Amended Guidelines for the Implementation of the Medical Assistance to Indigent and Poor Patients in Government Hospitals

June 16, 2015

DOH ADMINISTRATIVE ORDER NO. 2015-0025

 

I. Background and Rationale

Republic Act No. 10651, the General Appropriations Act (GAA) of FY 2015, allocated One Billion Eight Hundred Forty Nine Million Pesos (Php1,849,000,000.00) to the Department of Health (DOH). The fund shall be utilized for the grant of medical assistance to indigent and poor patients.

II. Scope

These guidelines shall apply to all offices and persons involved in the implementation of medical assistance to indigent and poor patients in government hospitals.

III. Objective

These guidelines are promulgated to rationalize the process in the allocation and utilization of the medical assistance fund.

IV. Definition of Terms

1. Government Hospitals — refers to hospitals owned or managed by the government through the DOH, Local Government Units (LGUs) and State Universities and Colleges (SUCs).

2. Medical Assistance Fund — represents the allocation in the 2015 GAA intended for medical assistance to indigent or poor patients.

3. Retained Hospitals — refers to all hospitals under the management and operation of the DOH.

4. Specialty Hospitals — refers to the four (4) corporate hospitals under the DOH namely, the Philippine Heart Center (PHC), National Kidney and Transplant Institute (NKTI), Lung Center of the Philippines (LCP) and the Philippine Children's Medical Center (PCMC).

5. LGU Hospitals— refers to hospitals owned or managed by LGUs.

6. SUC Hospitals — refers to hospitals owned or managed by SUCs.

7. Other government hospitals — hospitals owned or managed by other government agencies.

8. Indigent or Poor Patients — are persons who cannot meet their basic needs or who have income/s but are insufficient to fully meet their medical expenses, respectively, and are seeking medical services as in patient, whether confined in a ward, Intensive Care Unit (ICU) or small private room, or out patient in government hospitals.

V. Implementation Mechanisms

A. Eligible Beneficiaries. The beneficiaries shall be indigent or poor patients.

B. Implementation Process.

1. The amount of Seven Hundred Eighty Four Million Two Hundred Four Thousand Pesos (Php784,204,000.00) has automatically been incorporated in the budget of the DOH retained hospitals. (See Annex "A") SDHTEC

2. The DOH Financial Management Service shall transfer the remainder of the funds to the Regional Health Offices and DOH retained hospitals, however, for SUCs, and Specialty hospitals fund transfer shall be done after the previously downloaded funds have been liquidated in accordance with pertinent budgeting and auditing rules and regulations.

3. The Regional Office shall transfer funds to LGU Hospitals upon the submission of a bill of medical services incurred by the indigent or poor patient/s.

4. The Medical Assistance Fund may be utilized by SUCs, Specialty and LGU hospitals upon the signing of Memorandum of Agreement (MOA) between the following:

Types of Hospital	Parties to the MOA
SUCs and Specialty	DOH and Chief of Hospital/President of the
Hospitals	University (Annex B)
LGU Hospitals	DOH Regional Director, Head of LGU and
	Chief of Hospital (Annex C)

5. The downloaded or transferred funds shall be the responsibility and accountability of the Medical Center Chief of the concerned government hospital. He shall ensure that all the funds are properly utilized consistent with the GAA and COA guidelines.

6. Medical assistance extended to beneficiaries in government hospitals requiring MOA prior to the effectivity of this Order may be reimbursed and deducted from their respective fund allocation once the MOA is signed.

7. The medical assistance shall include the following:

a. All laboratory and other diagnostic procedures, including minor and major surgical procedures, whether emergency or elective as required by the attending physician, except those that are for aesthetic purposes.

b. All dental services such as examination and extraction, except prophylaxis and prosthesis;

c. All drugs, medicines, and medical supplies as prescribed by the attending physician; and

d. All hospital bills including professional fees, provided that the expenses for professional fees shall only be at most fifty percent (50%) of the amount of the assistance.

8. All concerned government health facilities shall ensure the availability of medicines, equipment supplies, materials and other health care services needed by eligible patients. In the event of non-availability of the needed medicines, equipment supplies, materials and other health care services, the concerned government health facility may enter into contract with DOH-accredited health care providers (e.g., hospitals, pharmacies) within its area to provide the same to the eligible beneficiaries.

