Foilsiú
Operational Guidelines: Treatment Benefit Scheme
Foilsithe
An t-eolas is déanaí
Teanga: Níl leagan Gaeilge den mhír seo ar fáil.
Foilsithe
An t-eolas is déanaí
Teanga: Níl leagan Gaeilge den mhír seo ar fáil.
The Treatment Benefit scheme provides dental, optical, aural and non surgical hair replacement services and products to insured workers, the self-employed, retired people and their dependant spouse/partner who have the required number of social insurance (PRSI) contributions.
Under the scheme, a person currently may qualify for:
- annual oral examination
A complete oral examination of hard and soft tissue, medical and dental history, recording of missing teeth, diagnosis and treatment plan. The fee for examination includes any necessary intra-oral radiographs
- payment of €42 towards either a scale and polish or, if clinically necessary, periodontal treatment, once a calendar year. If the cost of either cleaning or periodontal treatment is more than €42, the customer must pay the balance - capped at €15 for a scale and polish. There is no cap on the balance charged for periodontal treatment.
- free eyesight test every 2 years, up to 3 repeat exams can be covered if clinically necessary
- free spectacles or contribution of €42 if upgraded frames desired. Both reading and distance covered or bifocals
- Contact lenses instead of glasses if desired
- Repairs to glasses if required, max 2 in 2 years.
- a maximum grant of €500 per hearing aid every four years (this changed from a matching grant up to 27 March 2021)
- a maximum grant of €100 per hearing aid towards the cost of repairs, one repair every four years (this changed from a matching grant up to 27 March 2021)
- medically required contact lenses – up to €500 per lens, every two years (this changed from a matching grant up to 27 March 2021, frequency changed from every four years to every two years from June 2022)
- hair replacement benefit - a maximum grant of up to €500 per non-surgical scalp product such as wig or hairpiece, once a calendar year.
The main provisions are in
The Treatment Benefit scheme is administered from:
St Oliver Plunkett Road, Letterkenny, Co. Donegal.
A person must have a certain number of PRSI contributions paid in total and in the Governing Contribution Year (GCY)* to qualify for Treatment Benefit. The total required is either 39 or 260 according to the age of the insured person.
For persons over 21 years of age 39 contributions must also have been paid or credited in the relevant GCYs, with certain exceptions.
Qualified Adults (spouses or partners of qualified insured persons and subject to dependency conditions) are also entitled to Treatment Benefit.
* The Governing Contribution Year (GCY) is the second last complete contribution year before the benefit year in which the claim is made.
Almost two and a quarter million people are eligible for Treatment Benefit. To qualify, people must have paid class A, E, P, H or S social insurance (PRSI) contributions (2). The number of social insurance contributions needed depends on age and are set out in detail below.
- At least 39 paid or credited contributions in the governing contribution years (Example: For claims made in 2020, the second last contribution year is 2018 and the third last contribution year is 2017)
or,
- 26 paid contributions in each of the second and third last contribution years (Example: For claims made in 2020, the second last contribution year is 2018 and the third last contribution year is 2017)
- At least 39 weeks paid or credited contributions on which the claim is based. Governing contribution year (2018 is the governing contribution year for claims made in 2020)
or,
- 26 paid contributions in each of the second and third last contribution year. For claims made in 2020, the second last contribution year is 2018 and the third last contribution year is 2017.
- have 260 social insurance (PRSI) contributions paid at any time and 39 paid or credited contributions in any governing contribution year or the year immediately before it.
Note: The governing contribution year is the second last completed contribution year before reaching 66 years of age. Example: If they were 66 in 2010, the governing contribution year is 2008. If they were 66 in 2012, the governing contribution year is 2010.
- Have 260 social insurance (PRSI) contributions paid at any time and 26 paid contributions in both the governing contribution year and the year immediately before it. The governing contribution year is the second last completed contribution year before reaching 66 years of age.
If people satisfy these conditions when they reach pension age, they will remain qualified for life.
Qualified at 60 and over – if people qualify for benefit at age 60-65, they keep that entitlement for life.
(2) Serving members of the defence forces are not covered for dental or optical exams (these are to be provided by their employers) but they are covered once they have retired. Their spouses are covered.
- have a gross income (before deductions) of €100 or less per week. If earning more than €100 per week, they must have been dependent on you before entering or resuming insurable employment (at class A, E, H, P or S)
- not be getting a social welfare payment, except Disablement Pension, Supplementary Welfare Allowance, Carer's Benefit or Child Benefit. If getting Carer's Allowance or State Pension (Non-contributory) they can qualify if they were dependent on you immediately before getting the allowance or pension
If an insured person dies and the dependant spouse or civil partner was entitled to benefit at the time of the death, they keep their entitlement for as long as they remain widowed or a surviving civil partner.
A dependent widow/widower 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.
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 of PRSI contributions to qualify on their own insurance record.
A person who was regarded as a Qualified Adult prior to receiving a Carer’s Allowance or a State Pension (Non-Contributory) in their own right continues to be regarded as a Qualified Adult for Treatment Benefit.
Volunteer Development Workers 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.
Members of the Permanent Defence Forces are entitled to the full range of benefits under the Medical Appliance scheme but are not entitled to receive Dental or Optical examinations, both of which should be supplied by the Department of Defence. They are entitled to the supply and repair of spectacles.
The Qualified Adults of such members are entitled to the full range of treatments available under the Treatment Benefit scheme.
