Implementing Rules and Regulations of Program I of the Revised Philippine Medical Care Act

August 27, 1987

IMPLEMENTING RULES AND REGULATIONS OF PROGRAM I OF THE REVISED PHILIPPINE MEDICAL CARE ACT

Pursuant to Section 6 of Presidential Decree No. 1519, as amended, otherwise known as the Revised Philippine Medical Care Act defining the functions, powers and duties of the Philippine Medical Care Commission, to wit: LET05cd

(a) To formulate policies for, administer and implement the Medical Care Plan,

(b) To promulgate or prescribe rules and regulations necessary to carry out the provisions and purposes of the Revised Philippine Medical Care Act,

the implementing rules and regulations are hereby amended as follows:

RULE I

Definition of Terms

SECTION 1. For purposes of these rules, the following terms shall be understood as:

(a) ACCREDITED BED CAPACITY— Number of hospital beds authorized by the Commission to be used for Medicare purposes.

(b) ADMINISTRATIVE ORDERS — Written promulgations in the form of PMCC Resolutions, Medicare Circulars, Memorandum Circulars, Special Orders, and Office Orders issued and duly circularized by the Commission, pertaining but not limited to conducting, directing or superintending the execution, application or conduct and affairs of the Program as embodied in the Medicare Law, R.A. 6111 as amended by P.D. 1519 and its Implementing Rules and Regulations including Medicare accreditation warranties.

(c) BENEFICIARIES — The Medicare members and their legal dependents; death and total/permanent partial disability and old age pensioners of SSS and their dependents; GSIS retirees under RA 660, RA 1616 and their dependents. (As amended by PMCC Res. No. 90-2176).

(d) CIRCUMSTANCE — Any attendant situation present in a given case which tends to exempt or aggravate the violation and liability of the respondent.

(e) COMMISSION— The Philippine Medical Care Commission created under R.A. 6111, as revised.

(f) CONFINEMENT — Admission and stay in a hospital due to illness or bodily injury, medical and/or surgical, requiring hospitalization.

(g) DIAGNOSTIC/TREATMENT TERMINOLOGY— Terminology which conforms with the American Standard of Nomenclature of Diseases and Operations or the International Classification of Diseases.

(h) EMERGENCY— Means medical and surgical conditions that threaten immediate loss of life when not attended to. cd05LET

(i) GSIS — The Government Service Insurance System created under Commonwealth Act 186, as amended.

(j) HOSPITAL — A health care facility with an organization of professional health workers and supportive personnel housed in a physical plant having adequate facilities and equipment to render medical care and ancillary health service on an out-patient and in-patient basis, duly licensed by the Department of Health, member in good standing of a national association of government and privately owned hospitals whose membership comprises the majority of licensed hospitals in the Philippines, and with a continuing program for hospital administration and discipline of its members, accredited and categorized by the Commission under such terms and conditions as it may set.

(k) LEGAL DEPENDENT — The legal dependents of a member are: 1) The legitimate spouse who is not a Medicare member; 2) the unmarried and unemployed legitimate, legitimated, acknowledged children as appearing in the birth certificate; legally adopted or stepchildren below 21 years of age; 3) children who are suffering from congenital disability either physical or mental, or any disability acquired below the age of 21 that renders them totally dependent upon the member for support; 4) the parents who are 60 years old and above whose income is P1,000.00 or less a month.

(l) MEDICARE SERVICE BEDS — Hospital beds set aside for beneficiaries as may be prescribed by the Commission, and when occupied by a Medicare beneficiary, no fees beyond Medicare rates shall be charged to the account of the beneficiary.

(m) MEDICINE — A drug, mixture of drugs, active principle, chemical product, preparation mixtures or combination of drugs intended for cure and/or prevention of complications or rehabilitation.

(n) MEMBER — Any person covered by SSS or GSIS either compulsorily or by special coverage.

(o) OPERATING ROOM COMPLEX— Means emergency room, delivery room, operating room, and recovery room. 2005cdasia

(p) OTHERS — All items used in the management of the patient excluding medicine, consisting of but not limited to syringe, gloves, vaco sets, butterfly, including contrast media and other agents used in establishing the correct diagnosis and treatment of the patient.

(q) PRACTITIONER — Any doctor of medicine or dental medicine duly licensed/authorized to practice in the Philippines, a member in good standing of a national association of government and privately-employed physicians or dentists whose membership comprises the majority of registered practicing physicians or dentists in the Philippines and with a program of continuing medical education and discipline for its members, and accredited by the Commission under such terms and conditions as it may set.

(r) PROVIDER — A practitioner, hospital, or other persons or facilities engaged in health care services and accredited by the Commission under such terms and conditions as it may set.

(s) RELATIVE UNIT VALUE — Points assigned to surgical procedures according to their comparative complexity as adopted by the Commission.

(t) SINGLE PERIOD OF CONFINEMENT — A single confinement or series of confinements for the same illness, with intervals of not more than ninety (90) days.

When a patient is admitted in the same or another hospital within five (5) days immediately following a previous discharge, such patient shall be deemed to be suffering from the same illness unless the chief complaints, clinical manifestations, and the course of management are entirely different from its first confinement.

(u) SSS — The Social Security System created under R.A. 1161, as amended.

(v) SYSTEM— The GSIS or SSS as the case may be.

(w) VIOLATION— Any act or omission constituting infraction of: LPEcd2005

1) the provisions of P.D. 1519, as amended, and/or

2) the Medicare implementing rules and regulations; and/or

3) the warranties of accreditation; and/or

4) administrative orders of the Commission; and/or

5) other Medicare related laws, decrees, and regulations.

RULE II

Coverage

SECTION 1. The nature and scope of coverage under the Philippine Medical Care Act shall be compulsory on all persons covered by the SSS or GSIS including existing laws covering retirees from the government service and other special coverage.

SECTION 2. Registration of Membership.— Registration and recording of members shall be according to the respective charters of the System.

SECTION 3. Dual Membership.— A person covered by both Systems may choose under which System he shall be covered for purposes of Medicare under such procedures as may be circularized by the Commission.

SECTION 4. Dual Coverage.— In cases where both members-parents are covered by Medicare, one under SSS and the other under GSIS, the members shall have the right to choose under whose membership their dependents shall be covered. This rule shall however apply only if there is disparity in benefits from both Systems. (As amended by PMCC Res. No. 93-2418) 2005letcd

RULE III

Benefits

The benefits under the Medicare Act consist of the following: hospital room and board; medical expense consisting of medicines, x-ray, laboratory examinations, and others; professional fees which include surgical, medical/dental, and anesthesiologist fees; operating room fees; and surgical family planning procedures (sterilization benefits).