9. The Medical Assistance Fund can likewise be used for the payment of PhilHealth premiums under the Point of Care program subject to the guidelines specified in PhilHealth Circular No. 32 series of 2013. (Annex D)

C. Approving Authority. Requests for medical assistance under the program shall be approved by the concerned Chief of Hospital.

D. Maximum Amount. The Chief of Hospital is authorized to approve a maximum amount of One Hundred Thousand Pesos (P100,000.00) per patient. Any excess shall require approval of the Secretary of Health or by his/her authorized representative.

E. Documentary Requirements. The applicant shall present pertinent documents (e.g., Doctor's Prescription/Request, Billing Statement, Case Summary or Medical Abstract from DSWD/Certificate of Indigency from his/her Barangay) to the concerned hospital's Medical Social Worker (who may also issue a Case Summary/Medical Abstract/Case Referral in lieu of the one issued by DSWD), who will assist the patient in availing of the medical assistance.

VI. Monitoring and Evaluation

1. The concerned hospitals shall submit a monthly fund utilization report to the Financial and Management Service on or before the 7th day of succeeding month, including (a) names and addresses of patients and medical services rendered to and/or drugs and medicines they received, (b) type of medical assistance given and other related information, and (c) the amounts given to individual patients as well as the total amount of medical assistance given for the month.

2. An annual Program Review shall be conducted by the DOH to assess the impact of the program on its thrusts and to commend government hospitals for their support and partnership in the utilization of the Medical Assistance Fund.

VII. Separability Clause

If any part or provision of this Order is held invalid, the other provisions not affected shall remain in full force and effect.

VIII. Effectivity Clause

This Administrative Order shall take effect upon its publication in a newspaper of general circulation or in the DOH website.

IX. Repealing Clause

All existing administrative issuances and Memoranda of Agreement (MOA) relative to the medical assistance to indigent and poor patients are hereby repealed/rescinded. AScHCD

