Guidelines for the Implementation of the 2017 Medical Assistance Program (MAP) in DOH Hospitals and Other Selected Government Health Facilities

February 1, 2017

DOH ADMINISTRATIVE ORDER NO. 2017-0003

 

I. RATIONALE

The Philippine Health Agenda (PHA) 2016-2022, seeks to ensure financial protection for all Filipinos. In 1995, the Philippine Health Insurance Corporation (PhilHealth) was created to provide the National Health Insurance Program (NHIP) on a universal coverage. However, a significant proportion of Filipinos continue to have no access to adequate health services due to financial reasons. Because of low compliance rate of 40-50% to the DOH No Balance Billing Policy and uniform costing of PhilHealth benefits, high out-of-pocket expense at an average of 56% of the total health expenditure was estimated in 2013.

Thus, pursuant to Section 13 of the General Appropriations Act of 2017, the Assistance to Indigent Patients Budget shall fund the Medical Assistance Program (MAP) of the Department of Health (DOH) to provide financial assistance to poor and indigent patients seeking medical services in government health facilities.

Administrative Order No. 2016-0010 entitled "Revised Guidelines for the Implementation of the Medical Assistance Fund Program in Government Hospitals Starting 2016" has not explicitly discussed the role of PhilHealth and other financing programs. Overlaps of these different sources of funds make the system prone to fraud and weaken the purchasing power of PhilHealth, leading to inefficient fund utilization and ultimately, hindering the achievement of full financial risk protection.

Hence, there is a need to redirect the financing provisions of MAP and to expand and align its coverage with the thrusts of DOH. The revised guidelines will position MAP to supplement and augment provisionally, but not duplicate other existing health financing schemes to ensure that all Filipinos are provided with adequate health care service. HTcADC

II. OBJECTIVES

1. To define the beneficiaries of MAP;

2. To establish guidelines for the implementation of MAP, including but not limited to accessing, processing, monitoring and evaluation of the program; and,

3. To establish mechanisms of accountability and transparency in the use of the MAP fund.

III. SCOPE AND COVERAGE

These guidelines shall apply but not be limited to DOH offices, attached agencies and government health facilities involved in the implementation of MAP, whose intended beneficiaries are all Filipinos, classified as indigent or poor seeking health and medical services in government health facilities.

IV. DEFINITION OF TERMS

1. Medical Assistance Fund — refers to the fund intended for medical assistance to indigent and poor patients.

2. DOH Retained Hospital — refers to a hospital under the management and administration of the DOH.

3. DOH Specialty hospital — refers to the four (4) corporate hospitals under the Secretary of Health, namely: Philippine Heart Center, Lung Center of the Philippines, National Kidney and Transplant Institute and the Philippine Children's Medical Center.

4. Local Government Unit (LGU) Hospital — refers to a hospital managed by the local government units, usually the provincial government.

5. State Universities and Colleges (SUC) Hospital — refers to hospitals managed by State Universities and Colleges.

6. Department of National Defense (DND) Hospital — refers to a hospital managed by the Department of National Defense.

7. Indigent Patient — refers to patient who has no visible means of income, or whose income is insufficient for the subsistence of his/her family, as identified by the Department of Social Welfare and Development (DSWD), LGU social worker or the medical social worker of the health facility.

8. Poor Patient — refers to those not classified as indigent but are otherwise considered poor or with financial difficulty to access adequate medical care and/or pay hospital bills because of certain unavoidable circumstances, as certified by the medical social worker of the health facility where the patient is confined, such as but not limited to:

a. Senior citizens, persons with disability (PWD), orphans, abused women and children as defined by RA 9262 or the Anti-Violence Against Women and Their Children Act of 2004 and RA 7610 or the Special Protection of Children Against Abuse, Exploitation and Discrimination Act;

b. Patients with catastrophic illness or any illness as a primary condition that is life or limb-threatening and requires prolonged hospitalization, extremely expensive therapies or other special but essential care that would deplete one's financial resources, unless covered by special health funding policies;

c. Unemployed or without gainful employment;

d. Suspected or confirmed victims of torture as defined by Republic Act No. 9745 or the Anti-Torture Act of 2009; aScITE

e. Soldiers and police rendered disabled to be gainfully employed and their dependents and dependents of soldiers and police killed in action;

f. Rebel returnees, prisoners of war and their dependents;

g. Victims of calamities or disasters such as but not limited to typhoons, earthquake, whose place of residence are officially under a state of emergency or calamity.