SECTION 1. Entitlement to Benefits.— A beneficiary shall be entitled to benefits if he meets the following conditions:

(a) He is confined in a hospital due to illness or injury requiring hospitalization; or undergoes a surgical procedure in the operating room complex on an out-patient basis or receives chemotherapy, radiotherapy, or hemodialysis similarly on an out-patient basis.

(b) The member has paid at least three (3) monthly contributions through salary deduction within the immediate twelve (12) month period prior to the first day of confinement; provided that in the case of a self-employed member, he shall have qualified under the registration rules of the SSS and has paid the aforementioned monthly contributions prior to the first day of confinement.

(c) The 45-day room and board allowance for the calendar year has not been consumed.

SECTION 2. Types of Benefits.— A beneficiary of Program I who is confined in a hospital on account of sickness or injury requiring hospitalization is entitled to confinement days per calendar year as follows: a) Maximum of forty-five (45) days for all dependents. Any unused benefits for any prior year shall not be carried over to the succeeding year. The benefits for such confinement shall not exceed the following:

(a) ALLOWANCE FOR HOSPITAL ROOM AND BOARD PER DAY:

 BENEFICIARIES HOSPITAL CATEGORY

 MEMBERSHIP PRIMARY SECONDARY TERTIARY 

 SSS P30 P35 P45

 GSIS 20 24 33

(b) ALLOWANCE FOR MEDICAL EXPENSE PER SINGLE PERIOD OF CONFINEMENT iatdc2005

FOR SSS BENEFICIARIES

 MEDICAL EXPENSE HOSPITAL CATEGORY

 BENEFITS PRIMARY SECONDARY TERTIARY 

1. ORDINARY CASES: 

 Drugs & Medicines P175 P200 P300

 X-ray/Lab./Others 75 150 350 

2. INTENSIVE CARE CASES: 

 Drugs & Medicines 375 400 500

 X-ray/Lab./Others 125 200 500 

3. CATASTROPHIC CASES: 

 Drugs & Medicines  800 1,000

 X-ray/Lab./Others  400 1,000

FOR GSIS BENEFICIARIES

 MEDICAL EXPENSE HOSPITAL CATEGORY

 BENEFITS PRIMARY SECONDARY TERTIARY 

1. ORDINARY CASES: 

 Drugs & Medicines P150 P175 P250

 X-ray/Lab./Others 50 75 100 

2. INTENSIVE CARE CASES: 

 Drugs & Medicines 250 300 350

 X-ray/Lab./Others 100 125 250 

3. CATASTROPHIC CASES: 

 Drugs & Medicines  400 450

 X-ray/Lab./Others  150 300

CATASTROPHIC CASES shall include the following:

1. Illnesses or injuries such as cancer cases requiring chemotherapy and/or radiotherapy, meningitis, encephalitis, cirrhosis of the liver, myocardial infraction, cerebrovascular attack, rheumatic heart disease — Grade III, renal conditions requiring dialysis or transplant, massive hemorrhage;

2. Surgical procedures or multiple surgical procedures done in one sitting with a total Relative Unit Value of 20 and above such as coronary bypass, open heart surgery, neurosurgery shall be considered catastrophic.

INTENSIVE CARE CASES shall include the following:

1. All confinements in an intensive care unit other than those classified as catastrophic; 2005cda

2. Other similar serious illnesses or injuries such as cancer, pneumonia, moderately and far advanced pulmonary tuberculosis including its complications, cardiovascular attack, diseases of the heart, chronic obstructive pulmonary disease, liver disease, typhoid fever, H-fever, kidney disease, septicemia, diarrhea with severe dehydration, severe injuries, black water fever;

3. Surgical procedure or multiple surgical procedures done in one sitting with a total Relative Unit Value of 8 and above but not exceeding 10.99 shall be considered as intensive care cases.

ORDINARY CASES are illnesses or injuries other than those included in the above enumeration.

For purposes of reimbursement of medicines, a mark-up of not more than 50% of the price based on the latest and updated issue of Philippine Index of Medical Specialties (PIMS) shall be adopted. 2005cdtai

(c) ALLOWANCE FOR PROFESSIONAL FEES

1. Medical/Dental Practitioners fee of P15.00 per day but not to exceed P200.00 for ordinary cases and P300.00 for intensive care or catastrophic cases per single period of confinement.

2. Surgeons fee not exceeding P650.00 shall be paid in accordance with the Relative Unit Value promulgated by the Commission.

The surgeons fees shall include two (2) days of pre- and five 5 days post-operative care.

Surgical procedures without any assigned Relative Unit Value shall be evaluated taking into consideration its similarity to existing procedures.

Two or more surgical procedure done through the same incision shall be considered as a single procedure and shall be paid based on the highest Relative Unit Value.

A qualified beneficiary who undergoes surgical procedure in the hospital operating room complex on an out-patient basis is entitled to benefits provided that one day is deducted from his forty-five (45)-day room and board benefits.

All claims for surgical expense shall be made by listing the operation as appearing in the Standard Nomenclature of International Classification of Surgical Procedures.

3. Anesthesiologists fee not exceeding thirty percent (30%) of the allowable Surgeons fee. lpe2005cda

To be entitled to the above fee, the following must be observed:

a. Only one anesthesiologist shall be compensated for each operation.

b. Local anesthesia is not compensable except when it is a regional nerve block anesthesia.

c. When the operating surgeon administers anesthesia himself, no separate anesthesiologists fee shall be allowed.

(d) ALLOWANCE FOR OPERATING ROOM FEE:

 SURGICAL PROCEDURE WITH HOSPITAL CATEGORY

 RELATIVE UNIT VALUE OF: PRIMARY SECONDARY TERTIARY 

 0 — 5 P30 P35 P65

 5.1 — 10 — 120 165

 10.1 — above — 170 225

(e) SURGICAL FAMILY PLANNING PROCEDURES (STERILIZATION BENEFITS):

The following procedures are compensable under Medicare:

1. Vasectomy  P200.00

 Hospital services & medicines P120.00

 Professional fees 80.00

2. Tubal Ligation  P300.00

 Hospital services & medicines P180.00

 Professional fees 120.00

SECTION 3. Exclusions.— The above benefits shall not include expenses for the following:

(a) Cosmetic surgery or treatment — surgery or treatment to preserve, enhance or restore comeliness, the primary purpose of which is to beautify or bring about aesthetic effects;

(b) Optometric services;

(c) Psychiatric illness;

(d) Services which are purely diagnostic in nature such as routing physical and medical examinations, executive check-ups, and similar medical diagnostic services;

(e) Normal obstetrical delivery — any vaginal delivery which is not complicated by eclampsia, retained placenta, profuse bleeding requiring surgical intervention, breech extraction or similar complications. iatdclet

SECTION 4. Requirements for Availment of MEDICARE Benefits:

(a) Members:

1. A member must present to the hospital a duly accomplished PMCC Form I.

2. A self-employed member must present a true copy of his registration and receipt of payment (SSS Form, RS-5).

3. A retiree from the public sector must present a certificate or other evidence to prove that he is a qualified retiree from the public service such as annuity voucher or xerox copy of approved retirement application.