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 takes up employment on arrival in the State and 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.
Brexit : Ireland / United Kingdom Social Security arrangements from 1 January 2021.
The European Union and the United Kingdom agreed a Trade and Cooperation Agreement which contains a Protocol on Social Security to take effect from 1 January 2021. The Protocol provides for a wide range of social security issues into the future. On the 31 December 2020, the Convention on Social Security agreed between Ireland and the United Kingdom was commenced. Together these Agreements ensure, that all existing social security arrangements for Irish & UK citizens are maintained into the future. Ireland as an EU Member State, will extend on a unilateral basis the advantages of the Convention to Union citizens, as required.
For Brexit-related information see:
For information on social welfare entitlements see:
Under this scheme insured persons and qualified adults are entitled to one eye examination free of charge, and to the supply and repair of spectacles/contact lenses once every two calendar 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 and are included on a panel of approved providers.
Patient Fees: Payment in respect of Optical Benefit is only payable when the examination is carried out by a person who is a member of the department’s 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 gov.ie/treatmentbenefit.
(See also Part 2 re Optical and Medical Appliance Benefit Claims).
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 the Treatment Benefit Section. The patient pays the practitioner in full for services received abroad 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.
An annual free dental examination and a reduced annual fixed cost scale and polish are available to all qualified insured persons and their Qualified Adult.
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 and are included on a panel of approved providers.
Patient fees: Payment in respect of dental examinations will only be made when the examination is carried out by a dentist who is a member of the department's Panel.
Further information about Dental Benefit is available from your local dentist or on request from the Treatment Benefit Section or at gov.ie/treatmentbenefit.
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 the Treatment Benefit Section. The patient pays the practitioner in full for services received abroad 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.
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.
The department also pays the full cost of a non-surgical hair replacement product, subject to a fixed maximum.
Suppliers: Payment under the Medical Appliance scheme is only made in respect of products purchased or repaired by suppliers who have a contract with the department and are on the list of approved providers.
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. The patient pays the practitioner in full for services received abroad 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.
A claimant for Medical Appliance Benefit must supply certification from a medical practitioner (such as your GP, ophthalmologist or medical consultant), that a product is required for medical reasons, before the claim is approved
A non-surgical scalp hair replacement product can be provided where a medical practitioner (including a cancer nurse specialist) has certified that hair loss (Alopecia) results from one of the following conditions:
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 Optical and Dental examinations.)
Claims for Dental Benefit are made on behalf of the claimant by the dentist, who accepts the claimant as a patient.
They can check eligibility and claim payment on-line with the patient’s consent. Alternatively, you can check your eligibility for any of the benefits available with a provider or online at MyGovID.
Dental Benefit is a pre-approval scheme; your eligibility needs to be approved before you receive treatment.
For dependant spouse claims, eligibility must be checked using a DE2 form signed by both customer and their spouse. If qualified, an approval form will issue to customer and panellist (if nominated).
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.
Claims for Optical Benefit are made on behalf of the claimant by the optician who accepts the claimant as a patient.
They can check eligibility and claim payment on-line with the patient’s consent. Alternatively, you can check your eligibility for any of the benefits available with a provider or online at MyGovID.
Optical Benefit is a pre-approval scheme; your eligibility needs to be approved before you receive treatment.
For dependant spouse claims, eligibility must be checked using a OE2 form signed by both customer and their spouse. If qualified an approval form will issue to customer and panellist (if nominated).
Claims for medical appliances (hearing aids) are made on behalf of the claimant by the Audiologist who accepts the claimant as a patient.
Claims for medically required contact lenses are made in limited circumstances on behalf of the claimant by the optician or ophthalmologist who accepts the claimant as a patient.
Claims for non-surgical hair replacement, e.g. wigs or hairpieces, for people suffering from hair loss on their scalp as a direct result of a disease or treatment of a disease are made on behalf of the claimant by the hair replacement product provider who accepts the claimant as a customer
They can check eligibility and claim payment on-line with the patient’s consent. Alternatively, you can check your eligibility for any of the benefits available with a provider or online at MyGovID.
Medical Appliance Benefit is a pre-approval scheme; your eligibility needs to be approved before you receive treatment.
For dependant spouse claims eligibility must be checked using a ME2 form signed by both customer and their spouse. If qualified an approval form will issue to customer and panellist (if nominated).
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:
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.
The application must be submitted and approved before the treatment is commenced.
The time within which examination or appliance may be obtained is as follows:
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 certification form, which is provided by the department, ,signed by a doctor/medical practitioner before payment is made by the department.
Entitlement checks for Treatment Benefit are entered on the Treatment Benefit WelfarePartners on-line portal 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 is notified accordingly.
Where eligibility is not approved, the customer will be notified directly and given the opportunity to supply further information and/or appeal the decision.
Where an eligibility application is disallowed, a disallowance notice issues to the claimant. This gives
Payment for Treatment Benefit is made directly to the panellists on a monthly basis. Before payment is made the Panellist is required to confirm that the listed treatment has been completed.
Under the scheme, the department will only pay for one Dental Examination per year. 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 or pair of hearing aids once in four years.
Under the scheme, the department will only pay for medical lenses once in two years.
Under the scheme, the department will only pay for a non-surgical scalp hair replacement product once per calendar year
Claims and Furnishing of Information - see separate guideline "Claims and Late Claims" for more information.
Overpayments - see separate guideline "Overpayments" for more information.
To include list of hair replacement providers when available