Endorsement of All Complaints Filed against Health Maintenance Organizations (HMOs) with the Grievance Machinery of the Association of Health Maintenance Organizations of the Philippines, Inc. (AHMOPI) for Mediation during the Transition Period

December 22, 2015 INSURANCE CIRCULAR LETTER NO. 059-15 Supersedes: None TO : All Health Maintenance Organizations (HMOs) Doing or Intending to do Business in the Philippines and Planholders Concerned SUBJECT : Endorsement of All Complaints Filed against Health Maintenance Organizations (HMOs) with the Grievance Machinery of the Association of Health Maintenance Organizations of the Philippines, Inc. (AHMOPI) for Mediation during the Transition Period WHEREAS, Executive Order No. 192, Series of 2015 (EO 192, s. 2015) which transferred the regulation and supervision of Health Maintenance Organizations (HMOs) to the Insurance Commission (IC), was signed by the President on November 12, 2015 and took effect on November 17, 2015; aScITE WHEREAS, the IC is authorized to formulate, adopt and implement such rules, regulations, and other issuances as may be necessary for the effective implementation of the aforementioned executive order; WHEREAS, complaints filed against HMOs after the effectivity of EO 192, s. 2015 were endorsed by the Department of Health (DOH) to IC; WHEREAS, the IC is still in the process of formulating the implementing rules and regulation and the transfer of records and documents from the DOH to the IC; WHEREAS, there is a need to provide an adequate grievance machinery procedure during the transition period to protect the interests and welfare of the HMO plan holders; WHEREAS, the Association of Health Maintenance Organizations of the Philippines, Inc. (AHMOPI), an umbrella organizations of HMOs, has existing grievance machinery for complaints filed against its members; NOW, THEREFORE, pursuant to the authority vested in the Insurance Commission under existing laws, the following are hereby promulgated: 1. All complaints filed against an HMO received by the Insurance Commission, including its District Offices, will be endorsed to the grievance machinery of the Association of Health Maintenance Organizations of the Philippines, Inc. (AHMOPI); 2. AHMOPI is hereby authorized to conduct mediation proceedings of all complaints endorsed by this Commission against any HMO ( Whether or not a member of AHMOPI ); HEITAD 3. The AHMOPI is enjoined to conclude all mediation proceedings within thirty (30) days from receipt of the endorsement of the complaint from this Commission; 4. In the event that the parties fail to reach an amicable settlement, the AHMOPI will forward the complaint, including all records pertaining thereto, to this Commission for appropriate action in accordance with the implementing rules and regulations to be issued; and 5. The AHMOPI is authorized to mediate until such time that the Commission has already issued the appropriate implementing rules and regulation or until this Circular Letter is expressly revoked. All HMOs, including non-members of AHMOPI, are enjoined to recognize the authority to mediate given to the AHMOPI during the transition period. For strict compliance. (SGD.) EMMANUEL F. DOOC Insurance Commissioner