(b) Dependents:

1. Dependent parents/spouses/children — submission of a duly accomplished PMCC Form I shall be prima facie evidence of dependency status. Verification of the status of the dependent by the System shall not suspend the usual processing of the claim and payment to the hospital and medical or dental practitioner without prejudice to whatever recourse the System may take against the member. Whenever there is a need, it shall be the obligation of the member to furnish the corresponding System through his employer with an updated list of his legal dependents as defined herein. In the case of a newly born dependent, a certified xerox copy of the birth certificate shall be submitted. cdasia2005

SECTION 5. Benefits of Members while Abroad.—

(a) A member, including his legal dependents, who is abroad shall be eligible to Medicare benefits while outside the country provided the conditions for entitlement in Section 1(b) and (c) of this Rule are met.

(b) The medical care benefits to be granted shall be in accordance with the provisions of Section 12 of P.D. 1519, as amended.

SECTION 6. Benefits of Patients Confined in Service Beds.— The cost of medical care services of patients confined in Medicare service beds shall be limited to the prescribed medical care benefit allowances.

RULE IV

Payment of Claims

SECTION 1. General Provisions.—

(a) A member shall be free to choose from among the accredited hospitals and physicians. However, when he has no choice of physicians, he shall be considered under the care of the medical staff of the hospital.

(b) The hospital and the attending physician shall file their claims through the prescribed PMCC forms. LPrE05

(c) All claims for payment of services rendered shall be filed within sixty (60) calendar days from the day of discharge of the patient or from the time that he has been declared well, otherwise the claim shall be barred except in case of force majeure. If the claim is sent through the mail, the date of mailing as stamped by the Post Office of origin shall be considered as the date of filling.

A claim returned by the System for completion of supporting documents must be refiled within 120 days from its receipt by the hospital.

(d) When the beneficiary has complied with the requisites for availment as Medicare patient under Section 4 of Rule III, the hospital and the practitioner shall deduct from the hospitalization costs all expenses reimbursable by Medicare; Provided, that in highly exceptional circumstances as may be determined by the System, the beneficiary may be directly reimbursed of his or her expenses allowable under Rule III of these Rules.

(a) The System may deny or reduce any benefit provided by the Philippine Medical Care Plan when the beneficiary:

1. Fails without good cause or legal ground to comply with the advice of the medical practitioner with respect to the hospitalization; or

2. Furnishes false or incorrect information concerning any matter required by law or the Rules and Regulations on Medicare.

In such cases, the member may be required to pay for the amount denied or reduced except when false information was supplied by the employer, in which case the System shall intervene in behalf of the member or the hospital against the employer. iatdc2005

The System may deny or reduce any benefit provided by the Philippine Medical Care Plan when the health provider:

1. Furnishes false or incorrect information concerning any matter required by law or the Rules and Regulations of Medicare; or

2. Fails to comply with any provision of the Rules and Regulations governing the Medicare Program.

When the claim is reduced or denied, the amount thus reduced or denied shall not be charged directly or indirectly to the beneficiary involved unless the latter is directly responsible for the cause of such reduction or denial. Any and all actions taken by the System on the claims may be appealed to the Commission whose decision shall be final.

(f) Primary hospitals are required to submit clinical records of patients in connection with their Medicare claims.

(g) Family-owned secondary and tertiary hospitals which have violated rules and regulations may be required, upon recommendation of the Hearing Committee, to submit the same until such time that the Commission lifts such requirements.

(h) All employee hospitalization claims not compensable under the Employees' Compensation Program shall be automatically considered as a claim under the Medicare Program provided that the claim has been filed within the reglementary period of sixty (60) days.

(i) When the bed census as reflected by claims filed with the System exceeds its accredited bed capacity, such claims shall be accompanied by justification in writing, otherwise these shall not be given due course.

(j) Any operation performed beyond the authorized capability of the hospital shall be considered a violation, except when done in emergency to save life or referral to a higher category hospital is physically impossible. Primary care hospitals shall be compensated only for simple operations as listed by the Commission. 2005LPrE

RULE V

Collection/Remittance of Contributions

SECTION 1. Rates of Contributions.— Contributions shall be shared equally by the employer and the member in conformity with the following schedules:

SALARY

BRACKET  MONTHLY SALARY  CONTRIBUTION  EMPLOYERS  EMPLOYEES  TOTAL

NUMBER WAGE OR EARNING BASE CONTRIBUTION  CONTRIBUTION

1 Below P49.99 P25.00 P0.30 P0.30 P0.60

2 50.00 99.99 75.00 0.95 0.95 1.90

3 100.00 149.99 125.00 1.55 1.55 3.10

4 150. 199.99 175.00 2.20 2.20 4.40

5 200.00 249.99 235.00 2.80 2.80 5.60

6 250.00 349.99 300.00 3.75 3.75 7.50

7 350.00 499.99 425.00 5.35 5.35 10.50

8 500.00 699.99 600.00 7.50 7.50 15.00

9 700.00 899.99 800.00 10.00 10.00 20.00

10 900.00 Over 1,000.00 12.50 12.50 25.00

SECTION 2. Collection of Contributions.—

(a) The members contribution shall be deducted and withheld by the employer from the formers salary, wage or earnings. Failure of the employer to deduct the same shall not be a basis for invalidation of a property filed claim.

(b) The employers counterpart contribution shall not in any manner be recovered from the employee. LPrE05cd

SECTION 3. Remittance of Contribution.— The monthly contribution of members shall be remitted by the employer directly to the System, as the case may be, in accordance with the respective rules and regulations. Remittance shall be accompanied by the appropriate forms.

Failure of the employer to remit to the System the corresponding employees and employers contribution shall not be a reason for depriving the beneficiary of his benefits under the law.

RULE VI

Effect of Separation, Re-Employment or Transfer

SECTION 1. Separation from Employment.—

(a) When a covered employee is separated from employment, his employers obligation to remit the applicable Medicare contributions on his behalf ceases from the date of separation. The separated employee may elect to continue his Medicare membership by giving a written notice to the System and paying the same monthly Medicare contribution representing the employers and his own.