(SGD.) JANETTE P. LORETO-GARIN, MD, MBA-HSecretary

ANNEX A

		FY 2015 Medical Health Care Assistance of Hospitals
Program/Activity/Project
			Subsidies-Others
Total Hospital	784,204
Operation of Special Hospitals, Medical Centers and Institutes	160,090
for Disease Prevention and Control
	a.	Jose Reyes Memorial Medical Center, (A-450), (IBC-525)	28,105
	b.	Rizal Medical Center, (A-300), (IBC-273)	1,750
	c.	East Avenue Medical Center, (A-600), (IBC-586)	34,467
	d.	Quirino Memorial Medical Center, (A-350), (IBC-350)	21,950
	e.	Tondo Medical Center, (A-200), (IBC-243)	3,455
	f.	Jose Fabella Memorial Hospital (A-700), (IBC-513)	5,850
	g.	National Children's Hospital, (A-250), (IBC-200)	5,000
	h.	National Center for Mental Health (A-4200), (IBC-3151)	1,155
	i.	Philippine Orthopedic Center, (A-700), (IBC-645)	21,854
	j.	San Lazaro Hospital, (A-500), (IBC-463)	13,204
	k.	Research Institute for Tropical Medicine (A-50), (IBC-37)	4,550
	l.	Amang Rodriguez Medical Center, (A-150), (IBC-204)	18,750
Operation of Regional Medical Centers, Sanitari and Other Hospitals	624,114
	1.	Valenzuela Medical Hospital, Secondary (A-200) (IBC-	13,854
		100), Valenzuela, Metro Manila
	2.	Las Piñas General Hospital and Satellite Trauma Center,	5,000
		Secondary (A-200) (IBC-88), Las Piñas Metro Manila
	3.	San Lorenzo Ruiz Special Hospital for Women (A-10) (IBC-	755
		10), Malabon, Metro Manila
	4.	Dr. Jose N. Rodriguez Memorial Hospital, Sanitaria (A-	800
		2000) (IBC-Custodial Care-1419; General Care-50) Tala,
		Quezon City
	5.	Mariano Marcos Memorial Hospital and Medical Center,	2,700
		Tertiary-Medical Center (A-200) (IBC-200), Batac, Ilocos Norte
	6.	Region I Medical Center, Tertiary-Medical Center (A-300)	20,900
		IBC-300), Dagupan City
	7.	Ilocos Training and Regional Medical Center, Tertiary-	12,250
		Regional, (A-300) (IBC-250) San Fernando, La Union
	8.	Cagayan Valley Medical Center, Tertiary-Medical Center (A-	11,850
		500) (IBC-General Care-350), Tuguegarao, Cagayan
	9.	Veterans Regional Hospital, Tertiary-Regional (A-200) (IBC-	8,205
		200), Bayombong, Nueva Vizcaya
	10.	Southern Isabela General Hosp. Tertiary (A-50) (IBC-50),	12,350
		Santiago City, Isabela
	11.	Batanes General Hospital, Tertiary (A-75) (IBC-50),	-
		Basco, Batanes
	12.	Baguio General Hospital and Medical Center, Tertiary-	17,500
		Medical, (A-400) (IBC-400), Baguio City
	13.	Luis Hora Memorial Regional Hospital Tertiary-Regional (A-	700
		150) (IBC-75), Bauko, Mt. Province
	14.	Conner District Hosp. (A-25) (IBC-18), Conner, Apayao	250
		Province
	15.	Far North Luzon General Hospital and Training Center (A-	1,500
		100) (IBC-35), Luna, Apayao Province
	16.	Dr. Paulino J. Garcia Memorial Research & Medical Center,	17,250
		Tertiary-Medical Center (A-400) (IBC-400), Cabanatuan City
	17.	Talavera Extension Hospital, Secondary (A-50) (IBC-11),	-
		Talavera, Nueva Ecija
	18.	Jose B. Lingad Memorial General Hospital, Tertiary-	11,550
		Regional, (A-250) (IBC-296) San Fernando, Pampanga
	19.	Mariveles Mental Hospital (A-500) (IBC-500), Mariveles,	-
		Bataan
	20.	Bataan General Hospital, Tertiary (A-350) (IBC-200),	9,500
		Balanga, Bataan
	21.	Batangas Regional Hospital, Tertiary-Regional (A-250)	21,750
		(IBC-200), Batangas City
	22.	Culion Sanitarium and Balala Hospital, Sanitaria (A-600)	-
		(IBC-Custodial Care-200; General Care-50), Culion, Palawan
	23.	Ospital ng Palawan, Tertiary (A-150) (IBC-130), Puerto	16,150
		Princesa City, Palawan
	24.	Bicol Medical Center, Tertiary-Medical Center (A-500) (IBC-	31,850
		510), Naga City
	25.	Bicol Regional Training and Teaching Hospital, Tertiary-	36,000
		Regional (A-250) (IBC-279), Legaspi City
	26.	Bicol Sanitarium, Sanitaria (A-200) (IBC-200), Cabusao,	11,000
		Camarines Sur
	27.	Western Visayas Medical Center, Tertiary-Medical Center	26,700
		(A-400) (IBC-368), Iloilo City
	28.	Corazon Locsin Montelibano Memorial Regional Hospital,	30,450
		Tertiary-Regional (A-400) (IBC-400), Bacolod City
	29.	Western Visayas Sanitarium (A-300) (IBC Custodial Care-	1,250
		150; General Care 50), Sta. Barbara, Iloilo City
	30.	Don Jose S. Monfort Medical Center, Ext. Hosp., Tertiary	1,000
		Medical Center (A-50) (IBC-27), Barotac Nuevo, Iloilo
	31.	Vicente Sotto Sr. Memorial Medical Center, Tertiary-	83,650
		Medical Center (A-800) (IBC-619), Cebu City
	32.	Gov. Celestino Gallares Memorial Hospital, Tertiary-	19,300
		Regional (A-225) (IBC-250), Tagbilaran City
	33.	St. Anthony Mother and Child Hospital, Secondary (A-25)	-
		(IBC-25), Cebu City
	34.	Eversley Child Sanitarium, Sanitaria (A-500) (IBC	8,000
		Custodial Care-200; General Care-50), Mandaue City
	35.	Talisay District Hospital (A-25) (IBC-25), Talisay, Cebu	-
	36.	Don Emilio del Valle Memorial Hospital (A-50) (IBC-27),	1,500
		Ubay, Bohol
	37.	Eastern Visayas Regional Medical Center, Tertiary Medical	27,700
		Center (A-250) (IBC-273), Tacloban City
	38.	Schistosomiasis Hospital, Secondary Medical Center, (A-	350
		25) (IBC-25) Palo, Leyte
	39.	Zamboanga City Medical Center, Tertiary-Medical Center	23,300
		(A-250) (IBC-251), Zamboanga City
	40.	Mindanao Central Sanitarium, Sanitaria (A-450) (IBC
		Custodial Care-100; General Care-13), Pasabolong,	-
		Zamboanga City
	41.	Sulu Sanitarium, Sanitaria (A-130) (IBC-115), San	-
		Raymundo, Jolo, Sulu
	41.	Labuan Public Hospital (A-10) (IBC-10), Labuan,	300
		Zamboanga City
	42.	Basilan General Hospital, Tertiary (A-100) (IBC-25),	-
		Isabela, Basilan
	43.	Dr. Jose Rizal Memorial Hospital, Tertiary (A-200)	550
		(IBC-75), Dapitan City, Zamboanga del Norte
	44.	Margosatubig Regional Hospital, Tertiary-Regional (A-300)	300
		(IBC-121), Margosatubig, Zamboanga del Sur
	45.	Northern Mindanao Medical Center, Tertiary-Medical	22,000
		Center (A-300) (IBC-335) Center, Cagayan De Oro City
	46.	Mayor Hilarion A. Ramiro Sr. Regional Training and
		Teaching Hospital, Tertiary-Regional (A-150) (IBC-150),	5,000
		Ozamis City
	47.	Amai pakpak Medical Center, Tertiary-Medical Center (A-	6,100
		200) (IBC-75), Marawi City, Lanao del Sur
	48.	Southern Philippines Medical Center, Tertiary-Medical	65,750
		Center (A-1,200) (IBC-1,200), Davao City
	49.	Davao Regional Hospital, Tertiary-Regional (A-200) (IBC-	20,500
		300), Tagum, Davao Del Norte
	50.	Cotabato Regional and Medical Center, Tertiary-Medical	5,500
		Center (A-400) (IBC-200), Cotabato City
	51.	Cotabato Sanitarium, Sanitaria (A-250) (IBC-Custodial	-
		Care-100; General Care-10), Cotabato City
	52.	Caraga Regional Hospital, Tertiary-Regional (A-150) (IBC-	8,850
		150), Surigao City
	53.	Adela Serra Ty Memorial Medical Center (A-200) (IBC-	2,400
		100), Tandag, Surigao del Sur

