Ra 6111 - Medicare

REPUBLIC ACT NO.
6111
IMPLEMENTING RULES AND REGULATIONS OF PROGRAM I OF THE REVISED PHILIPPINE MEDICAL CARE ACT
AN ACT ESTABLISHING THE PHILIPPINE MEDICAL CARE PLAN AND CREATING THE PHILIPPINE MEDICAL CARE COMMISSION, PRESCRIBING ITS DUTIES, POWERS AND FUNCTIONS, AND APPROPRIATING FUNDS THEREFOR SECTION 1. Short Title. This Act shall be known as the Philippine Medical Care Act of 1969.
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SECTION 2. Declaration of Policy. It is hereby declared to be the policy of the Republic of the Philippines to gradually provide total medical service for our people by adopting and implementing a comprehensive and coordinated medical care program based on accepted concepts of health care, namely:
(a) There shall be total coverage of medical services according to the needs of patients; (b) There shall be coordination and cooperation in the use of all medical facilities of both the government and the private sector; and (c) The freedom of choice of physicians and hospitals and the family doctor-patient relationship shall be preserved. SECTION 3. Purposes and Objectives. The main purposes and objectives of this Act are:
(a) Extension of medical care to all residents in an evolutionary way within our economic means and capability as a nation;
(b) Providing the people of the country a practical means of helping themselves pay for adequate medical care; and (c) To establish a Medical Care Commission.
SECTION 4. Philippine Medical Care Commission. To carry out the above purposes and objectives, the Philippine Medical Care Commission, hereinafter referred to as the Commission, is hereby created to be composed of nine (9) members, namely: (1) the Chairman; (2) the Administrator of the Commission as ViceChairman; (3) The Administrator of the Social Security System; (4) The General Manager of the Government Service Insurance System; (5) The President or the duly designated representative of the Philippine Medical Association; (6) The President or the duly designated representative of the Philippine Hospital Association; (7) The Secretary of Health or the Director of Medical Services if designated by the former; and (8) two members, one of whom shall preferably be a duly registered physician with at least ten years private practice, representing the private sector.
The Chairman, the Administrator and the two members from the private sector shall be appointed by the President of the Philippines with the consent of the Commission on Appointments to serve for a term of six (6) years. SECTION 5. Functions, Powers and Duties of the Commission. The Commission shall have the following functions and powers: (a) To formulate policies, administer and implement the Medical Care Plan, hereinafter provided; (b) To organize its offices, fix the compensation of, and appoint such personnel as may be deemed necessary in accordance with Civil Service rules and regulations: Provided, That the plantilla of the Commission shall be included in the Appropriations Act for the next fiscal year, and yearly thereafter: Provided, further, That the respective Community Health funds of the provinces, cities and
municipalities shall not be used for payment of salaries of the employees of the Commission; (c) To establish the provincial, city and municipal Medical Care Councils; (d) To authorize actuarial studies for the purpose of determining and fixing, from time to time, the contributions necessary and the extent and scope of benefits of the beneficiaries of the Plan as its resources may permit in order to ensure adequate financing and disbursement of funds to all participants of the Plan; (e) To set up the requisites and procedures for the registration of beneficiaries under this Act;
(f)
To devise control measures to prevent abuses of the Plan;
(g) To provide from its funds the necessary amount for the Provincial Medical Care Council, the City Medical Care Council, and the Municipal Medical Care Council to carry out their respective functions under the Plan; (h) To be empowered to withhold, withdraw or suspend medical care benefits from any one who refuses to pay his contribution as provided herein except in emergency cases; (i) To promulgate such supplementary rules and regulations as may be necessary to implement the provisions of this Act; ( j) To submit to the President, and to each House of Congress of the Republic of the Philippines annually within the first ten days of each regular session, a report covering its activities in the administration and enforcement of this Act during the preceding fiscal year; and
(k) Generally to exercise all powers necessary to attain the purposes and objectives for which the Commission is organized.
SECTION 6. Board Meetings. Regular meetings of the Commission shall be held once a week. Special meetings not to exceed
four sessions a month may be held at the discretion of the Chairman or at the written request of the majority of the members of the Commission. The presence of five members of the Commission shall constitute a quorum. Members of the Commission who are government officials shall serve without additional compensation, but may be allowed traveling and other necessary expenses. Members who are not government officials shall receive a per diem of fifty pesos for each session actually attended by them. The Commission shall fix the compensation of, and appoint its secretary.