V. GENERAL GUIDELINES

1. MAP shall serve as a transitory measure, to be re-evaluated annually, in paying for medical and surgical services not currently paid for or sufficiently reimbursed by PhilHealth or other financing sources.

2. The DOH shall facilitate efficient sub-allotment, payment and/or transfer of MAP fund to government hospitals.

3. The DOH shall coordinate with other branches of government for the implementation of the MAP.

4. The DOH shall recommend the standard process for screening requests, documentation and reporting to be implemented by all MAP providers.

5. Government health facilities implementing the MAP shall judiciously enforce efficient use of funds through screening of beneficiaries, facilitate proper documentation and quarterly reporting of utilized funds to the Secretary of Health.

6. The DOH, through the Public Assistance Unit (PAU), Regional Offices and participating government health facilities shall coordinate to provide patients with financial assistance and educate and empower potential beneficiaries about its availability and how to avail medical assistance.

VI. IMPLEMENTATION MECHANISMS

1. Beneficiaries

a. Indigent and poor patients seeking outpatient and inpatients services in authorized government health facilities,

b. Patients who are confined in the pay ward of authorized government health facilities due to reasons beyond their control, as certified by the hospital, such as but not limited to:

i. Emergency cases

ii. Non-availability of ward services

iii. Cases of communicable disease requiring isolation

iv. Cases requiring intensive care

v. Chronic and catastrophic cases requiring prolonged admission

c. Patients confined in suite rooms, private rooms or private ward by choice will not be covered by MAP.

2. Eligibility

a. Beneficiary must be classified as indigent as evidenced by any one of the following documents:

i. Inclusion in the NHTS list or 4Ps membership card

ii. Sponsored Philhealth card or Member Data Record (MDR)

iii. Certificate of Indigency or social worker case summary from DSWD, LGU social worker or medical social worker of the facility.

b. Beneficiary must be certified as poor by the medical social worker of the government health facility based on the medical social worker case summary. In case of an outpatient, patients assessed in out-patient departments of qualified government facilities shall be eligible to avail MAP funds. HEITAD

3. Service Coverage

a. MAP shall be used for the following drugs, medicines, goods and other services prescribed by the physician of the government health facility such as but not limited to:

i. Laboratory, imaging and all other diagnostic procedures,

ii. Drugs and medicines included in the Philippine National Drug Formulary (exemptions to be cleared by Pharmaceutical Division),

iii. Supplies, orthopedic/assistive devices, prosthesis, blood and blood products;

iv. Dental services, except those that are for aesthetic purpose and not medically indicated,

v. All clinically indicated medical and surgical procedures, whether emergency or elective,

vi. Prescribed post-hospitalization rehabilitation services, aftercare program, appropriate mental and psychological support, including those done on an outpatient basis,

vii. In case of non-availability of clinically indicated drugs, medicines, tests, services or procedures in government health facilities, the concerned government health facility may enter into contract with DOH-accredited private health facility to provide the needed drug, test, service or procedure to the patient, charged against the DOH hospital

viii. All hospital bills including professional fees, provided that the expenses for professional fees shall not exceed fifty percent (50%) of the approved assistance,

ix. All other medical, health, documentary and related services billed by the hospital, including payment of PhilHealth insurance premium under Point of Care program subject to the guidelines specified in PhilHealth Circular No. 32 series of 2013.

4. Mechanism and Documentary Requirements to Access MAP

a. The following documentary requirements shall be submitted to avail MAP:

i. For all: Proof of eligibility as listed under Section VI.2.

ii. For Outpatients: prescriptions, diagnostic test requests and medical abstract or medical certificate (if consultation was not done at the OPD of the health facility)

iii. For elective procedures: treatment protocol and estimated cost

iv. For Inpatients: hospital bill for inpatients showing PhilHealth, HMO or other health insurances, PWD, Senior Citizen, Government Employees and other authorized discounts have been deducted

b. The amount of coverage shall be based on the following:

i. All indigent patients shall be eligible for full assistance, in excess of PhilHealth benefit package and other more easily available charities or subsidies.

