Under the provisions of the Health Act 1970 (as amended), eligibility for health services in Ireland is based primarily on residency and means. The Act provides that persons who are unable, without undue hardship, to arrange GP services for themselves and family can qualify for a medical card. The HSE can only award medical cards in accordance with the Health Act and, therefore, it must assess applicants on the overall financial situation of the applicant and his or her spouse or partner. The HSE gives effect to this legislation through its Medical Card National Assessment Guidelines.
The HSE is obliged to operate within the legal parameters as set out in the Health Act, while also responding to the variety of circumstances and complexities faced by individuals who apply for a medical card. Under the legislation, there is no entitlement to a medical card based on having a particular disease or illness (nor has there been previously). However, if an applicant’s means are above the financial thresholds as set out in the national guidelines, the HSE routinely examines for indications of medical or social circumstances which might result in undue financial hardship in arranging medical services and, exercising discretion, may grant eligibility for a medical card on this basis. Where persons submit an application, as a new applicant or a renewal review, without additional medical documentation and are refused, they will receive a letter giving a calculation of the guideline thresholds and where these have been exceeded. Also, at this stage, they are informed of the option to furnish further medical documentation, to demonstrate medical expenditure related to an illness or disease, in support their application. The HSE has a panel of Community Medical Officers to assist in the processing of applications for medical cards on a discretionary basis, where the income guidelines are exceeded but where there are difficult personal circumstances, such as an illness or physical disability.
Where discretion is exercised with regard to an applicant with an illness or disease, it is the medical costs of that condition on a person's financial situation that is relevant to the assessment for a medical card. In accordance with the legislation, it is not possible to award a medical card by virtue of an illness or a disease or the severity thereof.
The National Assessment Guidelines for a medical card or GP visit card state that the ‘exercise of discretion by the HSE, in favour of the applicant, should be considered where meeting the costs of services covered by a medical card or a GP visit card compromises the applicant’s or his/her family’s ability to meet reasonable expenditure.
The HSE will give consideration to a range of medical or social factors that present on an application in deciding whether to approve a medical card on grounds of "undue hardship" or "unduly burdensome", having regard to the applicant's overall financial situation, in the arranging of GP services by the applicant for himself/herself and dependants.
The decision maker may make appropriate inquires or seek advice from other sources to assist with coming to a decision on the applicant's overall financial ‘undue hardship’/’undue burden’, including the applicant’s doctor, Social Worker, Money Advice and Budgeting Service (MABS) and the HSE’s Medical Officers.
I trust the above reply outlines the circumstances, in addition to income, taken into account in deciding whether to approve medical card eligibility on discretionary grounds. More detailed information is contained in the HSE's Medical Card National Assessment Guidelines, which are available from the HSE's Primary Care Reimbursement Service.