SECTION 7. The Chairman of the Commission. The Chairman shall be a reputable member of the medical profession with at least twelve years of experience in medical practice and with proven executive ability in business or medical undertakings. He shall hold office on a full time basis and shall receive a compensation of at least thirty thousand pesos per annum. He shall be entitled to commutable traveling and representation expenses not to exceed six thousand pesos per annum. He shall preside at all meetings of the Commission and shall exercise such other duties as will achieve the purposes and objectives of this Act. SECTION 8. Administrator of the Commission. The Commission shall have under its general supervision an Administrator, who shall serve as its Chief Executive Officer. He shall hold office on a full-time basis for a term of six (6) years and may not be removed except for cause. The Administrator shall be a duly registered physician with at least ten years experience in practice, who has proven executive ability and experience in business or medical undertakings. He shall be appointed by the President of the Philippines with the consent of the Commission on Appointments and shall receive a minimum compensation of P24,000.00 per annum and such other privileges as may be fixed by the Commission. All travel and other representation expenses shall not be more than six thousand pesos per annum. No other allowances and/or representation expenses under any denomination shall be allowed. SECTION 9. The Philippine Medical Care Plan. The Philippine Medical Care plan shall consist of two basic programs, namely: (a) Program I For the members of the SSS and GSIS; and
(b)
Program II For those not covered in program I.
Beneficiaries under Program I shall be entitled to medical care benefits specifically provided for in subsequent sections of this Act. The Commission shall, within three years after the effectivity of this Act, formulate an integrated program for the proper implementation of program II as envisioned in this Act. Likewise, it shall, within the same period, recommend to Congress who shall be entitled to Medical Care benefits under Program II and the amount of contributions they shall make. PROGRAM I SECTION 10. Medical Care for SSS and GSIS Members. The SSS and the GSIS shall set up their respective medical care funds and shall administer the same in accordance with the following provisions of this Act, and the policies and implementing rules and regulations promulgated by the Commission.
Within five years from the approval of this Act, the SSS and the GSIS shall, with the approval of the Commission, respectively adopt a supplementary plan designed to take over the medical care needs of the legal dependents of their members from Program I for which the SSS and the GSIS may require additional premiums. SECTION 11. Compulsory Coverage. Coverage under this Act shall be compulsory and automatic upon all employees entitled under Section 35 of this Act: Provided, That in the case of an employee who is both covered by the SSS and GSIS, only his employment with the latter shall be considered for purposes of his coverage. SECTION 12. Effect of Separation from Employment. Subject to such rules, regulations and/or conditions as the SSS or GSIS may prescribe, an employee who is no longer obliged to contribute under Section 22 hereof by separation from employment, may elect to continue paying contributions representing the contribution of the employer as well as that of the employee only within sixty days following the date of such separation: Provided, That an employee
shall be entitled to the benefits under this Act if he has satisfied the contribution requirements specified in Section 21 of this Act. SECTION 13. Hospitalization Expense Benefit. Under such rules, regulations and/or conditions as the SSS and GSIS may prescribe, subject to the approval of the Commission, an employee who is confined in a hospital on account of sickness or bodily injury requiring hospitalization, shall be entitled to confinement not exceeding forty-five days annually to:
(a) Room and board expense benefit for each day of confinement in a hospital not exceeding twelve pesos (P12.00) a day; and (b) Special charge expense benefit for charges necessary for the care of the employee, such as laboratory examination fees, drugs, Xray, operating room and the like, not to exceed one hundred fifty pesos (P150.00). For drugs and medicines that may be essential under this sub-section, the employee shall have the option to secure the same from either the hospital pharmacy wherein he is confined or from any retail drug store of his own choice, subject only to the rules and regulations or as provided for in Section 18 hereof. SECTION 14. Surgical Expense Benefit. Under such rules, regulations, and/or conditions as the SSS or the GSIS may prescribe, subject to the approval of the Commission, an employee who shall have undergone surgical procedure in a hospital shall be entitled to a surgical expense benefit as may be determined by the SSS or GSIS, as the case may be, taking into account the nature and complexity of the procedure: Provided, That the amount of benefit shall not exceed fifty pesos for a minor operation, one hundred fifty pesos for a medium operation and three hundred fifty pesos for a major operation.
