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Treatment Benefit Operational Guidelines

PART 1 - DESCRIPTION OF SCHEME

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

QUALIFYING CONDITIONS IN DETAIL

            PRSI conditionas
            National Health Insurance Contributions
            Periods in another EU/EEA Member State
            Dependency condition. 

SPECIAL CATEGORIES

A.     Recipients of certain Social Welfare payments.
B.     Age 66 or over.
C.     Qualified at age 60.
D.     Widows/widowers
E.     Qualified Adults
F.     State Pension (Non-Contributory) or Carers Allowance.
G.     Volunteer Development Workers (VDW).
H.     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 to qualify for Treatment Benefit, 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 and P 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 65:    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 66 or over: 260 weeks PRSI paid since first starting work
After 29 May 2006     (See page 7 also)        

                                  and either:

                          39 weeks PRSI contributions* paid or credited
                          in either of the 2 relevant tax years 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. **

**The alternative contribution condition applies only to claims made on or after 29 May 2006.

* In the case of the 39 weeks paid or credited, a minimum of 13 weeks must be paid contributions in:

  • the relevant tax year(s) on which the claim is based OR
  • either one of the two previous tax years OR
  • any tax year subsequent to the relevant tax year.

 

CLAIMS MADE IN 2015 ARE BASED ON THE 2013 TAX YEAR.

CLAIMS MADE IN 2016 ARE BASED ON THE 2014 TAX YEAR.

 

CONTRIBUTIONS PAID UNDER THE NATIONAL HEALTH INSURANCE (NHI) ACTS .

Contributions paid under the NHI Acts may be taken into account to satisfy the contribution conditions for Treatment Benefit provided they are paid in the 18 month period prior to 5 th January 1953, when the Social Welfare Act was enacted.

 

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
  • earn more than €100 a week and were dependent on your spouse or partner before entering or resuming insurable employment at Class A, E, H or P,
  • 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)       RECIPIENTS OF CERTAIN SOCIAL WELFARE PAYMENTS

The requirement to have 13 weeks PRSI contributions paid does not apply to persons who are in receipt of any of the following payments from this Department:-

            1.         Illness Benefit (for 12 months or more)

            2.         State Pension (Transition)

            3.         Invalidity Pension

            4.         Long-Term Jobseekers Allowance

            5.         A combination of Jobseeker's Benefit and  
                        Jobseeker's Allowance for at least one year

            6.         Pre-Retirement Allowance

            7.         Carer's Allowance

            8.         Carer's Benefit

            9.         Persons aged 55 and over who are not in receipt of
                       any benefit or assistance from the Department but
                       are signing for Unemployment credited
                       contributions.

            10.       Persons who reached age 66 prior to 6th July 1992

            11.       Persons who received a State Pension after 6th
                       July 1992 to whom 1- 8 listed above applied 
                       immediately before receiving a State Pension

            12.       Persons on Community Employment Schemes, Back
                       to Work Schemes and Vocational Training
                       Opportunities Scheme and Community Employment
                       Development Programme.

 

(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)       QUALIFIED AT AGE 60

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

 

(D)       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.

 

(E)       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.

 

(F)       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.

 

(G)       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.

 

(H)       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 no longer entitled to receive Dental or Optical Benefits (the scheme now only covers the relevant examinations, both of which should be supplied by the Department of Defence).

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 for glasses free of charge once every two 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 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. A claim form, D1, is submitted on behalf of the insured person and a D2 claim form is submitted on behalf of the Qualified Adult of the insured person.

Authorisation to proceed with the dental treatment may be obtained by the dentist by telephoning the Treatment Benefits Section. In this instance the dentist can proceed with the dental treatment and forward the D1/D2 form for direct payment when the course of treatment is completed. If a claim is submitted by the dentist for written approval both the dentist and the claimant receive decision notices D3 and D4 form respectively.

If the dental treatment to be carried out is listed by the dentist on the claim forms (D1/D2) sent for written approval, the claimant is informed on the approval form (D4) of the fixed fees, if any, payable by them to the dentist for the various dental treatments.

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

Claim forms can be submitted directly by the claimant for Optical Benefit. The relevant forms are (O1) for the insured person and (O2) for the Qualified Adult applying for Optical Benefit.

When the optical claim is approved an authorisation form (03) is forwarded to the claimant for presentation to the optician. This informs the claimant of their entitlement to an eye examination.

Authorisation to proceed with the optical treatment may be obtained by the optician contacting the Treatment Benefit Section. The optician can proceed with the optical treatment and forward form (05) for an insured person and (06) for a Qualified Adult for direct payment when the treatment is completed.

 

Medical Appliance Benefit

Claim forms are submitted directly by the claimant for Medical Appliances Benefit. The relevant forms are MA1 for the insured person and MA2 for the Qualified Adult.

When the claim is approved an approval form (MA3) is sent to the claimant. Before the MA3 is returned to the Department for payment it must be certified by the claimant's doctor and details of the cost of the appliance completed by the Supplier.

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 3 months of the date of the authorisation.

Dental Benefit :

Examination must be obtained within 3 months of date of authorisation.

Medical Appliance :

Appliance must be supplied within 3 months 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

 Claims 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 and claimant are notified accordingly.

Where claims do not satisfy the qualifying conditions a report indicating the reason why they were not automatically approved is produced. These reports are examined by the Deciding Officers and appropriate action taken. In some cases the claims can be rejected immediately where it is clear that the conditions will not be satisfied. For other claims, further information is sought from the claimant and Local Offices regarding insurable employment and/or credited contributions before a final decision on a claimant's entitlement. On receipt of the requested information the claim is further examined by the Deciding Officer and appropriate decision made regarding entitlement.

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

Paymen t

Payment for Treatment Benefit is made directly to the Panellists on a monthly basis. Before payment is made the Authorisation forms must be returned to the Section duly certified by the claimant and the Panellist that the listed treatment has been completed.

Limitations on Payment

Under the scheme, the Department will only pay for one Dental Examination per year unless it is clinically necessary more often. 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 two years unless the aid has been lost or stolen.


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:19/03/2015
 

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