIGATION AND DECISION PROCEDURES   

Claims
Dental Benefit
Optical and Medical Appliance Benefit

Time of Claims and time limit to Benefit

Optical Benefit
Dental Benefit
Medical Appliance

Documentation
Investigation of Claim/Decisions
Appeals

PART 3: PROCEDURES FOLLOWING AWARD

Payment
Limitations on Payment

PART 4: GENERAL PROVISIONS WHICH APPLY TO TREATMENT BENEFIT

 

PART 1 - DESCRIPTION OF SCHEME

Description of Scheme

The Treatment Benefit Scheme provides assistance under certain conditions towards the provision of treatment and appliances or repair of appliances in respect of:

  • Dental treatment,
  • Optical treatment
  • Hearing Aids and
  • Contact lenses (if necessary on medical grounds).

Information Leaflet/Guide

"Treatment Benefits" SW 24

"The Community Provisions on Social Security - Your rights when moving within the European Union" - published by the European Commission.

Legislation  

The main provisions are in

  • Chapter 22 of Part II of the Social Welfare Consolidation Act, 2005 as amended (see especially SI 142 of 2007 which consolidated previous regulations and SI 578 of 2009)  
  • Title II, III (Chapter I) and VI and Annex VI of Council Regulation (EEC) No. 1408/71 and Title II, IV (Chapters 1 and 2) and VI of Council Regulation (EEC) No. 574/72."

Administration

The Treatment Benefit Scheme is administered from the Social Welfare Services Office, St. Oliver Plunkett Road, Letterkenny, Co. Donegal. 

Qualifying Conditions in Summary

A person must have a certain number of PRSI contributions paid in total and in the relevant tax year to qualify for Treatment Benefit, The total required is either 39 or 260 according to the age of the insured person.

For persons over 21 years of age, with certain exceptions, 39 contributions must also have been paid or credited in the relevant tax year(s). 

Qualified Adults (spouses or partners of qualified insured persons and subject to dependency conditions) are also entitled to Treatment Benefit.

QUALIFYING CONDITIONS IN DETAIL

PRSI CONDITIONS  

PRSI Classes A, E, H, P and S are reckonable for Treatment Benefit.

The PRSI conditions vary according to age as follows: 

Aged under 21 :  39 weeks PRSI paid since first starting work.

Aged 21 to 24
:   39 weeks PRSI paid since first starting work,

                                    and either:

                         39 weeks PRSI contributions* paid or credited in   
                         the tax year on which the claim is based.

                                           or,
 
                         26 paid PRSI contributions in both the
                         relevant tax year and the tax year immediately
                         before the relevant tax year. **

 
Aged 25 to 59:    260 weeks PRSI paid since first starting work,

                                    and either:

                          39 weeks PRSI contributions* paid or credited in
                          the tax year on which the claim is based.

                                         or,

                              
26 paid PRSI contributions in both the
                          relevant tax year and the tax year immediately
                          before the relevant tax year. **

Aged 60            260 weeks PRSI paid since first starting work    

                                  and either:

                          39 weeks PRSI contributions* paid or credited
                          in any relevant tax years year from aged 60 -66
                          the claim is based.

                                            or,

                          26 paid PRSI contributions in any two relevant consecutive tax years between age 60 and 66

 

CLAIMS MADE IN 2018 ARE BASED ON THE 2016 TAX YEAR.

CLAIMS MADE IN 2019 ARE BASED ON THE 2017 TAX YEAR.

 

AGGREGATION OF RELEVANT PERIODS IN ANOTHER EEA MEMBER STATE WHERE A PERSON HAS BEEN EMPLOYED.

An employed person who is a national of a Member State of the European Economic Area (EEA) or who is a stateless person or refugee residing in one of the EEA Member States, who

1. takes up employment on arrival in the State and

2. fails to satisfy the qualifying contribution conditions on their Irish social insurance record alone, can have reckonable periods as an employed person in another Member State of the EEA taken into account for the purpose of satisfying the qualifying contribution conditions under Irish legislation.

DEPENDENCY CONDITION

A Qualified Adult is entitled to Treatment Benefit based on the insured person's PRSI record provided they satisfy the qualification Conditions and they are dependent on their spouse or partner. 

To be dependent on their Spouse or Partner they must:

  • have gross income of €100 or less per week
  • or earn more than €100 a week but were dependent on your spouse or partner before entering or resuming insurable employment at Class A, E, H, P or S
  • are not getting a social welfare payment (except Disablement Pension, Supplementary Welfare Allowance, Carer’s Benefit or Child Benefit),
  • are getting Carer’s Allowance or State Pension (Non-Contributory) in their own right and were dependent on your spouse or partner immediately prior to getting the Allowance or Pension.

(See separate guideline on " Dependants" for further detail re dependency.)

 

SPECIAL CATEGORIES


(A)       QUALIFIED AT AGE 60

An insured person who qualifies for Treatment Benefit at age 60 remains qualified for life.

