Entitlement to health services is based primarily on residence and compliance with means test. Unlike other States there is not a comprehensive social insurance payment system linked to health services.
Any resident who satisfies the HSE that he is ordinarily is entitled to either full eligibility or limited eligibility for health services. Full eligibility is available to Medical Card holders. A limited eligibility is entitled to the balance of the population
Persons with full eligibility for health services are entitled to Medical Card. A Medical Card carries the following entitlement:
- Free GP services
- Prescribed drugs and medicine
- Public hospital services
- Dental, optical and aural services
- Maternity and infant care services
- A range of community care and personal social services.
The prescribed drugs and services are subject to a €0.50 charge per item since 2010.
Persons who are not entitled to a Medical Card, are entitled to free public hospital services. This is subject to an obligation to pay in-patient and out-patient hospital charges. They are entitled to subsidised prescribed drugs and medicines, infants and maternity care services. They may also be entitled to free or subsidised community care or personal social services.
A further category of entitlement is granted by a GP Visit Card. This gives entitlement to free GP services but limited other entitlements.
There are certain services which are available irrespective of means or whether or not a Medical Card is held. Persons with certain Long Term Illnesses are entitled to drugs and medicines free of charge for that illness. Child health services are available universally.
Ordinary residence requires proof of long-term residence in the state. This will typically be shown by evidence of permanency such as a residence, residence visa, bank accounts etc. Nationality is not a key test. In the case of non-EU nationals, dependents must satisfy the residence test as well.
EU Citizens living in Ireland who are entitled to a Social Security Pension from another state may be entitled to a Medical Card without having to satisfy a means test. They must not have any earned or unearned income in addition to pension income.
Generally, persons working in one state are entitled to the health services in the state where they live and work. Accordingly, persons resident in Ireland but working in the United Kingdom may be entitled to Medical Cards without means test on the basis of UK entitlement.
Short-term visitors from EU states are entitled to a urgent medical treatment without charge. Entitlement is decided by presentation of the European health insurance card. UK residents may establish entitlement by proof of UK residence. Non-EU visitors may be charged the cost of treatment provided. More favourable arrangements exist with some states.
General Practitioners register with the General Medical Services Scheme and enter contracts with the HSE to provide services. Patients may usually choose their doctor from a GMS panel provided the doctor is willing to take them as patients. Generally services are provided by the registered doctor, although in some circumstances services may be provided by other doctors in an emergency. Doctors must treat GMS patients on the same terms as other patients.
Application for Medical Cards is now made to the local health office. A doctor should not have more than 2000 GMS patients. Medical Cards may be issued on the basis of certain terms and are subject to review.
The GMS contract, specifies the range of services the doctor must provide. This includes
- consultation services, at his surgery, or in the patient\’s home.
- proper and necessary treatment of a kind normally undertaken
- issuing of medical certificates where required.
- drugs, medicines and appliances, prescriptions where required.
GPs must dispense drugs if they are more than 3 miles from the nearest pharmacy. Dispensing doctors are accordingly found in rural areas.
Certain services are not required to be provided free of charge. These may include for example medical check-ups for external purposes. Apart from this, services must be provided on the same terms and principles as for fee paying patients.
Doctors on the GMS scheme must provide emergency services for their own patients. A rota system may provide for out of hours cases.
If a person moves, HSE administrative areas, they should register with a new doctor. The existing card holds for three months. They must liaise with the relevant local health office.
Entitlement to a Medical Card requires that weekly income is below a certain figure. This is relative to family size. See below in respect of the means test. They are generally issued for three years subject to review.
Generally, a dependent spouse and children are covered for the same range of health services.
Medical Card holders are subject to the Universal Social Charge on income other than HSE and social welfare income. There is a maximum rate of 4%. There is exemption for persons earning less than €10,036 per annum.
A GP Visit Card allows free GP visits. The means test is pitched at 50% higher than for the general Medical Card.
There is an obligation to inform the HSE of any changes in circumstances relevant to entitlement of a Medical Card. If the periodic HSE review is not responded to, the card may be not be reissued. Entitlement continues on an unexpired card while the review is taking place.
Full-time students between the age of 16 and 25 years who are financially independent of parents may be entitled to quantify for a Medical Card in their own right.
Under certain back to work and labour market activation schemes, a person may be entitled to retain a Medical Card for up to three years after commencing or resuming employment. See separately the sections on social welfare.
Medical Cardholders are subject to a €1.50 charge per prescription item with a monthly ceiling of €90.50. HSE issues refunds if prescription charges exceed €19.50 per month.
Certain Medical Card holders did not pay the prescription charges including children in the care of HSE who have their own card.
- Methadone supplies,
- items supplied under long-term illness scheme,
- persons on high tech product scheme.
This does not apply to children in HSE care.
The means test differs for those under and over 70 years . Prior to 2010, there was no means test for those over 70 years.
The Health Act 2008 introduced a new scheme of entitlement to medical cards for persons over 70, as of the start of 2009. The Act replaced Section 45 of the Health Act which had provided for automatic entitlement to medical cards for persons aged 70 and over, ordinarily resident in the State without regard to means.
Persons over 70 retained the prior universal entitlement provided that their income did not exceed specified limits. Persons above those income limits were obliged to notify the HSE that their income exceeded the limits by 2 March 2009.