 

ANNEX B

Memorandum of Agreement

Know All Men by These Presents:

This agreement is entered into and executed by and between:

The DEPARTMENT OF HEALTH, with office address at ______________, herein represented by JANETTE LORETO-GARIN, MD, MBA-H, in her capacity as the Acting Secretary of Health, herein referred to as the "FIRST PARTY";

-and-

The ___________________, a hospital operating by virtue of ________________, with office address at ___________________, represented herein by ______________, in his capacity as _______________, and herein referred to as the "SECOND PARTY"

WITNESSETH

WHEREAS, the FIRST PARTY, has been providing assistance to patients seeking consultation or being admitted to government hospitals and health care facilities;

WHEREAS, the FIRST PARTY is authorized to enter into a Memorandum of Agreement (MOA) with Specialty and SUC Hospitals pursuant to Administrative Order No. _____ dated _______, 2015 (Amended Guidelines for the Implementation of the Medical Assistance to Indigent and Poor Patients of the Department of Health);

WHEREAS, the SECOND participation shall ensure the efficient implementation of the medical assistance to indigent and poor patients at the Specialty/SUC Hospital level; and

WHEREAS, to ensure a more effective and efficient system of implementation of the medical assistance to indigent and poor patients for Specialty and SUC hospitals, this MOA is being entered into by the Parties.

NOW THEREFORE, for and in consideration of the foregoing premises, the parties hereby agree as follows:

1. Responsibilities of the FIRST PARTY. — The FIRST PARTY shall:

1. Transfer funds for medical assistance to the indigent and poor patients to the SECOND PARTY upon the liquidation of the previously downloaded funds in accordance with pertinent budgeting and auditing rules and regulations.

2. The Public Assistance Unit shall consolidate annual inventory reports of approved medical assistance submitted by the SECOND PARTY, including reports of far-flung hospitals and other health facilities.

3. The Public Assistance Unit shall submit the above mentioned report to the Financial and Management Service in the Central Office.

4. The Office of the Secretary shall conduct periodic on-site monitoring to ensure compliance by the SECOND PARTY with the guidelines of the program.

