Background:
On the 28th June 2001 an agreement was reached between the Health Service Employers Agency (HSEA) and the Irish Medical Organisation (IMO) whereby General Practitioner are entitled to a complete rate in respect of persons aged 70 or over in private nursing homes (approved by the Health Service Executive) for continuous periods in excess of five weeks on or after 1st July 2001.

The terms of the agreement have effect from 1st July 2001. In view of the date on which the agreement was reached it was not possible to have all the necessary administrative arrangements in place to ensure the full implementation of the terms of agreement as of the 1st July 2001. Therefore on a transitional basis which was not to exceed the 31st December 2001, it was agreed that anyone who applied and was entitled to a medical card before the 31st December 2001, would have retrospective effect to 1st July 2001 for payment purposes.

Procedure for claiming payment:
Following the introduction of a coding structure within the PCRS, Medical Card staff effectively now code Nursing Home Clients thereby generating an automatic payment to the General Practitioner via the Primary Care Reimbursement Service.

The procedure to ensure correct coding of patients is as follows:
When a patient aged 70 or over enters a private Nursing Home registered with the Health Service Executive the General Practitioner or Manager of the Nursing Home should notify the medical card unit in the PCRS immediately by phone call and subsequently in writing.

To ensure accurate coding the Local Health Office will require the following information:

  1. The patients correct medical card number.
  2. The date the patient entered the nursing home.

When the patient is no longer a resident in the Nursing Home, either the Manager of the Nursing Home or the General Practitioner must immediately notify the PCRS medical card unit so that the nursing home code can be removed from the medical card system. This can be done by telephone call followed by verification in writing.

Similarly in the event of a deceased patient, either the Manger of the Nursing Home or the General Practitioner must immediately notify the medical card section so that the patient can be removed from the medical card system. The most effective way of doing this is by telephoning the PCRS medical card unit followed by written confirmation.

Where necessary ensure that a change of doctor form has been completed so that the patient is registered to the correct General Practitioner.

Patients are deemed ineligible for payment for the following reasons:

  1. Patient does not have a valid medical card or the card was withdrawn prior to the start of the scheme.
  2. Patient is not over 70 years of age.
  3. Patient is not a resident of a Nursing Home registered with the Health Service Executive.
  4. Patient is not a long-term resident of the Nursing Home (i.e. residents for 5 weeks or more since the 1st July 2001).

Coding
Patients are coded in two different categories:

903- A standard over 70’s medical card patient in a private nursing home (approved by the Health Service Executive).

906- An over 70’s patient with automatic medical card eligibility in a private nursing home (approved by the Health Service Executive).

Note: As per the terms of the agreement the capitation rate will apply to patients aged 70 or over in private nursing homes (approved by the health Service Executive) for continuous periods in excess of five weeks.

Therefore it should be noted that from the time a patient is coded in the PCRS retrospective payment will be made 5 weeks following the date of coding.

This will generate an automatic payment to the General Practitioner via the Primary Care Reimbursement Service.

Eligible for payment:
Clients must hold a medical card that was valid sometime between 1st April 2001 and the present. Must have registered first with the General Practitioner claiming payment, i.e. should not have been previously registered with another General Practitioner. The once off payment is issued to the General Practitioner that the patient is first registered with.

Coding
902 –
Asylum Seeker
This code applies to Asylum Seekers only not Non-EU Nationals.

Services rendered under the General Medical Services Scheme — Capitation Agreement—payment to a general practitioner in respect of the registration of asylum seekers

Description Amount
Asylum seeker/non EU registration fee (a once-off super-annual registration fee) €173.69