Persons in the age category who do not have a medical card are required to make an application to the HSE and have their eligibility assessed by reference to their gross income. The gross income limits are €700 per week for a single person and €1400 per week for a couple. In each case, this excludes income from savings and similar investments whose principal value is €36,000 or less, in the case of a single person or €72,000 or less in the case of a couple. The limits may be reviewed by the Minister for Finance to reflect changes in the Consumer Price Index.
In calculating gross income, only net income from property is included. This is gross rental income less necessarily incurred associated costs. The Minister may by regulations prescribe other payments such as compensation and redress payments which are excluded from the calculation of income.
The appeals process under the Health Act applies to persons who apply for a medical card under the legislation.
The HSE guidelines allow a Medical Card, to be issued in some circumstances even if income levels are exceeded the means test, if the income is derived solely from social welfare allowances and benefits and HSE allowances.
The following income is ignored in Medical Card assessments.
- certain civil compensation payments including from Redress Boards.
- certain HSE payments including foster care allowance, mobility allowance, weekly supplements under supplementary welfare allowance
- Social welfare payments including child benefit, family income supplement, fuel allowance, over 80 allowance, domiciliary care allowance
- certain third level maintenance grants,
- certain rehabilitation maintenance allowance,
- earnings from employment of a rehabilitative nature up to €120 euro a week.
In the case of persons under 70 years, the means test is based on a weekly income limit. This is income net of tax, universal social charge and PRSI. The test provides a threshold for a single person together with increments for married or cohabiting parents, (including lone parents with dependent children) together with allowances for children.
Deductions may be permitted for childcare costs, rental and mortgage payments. This is a matter of assessment and there is no monetary guidelines. Deductions may also be allowed for costs and traveling to work.
Capital from savings is taken into account .This does not apply to the family home. Saving up to €36,000 for single person and €72,000 for a married couple are disregarded.
There is a deemed rate of return which is deemed to increase the weekly means for the purpose of assessment.
- Above €36000 (and €72,000)
- the next €10,000 assessed at 5.2%.
- the next €20,000 is assessed at 10.4%.
- the balance is assessed at 20.8%.
Unused property other than the family home may be assessed notionally. There may be a notional assessment of the market rent or the percentage of the capital value per the above table.
Persons over the age of 70 years with gross incomes in excess of €700 for a single person and €1400 per week for a married couple are no longer entitled to Medical Cards. There are no deductions from this sum. A person over the limits may apply for an ordinary Medical Card or a GP Visit Card if they have high medical expenses.
The above limits were decreased to €600 and €1200 respectively for persons under 70 years in 2013. For persons in the range of €600-€70 years0/€1200-€1400 over 70 years, an entitlement to a GP Visit Card now applies.
The capital means test applies slightly differently to that for persons under 70 years. Investments on property other than the family home over €36,000 single person, €72,000 a couple are treated differently. The balance may be assessed either on basis of a notional rate or actual rate. The HSE may uses the basis which is better for the applicant.
A notional interest rate is set by the HSE, periodically taking account of average deposit interest rates. The applicant may be assessed on the actual interest return. In the case of long-term savings product, the HSE will at the option of the applicant determine interest at the date of maturity.
Income is not assessed on property where the family home, holiday home or otherwise unless it generates an income. Actual income is assessed less necessary cost.
Both spouses will qualify for a Medical Card if one is over 70 years and the other under 70 years provided the income thresholds are satisfied. Where a person is widowed and over 70 years, they retain the Medical Card for three years on the basis of the 1400/€1200 threshold. The single person threshold applies after that. This does not apply where a spouse or a cohabiting partner etc. dies under 70 years.
Medical Cards for persons over 70 years are subject to review generally every two years.
The GP practice must generally be within 7 miles of the place of residence of the applicant. The GP must accept the patient.
There is an appeal from a decision of the local health office to an appeals officer of the HSE area.
The Health General Practitioner Service Act 2014 amends existing legislation in relation to appeals. The current HSEP appeals process is extended to decisions regarding the operation of the new GP service for children aged five years and younger. The director general of the HSE appoints a person to carry out the appeal. The person undertaking the appeal is to be of a grade senior to that of the original decision-maker.
The existing criteria for ordinary residence in the Health Act is amended to effect changes to include the new GP service for all children aged five and younger. Children who have not yet attained the age of six are removed from the existing GP service under the medical card scheme and are covered by the new service.
Sections 58 B and C are inserted into the Health Act. It provides that the HSE shall make available general practitioner service without fees to all children aged five years and younger. The parents and guardians of such children seeking access to the service must provide evidence as it considers necessary to demonstrate entitlement of the service. Where possible, the HSE will offer a choice of GPs to those accessing the service.
The HSE is entitled to enter into a contract with qualified and vocationally trained general practitioners for the purpose of providing GP services to persons aged five years and younger. It may enter contracts for relevant services, with a registered practitioner who holds a GMS service contract.
The contract is to specify the service to be provided by the GP. The Minister for Health may by regulation with the consent of the Minister for Public Expenditure fix the rate of fees and allowance which is to be paid to GPs for services provided under the contract.
When the Minister is making regulations, he must engage in consultations with prescribed bodies and regarded is to be had to these consultations. Where the rates fixed under the regulations are varied under subsequent regulations, the GP who does not wish to continue to provide services, he may terminate his contract.