(b) The option to continue membership shall be approved when exercised within six (6) months following date of separation. If he fails to pay the corresponding contributions after the option to continue has been exercised, the membership is terminated.

SECTION 2. Effect of Re-Employment.— Should the separated employee be re-employed, his new employer shall assume the obligation of reporting and remitting the monthly contribution based on the employees covered wage under his new employment. dumrrI

SECTION 3. Transfer of Membership.— When an employee transfers from private to government employment, his medical care coverage under the SSS shall cease when he becomes covered under the GSIS. When the transfer is from government to private employment, medical care coverage under GSIS shall cease when the employee is covered under SSS. Provided, the rights of the beneficiary under Section 15 of the Medical Care Law shall not be prejudiced. The obligation to remit contributions shall be on the basis of his employment. The employee and the employer shall jointly notify the System of such transfer of employment.

RULE VII

Accreditation

SECTION 1. Prerequisites.— A hospital may be accredited if it satisfies the following prerequisites:

(a) It must be licensed by the Department of Health;

(b) It must be a member in good standing of a national association of government and privately-owned hospitals whose membership comprises the majority of licensed hospitals in the Philippines and with a continuing program for hospital administration and discipline of its members;

(c) It has been in operation for at least twelve (12) months prior to accreditation.

SECTION 2. Prerequisites.— A practitioner may be accredited if he satisfies the following prerequisites:

(a) He must be licensed to practice in the Philippines; and

(b) He must be a member in good standing of a national association of government and privately-employed physicians or dentists whose membership comprises the majority of licensed physicians/dentists in the Philippines and with a program of continuing medical education and discipline of its members. itenia

SECTION 3. Terms and Conditions:

(a) The hospital must comply at all times during the period of accreditation with all the requisites of R.A. 4226 otherwise known as the Hospital Licensure Act and its Implementing Rules and Regulations, and other DOH Administrative Orders;

(b) The practitioner must comply at all times with the Code of Ethics as prescribed under Section 24, Paragraph 12 of the Medical Act of 1959, as amended;

(c) The hospital and practitioner must comply at all times during the period of accreditation with all the requirements of the Medicare Law, including its Implementing Rules and Regulations, warranties of accreditation, and other administrative orders of the Commission;

(d) Hospitals and Medicare providers agree to have their pending claims with the System be applied in satisfaction of the fine imposed, if any, as provided under Rule X, Section 15(d).

SECTION 4. Period of Accreditation.— The period of accreditation shall be for two (2) calendar years for hospitals and three (3) calendar years for practitioners to take effect upon the approval by the Commission. irEEPr

SECTION 5. Accreditation Fees.— For purposes of documentation and processing of applications for accreditation of Medicare providers, the Commission shall impose accreditation fees as may be circularized from time to time.

SECTION 6. Commission Option.The Commission has the option to accredit a number of beds less than the authorized bed capacity per DOH license.

SECTION 7. Denial of Accreditation.— The Commission may deny accreditation where there is saturation of accredited hospitals based on the national hospital bed to population ratio or other standard as determined by the DOH or the renewal of such accreditation where there is a prima facie evidence of violation of the law and these rules and regulations. dnPuan

RULE VIII

Payment of MEDICARE Benefits of Members Abroad

SECTION 1. Requirements.— The requirements shall include the following documents (in addition to the pertinent requirements for settlement of claims):

(a) Statement of account or the official receipt of payment from the foreign hospital where the patient was confined;

(b) Certification of the attending physician as to the final diagnosis, period of confinement, and services rendered.

SECTION 2. Manner of Payment.— Payment shall be made to the beneficiary in Philippine Currency. rLrern

RULE IX

Supervision and/or Inspection

SECTION 1. The Commission and/or the System may exercise supervision through authorized representatives to perform such function.

SECTION 2. For purposes of inspection, all providers are required to give access to the medical records of Medicare patients to duly authorized representatives of the Commission and/or the System. Such representatives are likewise authorized to inspect the physical plant and equipment thereof.

SECTION 3. Whenever necessary and with the consent of the patient or the attending physician or director of the hospital, the Commission and the System representatives may conduct examinations on Medicare patients during confinement to determine whether laboratory procedures were actually performed or medications and/or treatment were actually administered. mmdrEs

RULE X

Hearing Procedures

In accordance with Section 29 of Presidential Decree No. 1519, as amended, the rules for hearing and/or investigation of cases or violation of Medicare Law and its Implementing Rules and Regulations shall be as follows:

SECTION 1. Grounds for Investigations.— Investigation shall be conducted by the Hearing Committee upon proper complaint for any violation of the following: teroEE

(a) the provision of P.D. 1519 as amended;

(b) its Implementing Rules and Regulations;

(c) the warranties of accreditation;

(d) administrative orders of the Commission;

(f) other subsequent Medicare related laws and regulations.

SECTION 2. Complaint.— The System, the Commission, any person, firm or corporation may file a complaint against any person, Medicare provider, and other juridical entities provided that complaints other than those filed by the System and the Commission shall be under oath.

The complaint shall state the name, residence, and such other personal circumstances of the complainant and those of the respondent, the substance of the facts and acts constituting the violation charged, the grounds of action and the relief sought. The complaint shall contain evidence in support of the complaint.

A complaint may be withdrawn by the complainant in writing which should also be verified. The Commission shall forthwith dismiss the complaint unless the Commission, for reasons of public interest, shall deem it necessary to prosecute, notwithstanding its withdrawal by the complainant.

SECTION 3. Summons.— The Hearing Committee, upon receipt of the complaint filed by the proper office or person, shall issue summons either by personal service or by registered mail to the respondent at his last known address or to his/her/its duly authorized representative or to any persons having charge thereof attaching thereto copies of the complaints and other documents necessary to inform the respondent of the charges against her/him/it. Luomdu

SECTION 4. Answer.— Within fifteen (15) days from receipt of the summons, the respondent shall file his/her/its answer in writing and under oath, submitting six (6) copies thereof. The answer shall contain either an admission or specific denial of the material allegations in the complaint, or explanation why no action shall be taken against him/her/it. Failure to specifically deny the allegation shall be deemed an admission.

Failure of the respondent to answer as prescribed shall be a waiver of respondents right to present evidence on his/her/its behalf and the Hearing Committee shall proceed to deliberate on the case.

SECTION 5. Deliberation of the Hearing Committee.— After the answer has been received by the Hearing Committee or after the 15-day period within which the respondent should file his/her/its answer has lapsed, the case shall be scheduled for deliberation. The Hearing Committee, for the purpose of this Rule, may sit en banc or in division. It shall sit en banc in cases of motions for reconsideration and petitions for reconsideration of Preventive Suspension. Pnamei

The Hearing Committee, in its deliberation or hearing, may render its findings in accordance with the facts presented or may, when deemed proper, issue either an order setting the case for formal hearing or an order of referral to the duly authorized investigating body or officer which shall conduct fact-finding investigation in accordance with the provisions of Section 6 hereof.