SECTION 15. Medical Expense Benefit. Under such rules, regulations and/or conditions as the SSS or the GSIS may prescribe, subject to the approval of the Commission, an employee who shall have received necessary professional medical treatment by a medical practitioner while confined shall be entitled to a medical expense benefit of P5.00 for each daily visit: Provided, That the maximum
benefit shall not exceed one hundred pesos for a single period of confinement or for any one sickness or injury: Provided, further, That in determining the compensable daily visit occasioned by any one sickness or injury not more than one visit for any one day shall be counted: Provided, finally, That specialists who are properly certified by the Philippine Medical Association shall be entitled to collect ten pesos for each daily visit. SECTION 16. Free Choice of Hospital or Medical Practitioner. Any employee who becomes sick or is injured shall be free to choose the hospital in which he will be confined and the medical practitioner by whom he will be treated. SECTION 17. Notification of Illness, Confinement and Supervision. When an employee becomes sick or is injured and confined in a hospital, his confinement as well as the nature of his sickness or injury shall be communicated by said hospital to the SSS or GSIS, as the case may be. The SSS or GSIS may exercise supervision over the confined employee and, at its expense, require him to be examined by a medical practitioner of his choice. SECTION 18. Payment of Claims. Benefits provided under this Act shall be payable directly to the hospital, the medical practitioner and the retail drug store, if any, under such rules, regulations and/or conditions as the SSS or GSIS may prescribe, subject to the approval of the Commission: Provided, That when the charges and fees agreed upon between the employee and the hospital and/or medical practitioner are in excess of the amount of the benefits provided for under this Act, such employee shall be liable only for the payment of that portion of such fees and charges as are in excess of the benefits payable under this Act.
SECTION 19.
Limitation on the Right to Benefits.
(a) No employee shall be entitled to the benefits herein granted unless he shall have paid at least three monthly contribution during the last twelve months prior to the first day of the single period of confinement: Provided, That in case of sickness on which surgery may be deferred at the election of the employee in such cases as hermictomy, hemorrhoidectomy, tonsillectomy, adenoidectomy and
the like, the required monthly contributions paid immediately prior to the operation shall be at least for twelve consecutive monthly installments: And, provided, further, That until such time that such an employee is entitled to the benefits under Program I, he shall be covered by Program II;
(b) When the SSS or GSIS, as the case may be, has not been duly notified by the hospital in the manner prescribed under Section 17 of this Act, no claim for any of the benefits of the Act shall be paid to the hospital concerned and said hospital shall further pay to the medical practitioner damages equivalent to the benefits which said medical practitioner would have received had there been due notification: Provided, That in no case may a claim for benefit filed after the lapse of sixty days from the last day of confinement be paid; (c) The SSS or GSIS may deny or reduce any benefits provided under Program I of this Act when an employee, hospital or medial practitioner, as the case may be: (1) Fails without good cause or legal ground to comply with the advice of the medical practitioner with respect to hospitalization; (2) Furnishes false or incorrect information concerning any matter required by this Act or the rules and regulations of the SSS or the GSIS; (3) Is guilty during his confinement or illness of gross negligence with regard to his health; (4) Refuses to be examined by or fails to comply with the advice of the medical practitioner appointed for supervision purposes by the SSS or GSIS; and (5) Fails to comply with any provision of Program I of this Act or rules and regulations of the SSS or GSIS required for entitlement to the benefits provided in this Act. SECTION 20. Exclusion. The benefits granted under this Act shall not cover any expense for:
(a)
Cosmetic surgery or treatment;
(b) Dental Service, except major dental surgery or operation which needs hospitalization; (c) Optometric service or surgery;
(d) Services related to the case of psychiatric illness or of diseases traceable to such illness; and (e) Services which are purely diagnostic.
SECTION 21. Rates of Contributions. For employees covered by the GSIS and the SSS, the initial monthly contributions shall be in accordance with the following schedule: Monthly Salary Wage or Earnings Below P49.99 P50.00 99.00 100.00 149.99 150.00 199.99 200.00 249.99 250.00 over Covered Wage P25.00 75.00 125.00 175.00 225.00 300.00 of Employers Contribution P0.30 0.95 1.55 2.20 2.80 3.75 Employees Employees Contribution P0.30 0.95 1.55 2.20 2.80 3.75 and Employers
SECTION 22. Collection Contribution.