ii. Amount of coverage for non-indigents but poor patients shall be guided by the medical social worker case summary evaluation, assessment and recommendation, which should be approved by the Chief of Hospital and Medical Director.

c. For cases referred to DOH Regional Office or Central Office for approval, the following must be submitted. ATICcS

i. Letter of endorsement from the Chief of Hospital/Medical Center Chief

ii. Updated medical social worker case summary report

iii. Updated medical abstract

iv. Latest hospital bill statements after PhilHealth and other routine or privilege deductions

5. Fund Administration and Authorization

a. Medical assistance to patient shall be based on need as recommended by the medical social worker attending physician approved by the Chief of Hospital/Medical Center Chief of institution involved and DOH authorized officials, subject to availability of funds.

b. No money or cash shall be released.

c. Not more than 1% of the sub-allotted/transferred funds shall be used for MOOE of the Regional Offices and government health facilities, for the purpose of MAP fund administration.

d. Utilization of fund shall be authorized by the officials with corresponding allowable amount per patient indicated in Table 1.

Table 1: Approving Authority for the Release of Funds

Approving Authority	Allowable Amount
Chief of Hospital of, - LGU Hospitals or duly authorized Officer-in-Charge of the facility	Up to PhP250,000 per patient
Chief of Hospital/Medical Center Chief/Medical Director of DOH Retained, Specialty and SUC hospitals or duly authorized representative	Up to PhP500,000 per patient
DOH Regional Director and DOH Assistant Secretaries	More than PhP250,000 to PhP500,000 per patient
DOH Undersecretary of Office for Administration, Finance and Procurement	More than PhP500,000 to PhP1,000,000 per patient
Head, Executive Assistant	More than PhP500,000 to PhP1,000,000 per patient
Secretary of Health	Above PhP1,000,000 per patient

6. Transfer of Funds

a. Funds shall be transferred by DOH Central Office thru the issuance of the Sub-Allotment Advice (SAA) to the Regional Offices, DOH Retained and Specialty Hospitals.

b. The DOH Central Office shall transfer funds directly to DOH Specialty Hospitals through the issuance of checks in favor of the hospitals concerned or as direct credit to their accounts subject to the Memorandum of Agreement (MOA) between the Secretary of Health and the Medical Director of the Specialty Hospital concerned.

c. Transfer of MAP funds to DND and SUC Hospital shall be effected after signing of the MOA among and between the DOH Secretary and the Chiefs of the concerned DND Hospitals and SUC President of the concerned SUC Hospitals.

d. The DOH Regional Office shall transfer MAP funds to the LGU hospitals through the following:

i. Memorandum of Agreement among and between the Regional Office Director, the Provincial Governor and the Chief of the LGU hospital concerned.

i.i. Fifty percent (50%) of the agreed amount shall be transferred upon the signing of the MOA, while the remaining 50% shall be released upon submission of the Liquidation Reports of the previously transferred funds. The Liquidation Reports shall be supported by the list of patients' names, current addresses and/or contact numbers, gender, age, nature of assistance and amount charged to the MAP funds. For LGU hospitals with outstanding fund transfers, availment of MAP funds may be allowed through the reimbursement basis supported by the list of patients' names, current addresses and/or contact number, gender, age, nature of assistance and amount charged to MAP funds.

ii. Issuance of the Memorandum of Agreement between the DOH Regional Office Director and the Chief of the LGU hospital. Funds shall be transferred through a reimbursement basis.

e. The DOH Regional Office may transfer funds to the DOH Retained Hospitals within their jurisdiction including unutilized funds that will lapse in four (4) months.

f. Fund transfer shall be limited to the availability of allotment balance of MAP specified in RA No. 10924 known as the General Appropriations Act for FY 2017. Additional request of availment either through the MOA or reimbursement shall be granted on a case to case basis subject for the approval by the Secretary of Health or authorized representatives. TIADCc

g. Downloaded or transferred MAP funds shall be utilized in accordance with the Special Provision No. 7 of the GAA for 2017 and subject to existing COA and accounting rules, regulations and guidelines. The respective Heads of recipient health facilities and signatories to the MOAs shall be responsible and be held accountable on the disbursement of MAP funds.

h. For transparency and monitoring purposes, transferred funds shall be posted in the EWEBPAIS.