SECTION 6. Order of Referral and Fact-Finding Investigation.—

(a) The order of referral shall contain the specifications of guidelines as to what problem areas or issues the Committee wants to be clarified, informed, or enlightened.

(b) Within twenty-one (21) working days from receipt of the order of referral from the Hearing Committee, the investigating body or officer shall conduct investigation in accordance with the following: oEumat

1. In case the Hearing Officer or a member of the investigating body shall be involved directly/indirectly in the complaint under investigation, he/she shall abstain or inhibit himself/herself from the investigation. The respondent shall be afforded ample opportunity to be heard in person and/or thru counsel during the investigation.

2. The minutes of the investigation shall be duly recorded, transcribed, and attested to by the Hearing Officer or members of the investigating body, as the case may be.

(c) Within thirty (30) days after the termination of the investigation, the investigating body or Hearing Officer shall forward its/his findings and recommendations to the Hearing Committee, attaching thereto all the transcribed stenographic notes, if any, and such documents and other papers presented at the investigation pertinent to the case. In case the investigation is not terminated within the 21-day period, the investigating body or Hearing Officer shall submit to the Hearing Committee an explanation or information in writing about the delay.

Upon receipt of the findings and recommendations of the body, the Hearing Committee shall convene within thirty (30) days to resolve the case with the report as its basis or to conduct further hearings when deemed necessary. aarwLu

SECTION 7. Hearing.— In case the Hearing Committee in its deliberation deems it necessary to conduct further hearing/investigation, the parties shall be notified in writing of the scheduled date thereof.

A subpoena or subpoena duces tecum or both may be issued by the Chairman of the Committee or his duly authorized representative to compel attendance of witnesses or the production of books, papers, and other records deemed necessary in connection with any question pending before the Hearing Committee.

The filing of a criminal case involving the same facts in the administrative case shall not suspend proceedings in the latter case.

SECTION 8. Contempt.—

(a) Direct Contempt. A person guilty of misbehavior in the presence of or so near the Chairman or any member of the Commission, or of the Chairman or any member of the Hearing Committee as to obstruct or interrupt the proceedings before the same, including disrespect toward said officials, offensive personalities towards others, or refusal to be sworn or to answer as a witness or to subscribe an affidavit or deposition when lawfully required to do so may be summarily adjudged in Direct Contempt by said officials and punished by a fine not exceeding One Hundred Pesos (P100.00) or imprisonment not exceeding two (2) days or both if it be in the presence of the Chairman of the Commission or a member thereof, or by a fine not exceeding Fifty Pesos (P50.00) or imprisonment not exceeding one (1) day or both if it be in the presence of the Chairman of the Hearing Committee or a member thereof. Judgment of Direct Contempt is immediately executory and unappealable in court. iewdou

(b) Indirect Contempt shall be dealt with by the Commission or Hearing Committee in the manner prescribed under Rule 71 of the Revised Rules of Court.

SECTION 9. Ex-parte Proceedings.— In case of failure of either party to appear at the time of hearing despite due notice, the Hearing Committee shall proceed to receive evidence ex-parte and decide on the basis of evidence adduced.

SECTION 10. Order of Hearing.—

(a) The lawyer of the Commission in charge of the case shall inform the members of the Hearing Committee of the nature of the complaint and/or status of the case every hearing thereafter.

(b) The complainant shall then proceed with the presentation of its evidence, oral or documentary. The complainant, his/her/its witness shall be subject to clarificatory questions by the respondent or by the members of the Hearing Committee.

(c) After the complainant has presented all his/her/its evidences, the respondent shall then proceed to present his/her/its evidences, oral or documentary, to support his/her/its answer. The respondent, his/her/its witnesses shall be subject to clarificatory questions by the members of the Hearing Committee. Presentation of rebuttal and/or surrebuttal evidence may be allowed upon motion by the proper party. ramsoa

SECTION 11. Hearing Committee Resolution.— After the deliberation or hearing, the Hearing Committee shall immediately submit its findings and recommendation in the form of resolution to the Commission signed by all members who participated therein and, shall contain clearly and distinctly the findings of facts and of the law which were the basis of the recommendation.

SECTION 12. Motion for Reconsideration.— A party not satisfied with the decision of the Commission may file a motion for reconsideration with the Commission in at least six (6) copies within the period for perfecting an appeal provided for in Section 13 thereof.

The motion for reconsideration shall clearly point out the following grounds:

(a) Error of law and/or fact relied upon by the party;

(b) Newly discovered evidence or fact which could not with reasonable diligence be discovered and produced at the hearing and when presented would probably alter the result of the investigation; and,

(c) Fraud, accident, mistake, or excusable negligence which ordinary prudence could not have guarded against and by reason of which the right of the aggrieved party may have been impaired, which if true and correct shall validly justify a consideration of the decision, otherwise, the same shall be deemed a pro-forma motion, hence, will not be given due course and therefore will not stay the running of the period after which the decision becomes final and executory in accordance with Section 13 hereof. Only one motion for reconsideration shall be entertained by the Commission.

SECTION 13. Finality of Decision.— The decision of the Commission on the case shall become final and executory after the lapse of thirty (30) days from receipt of the decision by the parties. Within and before the lapse of the said period of appeal, the party concerned may file a Motion for Reconsideration or Appeal which shall stay the running of the thirty (30)-day prescriptive period. PaLrtr

SECTION 14. Appeal. — The party who is not satisfied with the decision of the Commission may appeal the same to the Commission within thirty (30) days from his receipt of the decision in accordance with the procedure established under Administrative Order No. 18 dated February 12, 1987.

SECTION 15. Execution/Enforcement Decision.—

(a) A writ of execution shall be issued only upon a decision or order that finally disposes of the case or proceedings. Such execution shall be issued upon the expiration of the period to appeal therefrom if no appeal has been duly perfected, or if the appeal is denied.

(b) The penalty of suspension or revocation shall be enforced by the temporary or permanent cessation, as the case may be, of the privilege and benefits under the Medicare Program. In which case, both Systems shall be duly advised in writing of the same.

Where the respondent is meted the sanction of fine, the Commission shall issue a writ of execution enforceable in accordance with the Rules of Court.

(c) Except when the respondent voluntarily pays the fine within fifteen (15) days before the finality of decision, the Committee may motu proprio issue a writ of execution for the purpose.

