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RoI Reimbursement Scheme

The Health Services Republic of Ireland Reimbursement Scheme – Guidance and Application form

Background

The Department of Health has introduced a Republic of Ireland (ROI) Reimbursement Scheme for a period of 12 months. This new scheme opened on 1 July 2021 and is available to ordinary residents of Northern Ireland. The scheme provides an option for those patients who may wish to access private treatment in ROI and claim reimbursement of Health & Social Care (HSC) equivalent cost. The scheme is based on the EU Cross Border Healthcare Directive.

UPDATE:  The DoH has allocated a further £5m to continue to operate the scheme beyond the planned 30 June 2022 deadline. New applications will be accepted from 1 July 2022.  These will be processed in chronological order and the scheme will continue until the additional funding has been committed. Further information on the scheme will be provided on this website.

How it works

The eligible patient:

  • decides that s/he wishes to access private treatment in ROI,
  • sources their ROI provider,
  • applies to the SPPG for prior authorisation,
  • arranges and has treatment,
  • pays for treatment, and
  • then seeks reimbursement from the SPPG.

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.
  • Post-operative care should be arranged between by patient and his/her local treating Consultant or GP.

Responsibility

The treatment a patient receives in ROI under the temporary scheme is not being arranged by the Strategic Planning and Performance Group (SPPG) but by the patient and no clinical responsibility is borne by the HSC for the treatment.

In choosing to arrange access 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 (not under UK legislation).

The SPPG, 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.

Eligibility Criteria

There are some qualifiers to the right to seek ROI planned cross border treatment. The SPPG will reimburse treatment costs under the ROI planned treatment route provided:

  • 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 placed on the HSCT waiting list for the surgery/treatment.
  • The treatment for which the patient is seeking reimbursement is one which is commissioned by the SPPG for the diagnosis.
  • The patient is in need of 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 be paid for by the patient.
  • No other source of reimbursement has been sought.
  • The patient has sought and received prior approval from the SPPG for the treatment under the scheme.

Prior Approval

ROI planned cross border healthcare applications must be authorised by the SPPG prior to treatment. Retrospective applications will not be considered.

The SPPG 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; and
  • To protect the patient from the financial consequences of purchasing treatment for which they may not receive reimbursement.

There are commissioning restrictions on certain services and the SPPG, under Effective Use of Resources policies, do not commission certain procedures. Patients are therefore required to
contact the SPPG in advance of travelling to discuss obtaining prior approval, as well as information on the levels of reimbursement they can expect to receive.

The SPPG wishes to ensure that patients who are seeking diagnostics and treatment which is not offered by the HSC/NHS, and patients seeking treatment which is subject to conditional access for which the individual patient may not qualify, do not incur significant expense before establishing that they are not entitled to reimbursement.

There can also be major differences between the prices patients will be charged for private treatment and the equivalent NHS cost which is why the SPPG is operating a prior approval system.

  • The SPPG can only process claims for people ordinarily resident in Northern Ireland. Applicants are asked to provide proof of residency and entitlement to health and social care services (see application form for details of documentation to be submitted).
  • The SPPG aims to process applications within 30 working days, however it is not always possible with the volume of applications received and resources available.  Therefore it may take longer. You will be informed of the outcome of your application once a decision has been reached. The patient is responsible for providing accurate and complete information to support the decision-making process. Incomplete applications will cause delay in processing your request.

Exemptions

This scheme will not apply to:

  • Services in the field of long-term care the purpose of which is to support people in need of assistance in carrying out 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.

Reimbursement

Where the patient has opted to seek treatment under the provisions of this scheme.

The Strategic Planning and Performance Group will:

  • Reimburse the actual cost of treatment or the equivalent cost of treatment delivered locally in the HSC, whichever is the lesser
  • 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 SPPG.

Note:

  • 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 & accommodation costs.
  • If approved, the reimbursement can take up to 6 weeks to be processed.

The SPPG recommends that you should ensure that you have comprehensive medical insurance for your journey for treatment. The cost of such insurance is not reimbursable by the health service.

You should also ensure that you have a valid GHIC (Global Health Insurance Card) or EHIC for use in the event of a 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.

Download an application form here.

See Frequently Asked Questions for more information.

Contact information

If you are a resident in Northern Ireland seeking to travel to ROI for treatment, please contact:
National Contact Point Strategic Planning and Performance Group Commissioning Directorate – Patient Travel Team 3rd Floor 12-22 Linenhall Street Belfast BT2 8BS

Email: NationalContactPoint@hscni.net
Tel: +44 (0)28 9536 3152