2. Responsibilities of the SECOND PARTY. — The SECOND PARTY shall:

2.1 Facilitate the implementation of approved medical assistance to eligible patients.

2.2 Ensure the availability of medicines, medical supplies and other health care services needed by the eligible patients. In the event of non-availability of the aforementioned medicines, medical supplies and other health care services, the concerned Specialty/SUC Hospital may enter into contract with DOH-accredited health care providers (e.g., hospitals, pharmacies) within its area to provide the same to the eligible beneficiaries.

2.3 Prepare a monthly fund utilization report reflecting the list of patients and health care services provided. The report shall be signed by the chief accountant or his equivalent, approved by the Chief of Hospitals, and submitted to the DOH Regional Office on or before the 5th day of the succeeding month.

2.4 Secure COA post audit review over any and all transactions related to the medical assistance provided by their hospital.

2.5 Ensure that in no case shall the grant of assistance to eligible patients be delegated and/or transferred to a non-governmental organization, people's organization or other similar organizations.

3. Effectivity & Duration. — This agreement shall take effect upon the signing by authorized representatives of the respective parties, and shall continue to be valid and binding until terminated by any of the parties, or automatically terminated pursuant to paragraph 6 of this agreement. AcICHD

4. Amendment, Modification, Addition or Deletion. — Any amendment, modification, addition or deletion of any provision of this agreement shall be agreed upon by the parties in writing.

5. Termination. — This Agreement shall automatically terminate upon the depletion of the allocation for medical assistance to indigent and poor patients. Termination can also be commenced by any of the parties by giving written notice to the other Party. Such termination shall take effect thirty (30) days from receipt of said notice, unless otherwise qualified by the terminating party.

6. Settlement of Disputes. — The parties shall exert effort to settle amicably any dispute arising out of or in connection with the agreement or its interpretation. Should the parties fail to amicably settle said dispute, any legal action shall be filed before the courts of Manila.

7. Repeating Clause. — All existing Memoranda of Agreement (MOA) on the medical assistance to indigent and poor patients between the parties mentioned in this MOA are hereby repealed.

IN WITNESS WHEREOF, all parties have signed this Memorandum of Agreement on (date) at (place).

JANETTE LORETO-GARIN, MD, MBA-H Chief of Hospital, (name of hospital)

SIGN IN THE PRESENCE OF:

_____________________________ _____________________________

Acknowledgment

Republic of the Philippines )

BEFORE ME, a Notary Public, this ____th day of ____________, 2015 in ________________, personally appeared the following persons:

 Name Government Issued I.D. Place/Date of Issue

 _________________ _________________ _________________

 _________________ _________________ _________________

 _________________ _________________ _________________

known to me and to me known to be the same persons who executed the foregoing Memorandum of Agreement, consisting of three (3) pages including this page, and acknowledged to me that the same is their free and voluntary act and deed, and of the institutions they respectively represent.

WITNESS MY HAND AND SEAL this ____________ in __________________.

Doc. No. _______;

Page No. _______;

Book No. _______;

Series of 2015.

ANNEX C

Memorandum of Agreement

Know All Men by These Presents:

This agreement is entered into and executed by and between:

The DOH REGIONAL HEALTH OFFICE _____, with office address at ________________________________, in his capacity as the Regional Director and in representation of the Department of Health, herein referred to as the "FIRST PARTY"; 

-and-

The ___________________, a hospital operating by virtue of ___________________, with office address at ___________________, represented herein by __________________, in his capacity as ___________, and herein referred to as the "SECOND PARTY"

-and-

The duly elected governor of __________________, (name of governor), with postal address at _______________________ herein referred to as the "THIRD PARTY".

WITNESSETH

WHEREAS, the FIRST PARTY, as an office of the DOH, has been providing assistance to patients seeking consultation or being admitted to government hospitals and health care facilities;

WHEREAS, the FIRST PARTY is authorized to enter into a Memorandum of Agreement (MOA) with Local Government Units (LGUs) pursuant to Administrative Order No. _______ dated ________, 2015 (Guidelines for the Implementation of the Medical Assistance to Indigent and Poor Patients of the Department of Health);

WHEREAS, the SECOND and THIRD PARTY participation shall ensure the efficient implementation of the medical assistance to indigent and poor patients at the Provincial/District Hospital level; and

WHEREAS, to ensure a more effective and efficient system of implementation of the medical assistance to indigent and poor patients, inclusive of a systematic reimbursement process for LGU managed hospitals, this MOA is being entered into by the Parties.