7. Recording and Reporting

a. All DOH hospitals and Regional Offices shall log real time all MAP cases into the Enhanced Web-Based Public Assistance Information System (EWEBPAIS) the following information:

i. Date of fund release, complete name, age, date of birth, type of assistance, address, PhilHealth number, final and complete diagnosis, type of assistance.

ii. The DOH Knowledge Management and Information Service shall develop and maintain the EWEBPAIS and ensure secured access and integrity of the system.

b. The DOH and recipient government hospitals shall post on its website the following:

i. Name of recipient government hospitals and indigent patients, whether confined or out patient, types of medical assistance or services and/or drugs and medicines given.

ii. The heads of agencies and web administrator or their equivalent shall be responsible for ensuring that the said information are posted on the agencies' website.

c. DOH Retained Hospitals/LGU hospitals/SUCs hospitals shall submit a quarterly scanned copy of fund utilization report, stamp received by COA to the DOH Regional Office.

d. The DOH Regional Office shall submit a consolidated report on the fund utilization of government health facilities to OSec, copy furnished Financial and Management Service and PAU every 15th of the month following the end of each quarter.

8. Monitoring and Evaluation

a. Regular monitoring of fund utilization and program implementation review should be conducted by the Public Assistance Unit, DOH Regional Offices, DOH Retained and Specialty Hospitals to assess the impact of this financing scheme particularly on the targeted clientele.

b. The Office of the Secretary and PAU in consultation with target implementing offices shall draft and formulate monitoring and evaluation tools, systems and other mechanisms for the improvement of process flow.

VII. ROLES AND RESPONSIBILITIES

1. Department of Health — Central Office

a. Office of the Secretary (OSec)

i. Provide oversight and direction of program implementation

ii. Review and evaluate utilization reports quarterly and annually

iii. Review request and authorize release of funds as specified in Table 1 AIDSTE

b. Cluster Head of the Office of Administration, Finance and Procurement (OAFP) and Assistant Secretaries

i. Review request and authorize release of funds to participating offices and government hospitals as specified in Table 1

ii. Assist in ensuring that MAP funds shall be used according to the 2017 GAA and other accounting and auditing rules and regulations

b.1. DOH Financial Management Service

i. Shall facilitate transfer of funds to Regional Offices, SUCs, DND, DOH Specialty, and Retained hospitals

ii. Shall provide technical assistance on financial issues and concerns

b. n  Public Assistance Unit

i. Coordinate with government hospitals and other health facilities for referral of patients and financial and administrative concerns in implementing the program.

ii. Consolidate, screen and evaluate utilization reports and submit findings to OSec quarterly and annually.

iii. Formulate and implement monitoring and evaluation tools and systems.

iv. Report any suspected abuse or mishandling of funds to the Head Executive Assistant, OSec.

c. DOH — Knowledge Management and Information Service

i. Provide training and technical assistance in the usage, maintenance and upgrading of EWEBPAIS.

2. DOH Regional Office

a. Manage allocated funds and facilitate efficient transfer to LGU and DOH hospitals

b. Regional Director shall review request and authorize release of funds as specified in Table 1.

c. Monitor fund utilization and program implementation in the region.

d. Report any suspected abuse or mishandling of funds to the Public Assistance Unit

3. Government health facilities

a. Chief of Hospital/President of the University/Head of Agency

i. Review requests and authorize release of funds as specified in Table 1

b. Medical Social Worker or Duly Designated Hospital Staff

i. Screen eligibility of patients thoroughly, ensure completeness and authenticity of documents before recommending patient for coverage

ii. Ensure that all indigent and poor patients are informed about the availability of fund through poster and IEC materials

iii. Facilitate enrolment of all patients not yet members of PhilHealth

VIII. REPEALING CLAUSE

All other issuances and/or their provisions which are inconsistent with this Order are hereby repealed.

IX. EFFECTIVITY CLAUSE

This administrative order shall take effect 15 days after publication in a newspaper of general circulation or in the DOH website.

(SGD.) PAULYN JEAN ROSELL-UBIAL, MD, MPH, CESO IISecretary of Health

n Note from the Publisher: Copied verbatim from the official copy.