(d) Where a respondent has a pending claim for payment from the Health Insurance Fund (HIF),the fine imposed on such respondent may be enforced against the proceeds of such claim. simIor

The System, upon receipt of the decision of suspension or revocation of accreditation and fine, shall immediately given notice as to the existence of such claim of the respondent. Upon order from the Commission, the System shall remit to the Commission so much amount charged against the claim in satisfaction of the fine.

SECTION 16. Applicability of the Provisions of the Rules of Court. — Provisions of the Rules of Court which are consistent herewith may serve to supplement the provisions herein provided.

RULE XI

Preventive Suspension

SECTION 1. At any time after proper complaint has been filed in accordance with Rule X and pending the hearing and/or investigation of the case, the Hearing Committee hearing the case may preventively suspend any respondent beneficiary or provider from participation in the Medicare Program if any of the following circumstances is present: oEewis

(a) When the respondent has been found guilty of a violation of Presidential Decree No. 1519, as amended, or of its rules and regulations at least twice and there is reasonable ground to believe based on evidence that the respondent is guilty of the present charge.

(b) When the respondent, at the time of an authorized inspection thereof, has committed or is committing a violation.

SECTION 2. The preventive suspension order should contain or incorporate, by reference documents containing a recital of the antecedent facts and circumstances mentioned in the preceding section, serving as basis for its issuance. The order shall, likewise: umitdd

(a) specify the violation charged, citing also the particular evidence gathered or available in support of the violation;

(b) require the respondent to answer the charge within a period of ten (10) days from the date the respondent receives the order;

(c) require the respondent to appear on the date set for the hearing of the case; and

(d) state the period of the suspension, which period shall not exceed three (3) months from the date of its issuance.

SECTION 3. The order, being interlocutory in nature, shall be unappealable but a petition for reconsideration thereof may be filed with the Commission through the Hearing Committee. The mere filing of such petition shall not stay the preventive suspension order issued but the resolution of any petition for reconsideration shall not be delayed unnecessarily. mutumu

SECTION 4. When the hearing/deliberation and/or investigation of the case is not terminated within the period of suspension stated in the order, the preventive suspension order issued shall be automatically lifted after the expiration of such period stated in the order, except when the cause of non-termination is attributable to the respondent.

SECTION 5. The actual period of preventive suspension undergone or served by the respondent shall be credited in the service of the penalty of suspension that may be finally imposed upon the respondent in the decision of the case, in accordance with Section 15 of Rule X.

RULE XII

Penalties

In the promulgation of decision, order or ruling of penalty for violations of Medicare Law, Rules and Regulations, Warranties of Accreditation, Administrative Order, the Hearing Committee shall be guided as follows: rrwuPm

PART I

General Provisions

SECTION 1. Classification of Violation according to Gravity.—

(a) Serious violations are those that carry a penalty of fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation of accreditation. In case of permanent revocation, a recommendation will be submitted to the Department of Health for cancellation of license to operate.

(b) Less serious violations are those that carry a penalty of fine of Five Thousand Pesos (P5,000.00) or Fifteen Thousand Pesos (P15,000.00) and suspension from participation in the Medicare Program of six (6) months or one (1) year. Etwtsn

(c) Special less serious violations are breach of warranties and violations committed by beneficiaries which carry a penalty of three (3) or six (6) months suspension for the former and a fine of Five Thousand Pesos (P5,000.00) and a suspension from availing of benefits for three (3) or six (6) months for the latter.

SECTION 2. Circumstances.— The following circumstances shall affect the gravity of the violation and the liability of the respondent hospital or practitioner or beneficiary in the commission of the violation(s).

(a) Exempting Circumstances.The presence of force majeure shall exempt any hospital or practitioner or beneficiary from the liability for the violations except civil liability.

(b) Aggravating Circumstances.The following circumstances shall increase the liability for the violation from low to high: wsLdum

1. Previous commission of two or more violations where the hospital, practitioner, or beneficiary had been found guilty within a period of two (2) years;

2. Connivance;

3. Laxity or negligence in the preparation of Medicare claims, clinical records, and supporting documents;

4. Willful operation without license and/or accreditation;

5. Machinations; and

6. Membership in the Commission or in any of its intermediaries.

Provided, that when the aggravating circumstance is a violation in itself, it shall be treated as such and shall not be considered as aggravating circumstance anymore.

SECTION 3. Rules for the Application of Circumstances.—

(a) The presence of the exempting circumstance regardless of any aggravating circumstances makes the violation non-penalizable, except the denial of the claim or refund of claim already paid. IaEdLm

(b) The presence of any aggravating circumstance shall increase the penalty of the violation from low to high.

SECTION 4. Scale Penalties.— The scale or graduation of penalty shall be as follows:

(a) For Serious Violations:

High Penalty — a fine of Thirty Thousand Pesos (P30,000.00) and permanent revocation of accreditation. A recommendation shall be submitted to the Department of Health for cancellation of license to operate.

Low Penalty — a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months. IPemnw

(b) For Less Serious Violations:

High Penalty — a fine of Fifteen Thousand Pesos (P15,000.00) and one year suspension.

Low Penalty — a fine of Five Thousand Pesos (P5,000.00) and three (3) or six (6) months suspension.

(c) Common Provisions. All penalties shall carry with them denial of payment of claim(s) in question and/or refund to the System if already paid.

Suspension shall be carried out by the temporary cessation of the benefits or privilege under the Medicare Program. nuinse

Should the aggregate period of suspension to be imposed upon the provider on account of two or more violations exceed twenty-four (24) months, the high penalty for serious violations shall be imposed. In no case shall the penalty of fine exceed Thirty Thousand Pesos (P30,000.00).

A notice of suspension, for the benefit of beneficiaries, shall be posted indicating the period of suspension in such form and manner to be prescribed by the Commission.

SECTION 5. Rules for Application of Penalty.—

(a) Where there are no aggravating circumstances, the low penalty shall be imposed as follows:

1. For less serious violations — a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension.

2. For serious violations — a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four months. moEmda

3. For breach of warranties — three (3) months suspension.

4. For violation by beneficiaries — a fine of Five Thousand Pesos (P5,000.00) and three (3) months suspension of Medicare privilege.

(b) When there is an aggravating circumstance, the high penalty shall be imposed as follows:

1. For less serious violations — a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension.

2. For serious violations — a fine of Thirty Thousand Pesos (P30,000.00) and permanent revocation of accreditation. A recommendation shall be submitted to the Department of Health for revocation of license to operate.

3. For breach of warranties — six (6) months suspension.

4. For violations by beneficiaries — a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension of Medicare privilege. tLuItr

PART II

Violations and Penalties

SECTION 6. Fraudulent Practices.—

(a) Misrepresentation.