NOW THEREFORE, for and in consideration of the foregoing premises, the parties hereby agree as follows:

1. Responsibilities of the FIRST PARTY. — The FIRST PARTY shall:

1.1 Issue a guarantee letter to the SECOND PARTY for eligible patients through the Public Assistance Unit.

1.2 The Public Assistance Unit shall consolidate annual inventory reports of approved medical assistance submitted by the SECOND PARTY, including reports of far-flung hospitals and other health facilities.

1.3 The Public Assistance Unit shall submit the above mentioned report to the Financial and Management Service in the Central Office.

1.4 Conduct periodic on-site monitoring to ensure compliance by the SECOND PARTY with the guidelines of the program.

2. Responsibilities of the SECOND PARTY. — The SECOND PARTY shall:

2.1 Facilitate the implementation of approved medical assistance to eligible patients.

2.2 Ensure the availability of medicines, medical supplies and other health care services needed by the eligible patients. In the event of non-availability of the aforementioned medicines, medical supplies and other health care services, the concerned LGU Hospital may enter into contract with DOH-accredited health care providers (e.g., hospitals, pharmacies) within its area to provide the same to the eligible beneficiaries.

2.3 Prepare a monthly billing statement reflecting the list of patients and health care services provided. The report shall be signed by the chief accountant or his equivalent, approved by the Chief of Hospitals, and submitted to the DOH Regional Office on or before the 5th day of the succeeding month.

2.4 Secure COA post audit review over any and all transactions related to the medical assistance provided by their hospital.

2.5 Ensure that in no case shall the grant of assistance to eligible patients be delegated and/or transferred to a non-governmental organization, people's organization or other similar organizations.

3. Responsibilities of the THIRD PARTY. — The THIRD PARTY shall:

3.1 Ensure availability of medicines, medical supplies and other health care services at the Provincial/District hospitals.

3.2 Ensure compliance of the SECOND PARTY of all its repertorial responsibilities under this agreement. TAIaHE

4. Effectivity & Duration. — This agreement shall take effect upon the signing by authorized representatives of the respective parties, and shall continue to be valid and binding until terminated by any of the parties, or automatically terminated pursuant to paragraph 6 of this agreement.

5. Amendment, Modification, Addition or Deletion. — Any amendment, modification, addition or deletion of any provision of this agreement shall be agreed upon by the parties in writing.

6. Termination. — This Agreement shall automatically terminate upon the depletion of the allocation for medical assistance to indigent and poor patients. Termination can also be commenced by any of the parties by giving written notice to the other Party. Such termination shall take effect thirty (30) days from receipt of said notice, unless otherwise qualified by the terminating party.

7. Settlement of Disputes. — The parties shall exert effort to settle amicably any dispute arising out of or in connection with the agreement or its interpretation. Should the parties fail to amicably settle said dispute, any legal action shall be filed before the courts of Manila.

8. Repealing Clause. — All existing Memoranda of Agreement (MOA) on the medical assistance to indigent and poor patients between the parties mentioned in this MOA are hereby repealed.

IN WITNESS WHEREOF, all parties have signed this Memorandum of Agreement on (date) at (place).

 _____________________________ _____________________________ DOH Regional Director for (place) Chief of Hospital, (name of hospital)

_________________________

SIGN IN THE PRESENCE OF:

 _____________________________ _____________________________

Acknowledgment

Republic of the Philippines)

BEFORE ME, a Notary Public, this _____th day of ____________, 2014 in ________________, personally appeared the following persons:

 Name Government Issued I.D. Place/Date of Issue

 _________________ _________________ _________________

 _________________ _________________ _________________

 _________________ _________________ _________________

known to me and to me known to be the same persons who executed the foregoing Memorandum of Agreement, consisting of four (4) pages including this page, and acknowledged to me that the same is their free and voluntary act and deed, and of the institutions they respectively represent.

WITNESS MY HAND AND SEAL this ____________ in _____________.

Doc. No. _______;

Page No. _______;

Book No. _______;

Series of 2015.

