Waiting List Reimbursement Scheme

• A person is ordinarily resident if they are living in the United Kingdom lawfully, voluntarily or for settled purposes as part of the regular order of their life for the time being, whether for a long or short duration. Further information on what constitutes an ‘ordinary resident’ can be accessed on the GOV.UK website – Ordinary residence tool – GOV.UK

Phase One of the scheme provided an option for eligible patients who sought private treatment in the Republic of Ireland to claim reimbursement for the cost of treatment.

From 15^th September eligible patients (see criteria below) can now access treatment across the European Union (EU).

The scheme is based on the previous RoI Reimbursement Scheme and EU Cross Border Healthcare Directive.

Reimbursement covers the actual cost of treatment or the Health and Social Care (HSC) Northern Ireland average cost (whichever is lower) provided the treatment is one which the patient could have been received in the NI HSC system.

Download the Waiting List Reimbursement Application form

Eligibility criteria

The Department of Health will reimburse treatment costs under the ROI or EU planned treatment route provided the following criteria are met by patients:

• The patient is an ordinary resident of Northern Ireland.
• The patient has been diagnosed as having a clinical need for the treatment and has been on the treatment or surgical waiting list in Health and Social Care Northern Ireland (HSC NI) services for more than 52 weeks or 1 year.
• The treatment for which the patient is seeking reimbursement is one which is commissioned by the Department of Health for the diagnosis.
• The patient needs the treatment purchased based on HSC criteria i.e. the treatment is one the patient would have received within the HSC in the same clinical circumstances.
• The treatment will initially be paid for by the patient.
• No other source of reimbursement has been sought.
• The patient has sought and received prior approval from the Department of Health for the treatment under the scheme.

The Department of Health can only process claims for people ordinarily resident in Northern Ireland. Applicants are asked to provide evidence in the form of a letter from an HSC Trust in Northern Ireland confirming their place on a treatment waiting list in addition to a Health and Care number to confirm GP registration and a National Insurance number.

It can take up to 20 working days or four (4) weeks for a fully completed application form to be processed and a decision made. You will be informed of the outcome of your application in writing once a decision has been reached.

The patient/carer is responsible for providing accurate and complete information to support the decision-making process.  Incomplete applications will not be processed.

How it works

The eligible patient:

1. Decides that s/he wishes to access private treatment in ROI or wider EU.
2. Sources the provider i.e. private clinic they plan to undergo their treatment/surgery.
3. Applies to the Department of Health’s National Contact Point Team for prior authorisation using form <insert number and link>.
4. Treatment is then arranged by the patient/carer.
5. Treatment is paid directly to the private provider by the patient.
6. Reimbursement is then sought from the Department of Health using the reimbursement form that will be issued to approved patients.

Applicants are asked to provide evidence in the form of a letter from a HSC Trust in Northern Ireland confirming their place on a treatment waiting list in addition to a Health and Care number to confirm GP registration and a National Insurance number. (see application form for details of supplementary documents to be submitted).

The patient/carer is responsible for providing accurate and complete information to support the decision-making process.  Incomplete applications will not be processed.

Please note:

• Reimbursement will be the actual cost of treatment or the HSC NI average cost (whichever is lower) provided the treatment is one which the patient would have received within the HSC.
• Initial consultation, surgery and immediate post op review is covered under the scheme and must be carried out by the provider.
• Any additional post-operative care should be discussed and where clinically appropriate, arranged between the patient and local HSC services in Northern Ireland before completion of the application- this may include, ongoing prescriptions, additional physiotherapy and general monitoring of post-operative condition.

Responsibility

The treatment a patient receives in ROI or the wider EU under the scheme is not being arranged by the Department of Health but by the patient and no clinical responsibility is borne by the Department for the treatment.

In choosing to arrange healthcare themselves, the patient is effectively stepping outside of the HSC system.  At this point, the patient is taking individual responsibility for ensuring that the service they obtain is appropriate and safe within the laws of ROI or EU (not under UK legislation).

The Department of Health under this scheme will not be formally commissioning services from providers abroad and therefore will not be liable for the outcome of the treatment provided.

Prior approval

All EU cross border healthcare applications must be authorised by the Department of Health prior to treatment. Retrospective applications will not be considered.

The Department of Health requires that patients seek prior approval:

• To ensure that such patients meet the same thresholds and qualifying criteria as those seeking treatment in the HSC.
• To protect the patient from the financial consequences of purchasing treatment for which they may not receive reimbursement.

Exemptions

This scheme will not apply to:

• Long-term care services to support people with routine, everyday tasks.
• Allocation of and access to organs for the purpose of organ transplants.
• Public vaccination programmes against infectious diseases which are exclusively aimed at protecting the health of the population.
• Clinical trials.

Reimbursement

Where the patient has opted to seek treatment under the provisions of this scheme the Department of Health will;

• Reimburse the actual cost of treatment or the equivalent cost of treatment delivered locally in the HSC NI, whichever is the lesser amount.
• The Department will not pay the provider directly.

The patient will;

• Pay the provider directly for the cost of treatment.
• Submit original receipts as proof of payment to the Department of Health for reimbursement.

Please read the following important information

• Reimbursement will be made when the patient provides proof of having received the service and incurred the cost. No other costs will be reimbursed including travel and accommodation costs.
• If approved, the reimbursement can take up to six weeks to be processed.
• The Department of Health recommends that patients should have the necessary comprehensive medical and travel insurance for the journey and treatment. The cost of such insurance is not reimbursable by the Department of Health.
• You should also ensure that you have a valid GHIC (Global Health Insurance Card) or EHIC for use in the event of medical emergency unrelated to the planned treatment.
• Please note that the GHIC or EHIC does not allow you to go abroad for the purpose of receiving planned treatment and does not cover the costs of private healthcare or services that are not part of the state healthcare system.

Waiting List Reimbursement Scheme Frequently Asked Questions

Contact information: Northern Ireland

National Contact Point
Strategic Planning and Performance Group
Finance and Corporate Governance
Department of Health
12-22 Linenhall Street
Belfast BT2 8BS

Email: NationalContactPoint@hscni.net

Tel: +44 (0)28 9536 8303

Contact information: Republic of Ireland

You may wish to seek further information on ROI providers and the services they offer.
The National Contact Point for cross border healthcare in ROI may be able to assist you.

National Contact Point,
Cross-Border Healthcare Directive Department,
HSE, St Canice’s Hospital,
Dublin Road,
Kilkenny

Email: crossborderdirective@hse.ie