(a) Within such time and manner as the SSS or GSIS may prescribe, the employer shall deduct and withhold from his employees monthly compensation the employees contribution; and (b) Within such time and manner as the SSS or GSIS may prescribe, but not beyond twenty days from the date due, the employer shall remit directly to the GSIS or the SSS, as the case may be, his corresponding contributions together with the employees contribution. No employer shall deduct, directly or indirectly, from the compensation of the covered employees or otherwise recover from them his own contributions in behalf of such employees: Provided,
That failure of the employer to remit to the GSIS or the SSS the corresponding employees and employers contributions shall not be a reason for depriving the employee of the benefits of this Act.
SECTION 23. Health Insurance Fund. The Health Insurance Funds of the SSS and the GSIS are hereby created which shall consist of all contributions and all accruals thereto and shall be kept separate and distinct from all other funds paid to and collected by said agencies to be utilized for the purpose of meeting claims for benefits under this Act. SECTION 24. Administration and Disbursement of Funds. Subject to Section 25 hereof, the Health Insurance Funds of the SSS or GSIS shall be administered and disbursed in the same manner and under the same conditions, requirements and safeguards as provided by Republic Act Numbered One thousand one hundred sixty-one, as amended, and Commonwealth Act Numbered One hundred eightysix, as amended, with regard to such other funds as are thereunder being paid to or collected by the SSS and the GSIS, respectively: Provided, That they conform with the policies, rules and regulations established by the Commission. SECTION 25. Deposit of Contributions. All the contributions collected by and remitted to the GSIS and the SSS under this Act shall, within thirty days of receipt be deposited in interest bearing government deposit banks doing business in the Philippines, having an unimpaired paid-up capital and surplus equivalent to one million five hundred thousand pesos or over.
SECTION 26. Records and Reports. The Philippine Medical Care Commission, the provincial, city and municipal Medical Care Councils, the SSS and the GSIS shall keep and cause to be kept records of the operation of their respective funds and of disbursement thereof, and all accounts or payments made out of said funds. They shall also cause to be kept such records as may be required for the purpose of making actuarial valuations including such data necessary in the computation of the rate of morbidity in the Philippines and any other information that may be useful for the adjustment of benefits.
PROGRAM II SECTION 27. Hospitalization, Out-Patient and Domiciliary Care. Subject to the provisions of Section 13 hereof, for purposes of hospitalization under this Act, private hospitals and clinics duly licensed by the Bureau of Medical Services shall set aside at least twenty percent (20%) of their total bed capacity as service beds to be subsidized at the rate of P10.00 per bed per day to be paid by the month not later than the tenth day of the following month, from any special fund appropriated for this purpose: Provided, That said service beds shall remain such only when payments of these monthly subsidies do not become delinquent for more than three consecutive months. Hospital loans shall be given priority by government financing institutions, especially in the rural areas where there are no existing government or private hospitals, at a maximum rate of six percent (6%) per annum on a long-term basis.
Until such time as the Commission can otherwise provide therefore, the major aspect of out-patient and domiciliary care shall be carried out initially by existing government hospitals, rural health units and other government clinics.
SECTION 28. Registration and Contribution. To be entitled to the benefits under this Act, and subject to the regulations and procedures for registration to be promulgated by the Commission, every resident shall be registered and issued a medical care card upon payment to the respective provincial, city, or municipal treasurer concerned of the required yearly assessments to be fixed by the Commission. The yearly assessments shall be payable on or before January 20 of each year to be collected by the City or Municipal Treasurer concerned, and shall respectively be held by them in trust for the City Medical Care Council or the Municipal Medical Care Council, as agents of the latter. SECTION 29. Provincial Medical Care Council. The Commission shall establish in each province a Provincial Medical Care Council of seven (7) members, to be composed of: 1) the
Provincial Health Officer; 2) the Provincial Treasurer; 3) a representative of the Provincial Governor; 4) the duly designated representative of the component society of the Philippine Medical Association; 5) a representative of the Philippine Hospital Association from one of the private hospitals in the province if any, preferably a chief of a hospital; and 6) and 7) two (2) private citizens from the province, one of whom shall be a duly registered physician, to be appointed by the Commission. The last four (4) mentioned members shall be appointed for a term of four (4) years each, arranged on a staggered basis so that only one is appointed annually, except the initial appointees who shall have terms of one, two, three, and four years, respectively. The Council shall elect its Chairman and shall: (a) Supervise the operation of the program on the municipal level;