   

(B)       AGED 66 OR OVER

The contribution requirements vary depending on when the person reached age 66:

Aged 66 before          156 weeks' PRSI paid since first starting
1 October 1987         work and 26 contributions paid or credited in
                                either of the 2 relevant tax years on which
                                the claim is based.

                                               

Aged 66 between         208 weeks' PRSI paid since first starting
1 October 1987 and     work and 39 contributions paid or credited
5th July 1992              in either of the 2 relevant tax years on
                                  which the claim is based.

                                                 

Aged 66 between        260 weeks' PRSI paid since first starting
6 July 1992 and           work and 39 contributions paid or credited
29 May 2006               in either of the 2 relevant tax years on
                                  which the claim is based.

                                                 
Aged 66 on or
After 29 May 2006
(see page 4 also)

 

(C)       WIDOWS/WIDOWERS

A dependent widow/er who was entitled to Treatment Benefit on their spouse's or partner's record at the time of their death remains qualified for as long as they remain widowed.

 

(D)       QUALIFIED ADULTS

A spouse who was dependent prior to entering or resuming insurable employment will continue to be treated as qualified for Treatment Benefit until such time as they accumulate a sufficient number of weeks PRSI contributions to qualify on their own insurance record.

 

(E)       PERSONS IN RECEIPT OF A STATE PENSION (NON-CONTRIBUTORY) OR CARERS ALLOWANCE

A person who was regarded as a Qualified Adult prior to receiving a Carers Allowance or a State Pension (Non-Contributory) in their own right continues to be regarded as a Qualified Adult for Treatment Benefit.

 

(F)       VOLUNTEER DEVELOPMENT WORKERS (VDW).

VDW's can qualify for Treatment Benefit in respect of any claim made in the benefit year in which they return to the State and in the next succeeding benefit year provided they have a total of 26 PRSI contributions paid since entry into insurable employment and 26 weeks' PRSI paid or credited in the tax year on which the claim is based.

 

(G)       MEMBERS OF THE PERMANENT DEFENCE FORCES

Since 1/1/10 Members of the Permanent Defence Forces are entitled to the full range of benefits under the Medical Appliance Scheme but are not entitled to receive Dental or Optical exams, both of which should be supplied by the Department of Defence). But are entitled to the supply and repair of spectacles.

The Qualified Adults of such members however are entitled to the full range of treatments available under the Treatment Benefit Scheme.

 

BENEFIT STRUCTURE

Optical Benefit Scheme: Under this Scheme insured persons and qualified adults are entitled to one eye examination free of charge, and to the supply and repair of spectacles/contact lenses once every two calendar years.

Panellists: The Optical Benefit Scheme is operated by Opticians/Optometrists who have signed a contract with the Minister to operate the Scheme on behalf of the Department.

Patient Fees : Payment in respect of Optical Benefit is only payable when the examination is carried out by a person whose name is on the Optical Panel.

Further information about the Optical Benefit Scheme is available from the Optician or on request from Treatment Benefit Section or on the Internet at 'www.welfare.ie' (See also Part 2. re Optical and Medical Appliance Benefit Claims).

EU: Optical Benefit may be paid in respect of eye examinations carried out in other EU member states. Claim forms and details regarding the amounts which the Department will pay towards same are available directly from Treatment Benefit Section. For services received abroad the patient pays the practitioner in full and afterwards sends the application form (completed by the optician) to the Department. Payment is issued to the patient directly, rather than to the practitioner.

Dental Benefit Scheme : An annual examination and cleaning is free of charge to all qualified insured persons and their Qualified Adults.

Dental Panel : The Dental Benefit Scheme is operated by dentists who have signed a contract with the Minister to operate the Scheme on behalf of the Department.

Patient Fees : Payment in respect of dental examinations will only be made when the treatment is carried out by a dentist who is a member of the Department's Panel.

Further information about Dental Benefit is available at the Dental Surgery or on request from Treatment Benefit Section or on the Internet, ' www.welfare.ie'. (See also Part 2. re Dental Benefit claims).

EU : Dental Benefit may be paid in respect of dental examinations carried out in other EU member states. Claim forms and details regarding the amounts which the Department will pay towards same are available directly from Treatment Benefit Section. For services received abroad the patient pays the practitioner in full and afterwards sends the application form (completed by the dentist) to the Department. Payment is issued to the patient directly, rather than to the practitioner.

Medical Appliance Scheme : The Department pays half the cost of a hearing aid or repairs to a hearing aid, subject to a fixed maximum per aid or repair.

The Department also pays half the cost of Contact Lenses required for medical reasons, subject to a fixed maximum.

Suppliers : Payment under the Medical Appliance Scheme is only made in respect of appliances purchased or repaired by Suppliers who have a contract signed with the Minister to operate the Scheme.

EU : Medical Appliance Benefit may be paid in respect of appliances supplied in other EU member states. Claim forms and details regarding the amounts which the Department will pay towards same are available directly from Treatment Benefit Section. For services received abroad the patient pays the practitioner in full and afterwards sends the application form (completed by the supplier) to the Department. Payment is issued to the patient directly, rather than to the practitioner. 