October 14, 2013

PHILHEALTH CIRCULAR NO. 032-13

 

I. Rationale

Republic Act (RA) 7875, as amended by RA 10606, otherwise known as The National Health Insurance Act of 2013 under Section 6 states that: "All citizens of the Philippines shall be covered by the National Health Insurance Program. In accordance with the principles of universality and compulsory coverage enunciated in Section 2 (b) and 2 (l) hereof, implementation of the Program shall ensure sustainability of coverage and continuous enhancement of the quality of service: Provided, That the Program shall be compulsory in all provinces, cities and municipalities nationwide, notwithstanding the existence of LGU-based health insurance programs . . ." CASTDI

Furthermore, Section 3 (c) of the same Act emphasizes the need to "prioritize and accelerate the provision of health services to all Filipinos, especially that segment of the population who cannot afford such services". Moreover, Section 7 clearly mentions that "all indigents not enrolled in the Program shall have priority in the use and availment of the services and facilities of government hospitals, health care personnel and other health organizations: Provided, however that such government health care providers shall ensure that said indigents shall subsequently be enrolled in the Program".

Under the ambit of Universal Health Care (UHC) or Kalusugang Pangkalahatan (KP), the Corporation aspires to ensure that all Filipinos, especially the most vulnerable are covered by PhilHealth. Despite the national government appropriations, sin tax collections, local government sponsorship and other sources, statistics and anecdotes have shown that a vast number of poor are not yet covered by PhilHealth. Ergo, it is deemed necessary that as the other mechanisms of capturing the poor are being undertaken, a mechanism of enrolling these patients at the Point of Care shall be established to ensure that all poor in dire need of quality health services in government hospitals are covered by PhilHealth.

II. Coverage

The following patients, and their families, shall be provided with PhilHealth coverage and shall be considered as Sponsored Program Members by the Hospital if they qualify on the assessment administered by the Medical Social Worker at the time that they were admitted to Government Health Care Institutions:

1. Non-members, who were assessed and classified as Class C-3 or D.

2. Members who are not covered due to lack of qualifying contribution and classified as Class C-3 or D.

Corollary to this, patients availing of outpatient services (e.g., Cataract Surgery, Hemodialysis and the like) shall not be enrolled. However, Hospital-Sponsored Members (HSMs) may avail of these outpatient services for their succeeding hospitalization.

III. Participation of Health Care Institutions

All DOH-retained hospitals shall mandatorily implement the program while participation of Local Government Unit (LGU) hospitals shall be subject to the Corporation's approval upon submission of Letter of Intent. Other government hospitals (i.e., DND hospitals, academic hospitals, state hospitals and the like) may also participate in the program upon approval of the Corporation on the Letter of Intent submitted. cAaDCE

IV. General Policies

1. Identification of Qualified Hospital-Sponsored Members

All non-members and non-eligible members for admission/admitted shall be interviewed and assessed by the Medical Social Worker using the intake survey sheet prescribed in DOH Administrative Order 51, s-2001 and/or other issuances relative to it. As much as practicable, assessment by the MSW shall be conducted upon admission. Patients classified as Class C3 or Class D shall be enrolled accordingly. 

2. Sponsor. The Health Care Institution (HCI) shall be the premium donor for these HSMs. Under no circumstance shall the hospital ask the patient of any amount as their share for premium.

3. Premium Cost & Coverage

a. Rate. The amount of premium shall be the same rate as the annual premium for Sponsored Program Members. (Currently at Php2,400 per year).

b. Validity. The coverage of HSMs shall be from the first day of the confinement month and shall end on the last day of the same year.

4. Benefits. HSMs shall be provided an immediate availment of NHIP benefits, including but not limited to: inpatient benefits, outpatient benefits (except Primary Care Benefit 1) and No Balance Billing.

5. Claims Reimbursement

a. HSM claims shall be processed by PhilHealth within thirty (30) days upon receipt of completed claim documents.

b. HSM claims shall not be returned to hospital for membership and eligibility concerns. However, policies for claims processing shall still apply and the Corporation reserves its right to return or ultimately, deny claims for other benefit availment and accreditation issues.

6. Ensuring Sustainability of Coverage. PhilHealth shall submit a list of HSMs to DSWD for validation. Those validated as poor shall be included in the National Household Targeting System (NHTS) list and thus, shall be covered for the succeeding years under the Sponsored Program.

7. Monitoring and Evaluation. The Corporation shall device a mechanism for monitoring and evaluation of the program with consideration to utilization of benefits and other pertinent statistical reports. aDHCEA

V. Repealing Clause

All provisions of previous issuances that are inconsistent with any provisions of this Circular are hereby amended/modified or repealed accordingly.

VI. Effectivity

This Circular shall take effect fifteen (15) days after publication in any newspaper of general circulation and shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.

(SGD.) ALEXANDER A. PADILLAPresident and CEO