1. Misrepresentation by Padding of Claims — Any provider who, for purposes of claiming payment from the System, files a Medicare claim for an amount more than the benefits actually used by adding drugs, medicines, procedures, services, supplies not actually done or given, shall be punished by a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The padded claims shall be barred from payment or denied and, if paid, refunded.

2. Misrepresentation by Claiming for Non-admitted Patients — Any provider who, for the purpose of claiming payment for non-compensable out-patient illness from the System, files a Medicare claim for non-admitted patients:

a. By making it appear that the patient is actually confined in the hospital when he is not; or

b. By making it appear that the non-compensable illness or procedure is compensable; and

c. By such other machinations,

shall be penalized by a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The claim shall be denied and, if paid, refunded. wntdmL

3. Misrepresentation by Extending Period of Confinement — Any provider who, for the purpose of claiming payment from the System, files a Medicare claim with extended period of confinement:

a. By increasing the period of actual confinement of any patient; and/or

b. By continuously charting entries in the Doctors Order, Nurses Notes and Observations despite actual discharge or absence of the patients.

c. By such other machinations,

shall be penalized by a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The claim shall be denied and, if paid, refunded.

4. Misrepresentation by Postdating of Claims — Any provider who, for purposes of claiming payment from the System, files a Medicare claim for payment of services rendered not within sixty (60) days from the date of discharge of the patient but makes it appear to be so by changing, erasing, adding to the period of confinement or in any manner altering dates so as to defeat or conform to the sixty (60) days prescriptive period shall be punished by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from participation in the Medicare Program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension. The claim shall be barred from payment and, if paid, refunded. Eiisoe

5. Other Misrepresentations — Any hospital or practitioner shall be liable for fraudulent practice by other misrepresentation when, for purposes of participating in the Program or claiming payment from the System, he/it furnishes false or incorrect information concerning any matter required by the Medicare Law and its Implementing Rules and Regulations not otherwise punishable under this, sub-sections (1) to (4) of this Rule, shall be penalized by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from participation in the Medicare Program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension. All claims shall be barred from payment, and if paid, refunded.

(b) Other Fraudulent Practices.

6. Filing of Multiple Claims — Any provider who, for the purpose of claiming payment from the System, files two or more Medicare claims for a patient who has been confined once but was made to appear as having been confined for two or more times and/or for two or more different illnesses shall be punished by a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The claims shall be denied and, if paid, refunded. memimo

7. Violation of Accredited Bed Capacity — Any hospital which, for purposes of claiming payment from the System, files Medicare claims for patients confined in excess of the accredited bed capacity at any given time without explanation in form and manner prescribed by the Commission shall be punished by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from participation in the Medicare Program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension. Its excess claims shall not be paid.

8. Unauthorized Operations Beyond Service Capability — Any primary hospital which performs a surgical operation beyond its authorized capability shall be liable for unauthorized operations and shall be punished by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from participation in the Medicare Program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension except when the operation is done in emergency to save life or referral to a higher category hospital is physically impossible.

9. Fabrication or Possession of Fabricated Medicare Forms and Supporting Documents — Any provider who is found preparing claims with misrepresentations or false entries or to be in possession of Medicare claim forms and other documents with false entries to support Medicare claims shall be punished by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from participation in the Medicare Program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension.

10. Fraudulent Acts — Any provider or beneficiary shall be liable for fraudulent acts by: eLIird

a. failure or refusal to give the benefits due a qualified Medicare beneficiary; or

b. charging the qualified Medicare patients for services or medicines which are legally chargeable to and covered by Medicare; or

c. failure or refusal to refund to the beneficiary the payment received from the System within thirty (30) days when the bill is fully paid in advance by the beneficiary; or

d. failure or refusal to accomplish and submit the required PMCC forms in connection with letter c; or

e. deliberate failure or refusal to comply with the requisites of P.D. 1519 as amended and its Implementing Rules and Regulations,

shall be penalized by a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The claims shall be barred from payment and, if paid, refunded.

In paragraph (a),a mere refusal or failure to give benefits completes the violation.

In paragraph (b),payment of the patient completes the violation.

In paragraph (c),lapse of thirty (30) days completes the violation.

In paragraph (d),a mere refusal or failure to accomplish and submit the forms completes the violation. edrtwm

SECTION 7. Gross Negligence.—

(a) Violation Through Gross Negligence. Any provider or beneficiary who, by gross negligence, caused a serious violation shall be penalized with the high penalty for serious violations; if a less serious violation had been caused, it shall be penalized with the high penalty for less serious violations.

Gross negligence is the want of even slight care and diligence as to raise a presumption that the practitioner or hospital or beneficiary at fault is conscious of the probable consequences or carelessness and is indifferent, or worse, oblivious to the danger of the injury to the person or property of others.

SECTION 8. Breach of Warranties of Accreditation.— Any hospital or practitioner who shall be found to have made any breach of warranties of accreditation shall be penalized by three (3) months or six (6) months suspension from participation in the Medicare Program; Provided, that when the breach is in itself another violation or results to another violation as provided in Section 6 and 7, it shall be penalized accordingly.

SECTION 9. Penalty for Beneficiary.— A beneficiary who, for purposes of claiming Medicare benefits or entitlement thereto, commits any of the violations as provided for in Sections 6 and 7 of this Rule independently or in connivance with the hospital or practitioner shall be penalized by a fine of Five Thousand Pesos (P5,000.00) and suspension from availing of Medicare benefits for three (3) or six (6) months. momPia

SECTION 10. Final Provisions.—

(a) When one single act constitutes or results to two or more violations, or when the violation is a necessary means of committing the other violation, the high penalty for the more serious violation shall be imposed.

(b) Pendency of a complaint before the Commission of a decision thereon shall not bar a separate independent criminal action and/or appropriate action before any board, office, tribunal or court against the erring respondent and vice-versa.

(c) When a hospital has ceased operations or the practitioner stops his practice before serving its/his penalty, execution shall be deferred, to be implemented when the same owner or medical director opens or operates a new hospital irrespective of the name or location or when the practitioner practices again. A spouse or a relative within the second degree of consanguinity of the hospital owner or medical director shall be presumed the alter-ego of the owner or medical director; Provided, that the dispositive part of the resolution requiring reimbursement of paid claim or denial of payment shall be immediately executory, notwithstanding the motion for reconsideration. Pmsaow

(d) Violations and penalties shall prescribe as follows:

1. Violations punishable by revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation with recommendation to the Department of Health for cancellation of license to operate shall prescribe in five (5) years.