Medical Certificates

A claimant for Medical Appliance Benefit must supply certification from a medical practitioner that an aid is required before the claim is approved.

A claimant for Treatment Benefit may be granted the cost of any medical certificate required and necessarily incurred for the purposes of the claim.

 

PART 2: CLAIMS, INVESTIGATION AND DECISION PROCEDURES :

Claims

Insured persons, including Members of the Permanent Defence Forces, and their Qualified Adults can claim Treatment Benefit. (However, members of the Defence Forces should apply to the Department of Defence for the Optical/Dental exams.)

Dental Benefit

Claims for Dental Benefit are made on behalf of the claimant by the dentist, who accepts the claimant as a patient.

They can check eligibility and claim payment on-line with the patients consent. Dental Benefit is a pre-approval scheme, your eligibility needs to be approved before you receive treatment.

For dependant spouse eligibility must be checked using a DE2 form signed by both customer and their spouse. If qualified an approval form will issue to customer and panelist (if nominated).

Claim forms in respect of treatment which is to be availed of in other EU member states are available directly from the Treatment Benefit Section before you travel.

Optical Benefit

Claims for Optical Benefit are made on behalf of the claimant by the optician denttist, who accepts the claimant as a patient.

They can check eligibility and claim payment on-line with the patients consent. Optical Benefit is a pre-approval scheme, your eligibility needs to be approved before you receive treatment.

For dependant spouse eligibility must be checked using a OE2 form signed by both customer and their spouse. If qualified an approval form will issue to customer and panelist (if nominated). 

Medical Appliance Benefit

Claims for medical appliances (Hearing aids) are made on behalf of the claimant by the Audiologist who accepts the claimant as a patient.

They can check eligibility and claim payment on-line with the patients consent. Medical Appliance Benefit is a pre-approval scheme, your eligibility needs to be approved before you receive treatment.

For dependant spouse claims eligibility must be checked using a ME2 form signed by both customer and their spouse. If qualified an approval form will issue to customer and panelist (if nominated).

Claim forms in respect of treatment which is to be availed of in other EU states are available directly from Treatment Benefit Section before you travel.

The following information is required on Treatment Benefit claims: -

  • Claimant's Personal Public Service number (PPS No.)
  • Name and Address
  • Date of Birth
  • Details regarding employment in EU/EEA country,
  • Employment Schemes, Social Welfare Payments
  • Dentist/Optician Panel number and signature
  • Details of treatment/appliances required.

Claim forms in respect of treatment which is to be availed of in other EU member states are available directly from Treatment Benefit Section before you travel.

Time of Claims and time limit to Benefit 

The application must be submitted and approved before the treatment is commenced.

The time within which examination, service or appliance may be obtained is as follows:-

Optical Benefit :

Examination must be obtained within 100 days of the date of the authorisation.

Dental Benefit :

Examination must be obtained within 100 days of date of authorisation.

Medical Appliance :

Appliance must be supplied within 100 days of the date of the authorisation.


DOCUMENTATION

Any dental/optical treatment which is provided outside the limitation periods laid down by Treatment Benefit Section (see "Limitations on Payment" below) must be accompanied by a written explanation from the Panellist. Payment for the treatment is not made until the necessary information is received.

Claimants for Medical Appliance Benefit must have a medical certificate, which is incorporated into the authorisation form, signed by a doctor before payment is made by the Department.

INVESTIGATION OF CLAIM/DECISIONS

Entitlement checks for Treatment Benefit are entered on the TB Computer system, which checks whether the qualifying conditions are satisfied on the insured person's record. Where the conditions are satisfied, the claim is approved and the Panellist is notified accordingly.

Where claims do not satisfy the qualifying conditions the customer will be notified and given the opportunity to supply further information and/or appeal the decision.

APPEALS

Where a claim is disallowed, a disallowance notice issues to the claimant. This gives details of the reason for disallowance and informs the claimant of the right to appeal the decision, if dissatisfied with the grounds stated for the refusal and the address to contact stating the reasons for dissatisfaction.

 

PART 3: PROCEDURES FOLLOWING AWARD

Payment

Payment for Treatment Benefit is made directly to the Panellists on a monthly basis. 

Limitations on Payment

Under the scheme, the Department will only pay for one Dental Examination per year. Under the scheme, the Department only pays for an eye examination once every two years unless it is clinically necessary more often.

Under the scheme, the Department will not pay for an eye examination for a driving test or VDU work.

Under the scheme, the Department will only pay for a hearing aid once in four years.

 

PART 4: GENERAL PROVISIONS WHICH APPLY TO TREATMENT BENEFIT

Claims and Furnishing of Information - see separate guideline " Claims and Late Claims" for more information.

Overpayments - see separate guideline "Overpayment"​​​

Last modified:12/10/2018
 

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