Violations punishable by three (3) or six (6) months suspension or one (1) year suspension and penalties therefore shall prescribe in three (3) years.

2. The period of prescription of violations shall commence from the day the violation is discovered by the complainant and shall be interrupted by the filing of the complaint/memorandum and shall commence again if there is failure to act within a reasonable time which should not be more than one (1) year.

The term of prescription shall not run when the erring respondent is not in the Philippines or when he/it cannot be served with summons due to his/its fault.

3. The period of prescription of penalties shall commence to run on the thirty-first (31st) day from the date the decision becomes final and executory.

SECTION 11. Applicability of this Rule.— Complaints already filed with and under deliberation by the Hearing Committee shall be penalized in accordance with previous rules. iIiesr

RULE XIII

Implementing Provisions

SECTION 1. These amended rules and regulations shall take effect immediately as provided by law.

Approved by the Commission on August 27, 1987, during the 755th Regular Meeting under Medicare Resolution Number 87-1962 and confirmed on December 8, 1987 during the 758th Regular Meeting under Medicare Resolution Number 87-1987.

MEDICARE SCHEDULE OF CONTRIBUTIONS

I. The following shall take effect on January 1, 1991:

		BENEFIT	PRIMARY	SECONDARY	TERTIARY
1.	Room and Board not
	exceeding 45 days per
	year for each member
	of the Program I and
	another 45 days per
	year to be shared by
	all his legal dependents	P55.00/day	P100.00/day	P145.00/day
2.	Medical Expense (per
	Single Period of
	Confinement)
	2.1	Ordinary Cases
		2.1.1	Drugs & Medicines	P595.00	P790.00	P1,015.00
		2.1.2	X-ray/Laboratory/Others	150.00	360.00	635.00
	2.2	Intensive Care Case
		2.2.1	Drugs & Medicines	P1,350.00	P1,620.100	P2,915.00
		2.2.2	X-ray/Laboratory/Others	325.00	830.00	1,260.00
	2.3	Catastrophic Cases
		2.3.1	Drugs & Medicines	P3,650.00	P4,170.00
		2.3.2	X-ray/Laboratory/Others	1,620.00	3,845.00
3.	Medical/Dental
	Practitioner's Fee
	shall be P55.00 per
	day for a General
	Practitioner and
	P80.00 for a
	Specialist but not to
	exceed:
	3.1	For Ordinary
		Cases (per single
		period of confinement)
		For General Practitioner	P300.00	P300.00	P300.00
		For Specialist	450.00	450.00	450.00
	3.2	For Intensive
		Care/Catastrophic
		Cases (per single
		period of confinement
		For General Practitioner	P450.00	P450.00	P450.00
		For Specialist	750.00	750.00	750.00
4.	Surgeon's Fee shall be
	in accordance with the
	Relative value Scheme
	prescribed by the
	Commission not to
	exceed P7,080.00.
5.	Anesthesiologist's Fee
	(30% of allowed
	Surgeon's fee) not to
	exceed P1,410.00
6.	Operating Room fee for
	Surgical Procedures
	with Relative Unit
	Value of:
		0 – 5		P170.00	P295.00	P470.00
		5.1 – 10	505.00	600.00
		10.1 – Above	960.00	1,550.00
7.	Fees for Surgical
	Family Planning
	Procedures as may be
	determined by the
	Commission.
	Vasectomy		400.00	400.00	400.00
	Tubal Ligation	500.00	500.00	500.00

II. The following shall take effect on January 1, 1992:

 

		BENEFIT	PRIMARY	SECONDARY	TERTIARY
1.	Room and Board not
	exceeding 45 days per
	year for each member
	of the Program I and
	another 45 days per
	year to be shared by
	all his legal dependents	P55.00/day	P100.00/day	P120.00/day
2.	Medical Expense (per
	Single Period of
	Confinement)
	2.1	For Ordinary Cases
		2.1.1	Drugs & Medicines	P595.00	P790.00	P845.00
		2.1.2	X-ray/Laboratory/Others	125.00	300.00	530.00
	2.2	For Intensive Care Cases
		2.2.1	Drugs & Medicines	P1,125.00	P1,350.00	P2,430.00
		2.2.2	X-ray/Laboratory/Others	270.00	690.00	1,050.00
	2.3	For Catastrophic Cases
		2.3.1	Drugs & Medicines	–	P3,040.00	P3,475.00
		2.3.2	X-ray/Laboratory/Others	–	1,350.00	3,205.00
3.	Medical/Dental
	Practitioner's Fee
	shall be P55.00 per
	day for a General
	Practitioner and
	P80.00 for a
	Specialist but not to
	exceed:
	3.1	For Ordinary
		Cases (per single
		period of confinement)
		For General Practitioner	P300.00	P300.00	P300.00
		For Specialist	450.00	450.00	450.00
	3.2	For Intensive
		Care/Catastrophic
		Cases (per single
		period of confinement)
		For General Practitioner	P450.00	P450.00	P450.00
		For Specialist	750.00	750.00	750.00
4.	Surgeon's Fee shall be
	in accordance with the
	Relative Value Scheme
	prescribed by the
	Commission not to
	exceed P7,080.00.
5.	Anesthesiologist's Fee
	(30% of allowed
	Surgeon's fee) not to
	exceed P1,410.00
6.	Operating Room fee for
	Surgical Procedures
	with Relative Unit
	Value of:
			0 – 5	P140.00	P245.00	P300.00
			5.1 – 10	420.00	500.00
			10.1 – Above	960.00	1,290.00
7.	Fees for Surgical
	Family Planning
	Procedures as may be
	determined by the
	Commission.
	Vasectomy		P400.00	P400.00	P400.00
	Tubal Ligation		500.00	500.00	500.00

III. The following shall take effect on January 1, 1993: usniLm

SALARY BRACKET	CONTRIBUTION	EMPLOYEE'S	EMPLOYER'S
	BASE	SHARE	SHARE
less than P149.99	P125.00	P1.55	P1.55
150.00 – 199.99	175.00	2.20	2.20
200.00 – 249.99	225.00	2.80	2.80
250.00 – 349.99	300.00	3.75	3.75
350.00 – 499.99	425.00	5.35	5.35
500.00 – 699.99	600.00	7.50	7.50
700.00 – 899.99	800.00	10.00	10.00
900.00 – 1,099.99	1,000.00	12.50	12.50
1,100.00 – 1,399.99	1,250.00	15.65	15.65
1,400.00 – 1,799.99	1,500.00	18.75	18.75
1,750.00 – 2,249.99	2,000.00	25.00	25.00
2,250.00 – 2,749.99	2,500.00	31.25	31.25
2,750.00 – over	3,000.00	37.50	37.50