(b) Insure homogenous distribution and maximum utilization of medical facilities within the province; (c) Act as an adjudicatory body for the parties involve in claims for payment; (d) Perform such other functions and duties as may be assigned to it by the Commission; and
(e) Hold in trust, through the Provincial Treasurer as Member of the Provincial Medical Care Council, Community Mutual Health Funds of cities and municipalities as provided for under Section 32(b). SECTION 30. City Medical Care Council. The Commission shall establish in each chartered city the City Medical Care Council of seven (7) members, to be composed of 1) the City Health Officer; 2) the City Treasurer; 3) a representative of the Mayor; 4) the duly designated representative of the component society of the Philippine Medical Association; 5) a representative to be appointed by the Commission upon the recommendation of the Philippine Hospital Association preferably from one of the City private hospitals; and 6) and 7) two (2) private citizens from the City, one of whom shall be a duly registered physician to be appointed by the Commission. The last four (4) mentioned member shall have terms of four (4) years each,
arranged on a staggered basis so that only one is appointed annually, except the initial appointees who shall have terms of one, two, three, and four years, respectively. This Council shall elect its Chairman, shall administer the Community Mutual Health Fund, as provided for in Section 32, and implement the rules and regulations set forth by the Commission. It shall disburse funds for the payment of medical and hospital care for its members directly to the institutions or medical practitioner concerned. Wherever it may be deemed expedient or necessary, the City Medical Care Council may set up a number of Community Medical Care Councils to be composed of five (5) members chosen from representatives of the community, civic, and government sectors. The latter shall assist the City Medical Care Council in the discharge of its functions.
SECTION 31. Municipal Medical Care Council. The Commission shall establish in each municipality a Municipal Medical Care Council of seven (7) members, to be composed of: 1) the Municipal Health Officer; 2) the Municipal Treasurer; 3) a representative of the Mayor; 4) a designee of the component society of the Philippine Medical Association preferably a resident medical practitioner; 5) a representative of the Philippine Hospital Association in places with registered hospitals, or in their absence, the highest public school official in the town; and 6) and (7) two (2) private citizens from the municipality, one of whom shall preferably be a duly registered physician, to be appointed by the Commission. The last four (4) mentioned members shall be appointed for a term of four (4) years each, arranged on a staggered basis so that only one is appointed annually, except the initial appointees who shall have terms of one, two, three, and four years respectively. This Council shall elect its own Chairman, Vice-Chairman, and Secretary; administer the Community Mutual Health Fund; implement the rules and regulations promulgated by the Commission; and disburse funds for the payment of hospitalization and hospital care for its members directly to the institution or medical practitioner concerned, within ten (10) days after receipt of the bill.
SECTION 32.
Community Mutual Health Fund.
(a) There is hereby established in each city or municipality, a Community Mutual Health Fund. To this Fund shall accrue the yearly contributions of residents in the city or municipality, and a national government counterpart in aid amounting to one hundred percent (100%) of the amount collected by the city or municipality. (b) Community Mutual Health Funds of cities or municipalities which, by virtue of their change of corporate personality, or loss of any portion thereof through regrouping, shall be held in trust by the Provincial Treasurer as Member of the respective Provincial Medical Care Council until such time as the Commission shall have established the new Medical Care Council and defined its jurisdiction. SECTION 33. Revolving Funds. The gross income of the government hospitals shall be constituted into a revolving fund for that particular hospital for the upgrading, expansion of its facilities, and for its maintenance and operation, subject to the approval of the Department of Health. SECTION 34. Reparations Allocations. The reparations Commission shall allocate and include in accordance with the reparations law, as amended, in its annual schedule beginning with the fourteenth up to the twentieth reparations year, the procurement of machineries, equipments and instruments worth at least $1.5 million annually as the Philippine Medical Care Commission may recommend. The latter shall, with the approval by the Department of Health, distribute such machineries, equipments and supplies to the different government hospitals and rural health units. A similar allocation of at least $1.5 million shall likewise be made for the private hospitals involved in this plan pursuant to the provisions of this Act.
SECTION 35. Terms Defined. For the purposes of this Act, the following terms shall, unless the context indicate otherwise, have the following meanings:
(a) SSS. The Social Security System created under Republic Act Numbered One thousand one hundred sixty-one, as amended.
(b) GSIS. The Government Service Insurance System created under Commonwealth Act Numbered One hundred eighty-six, as amended. (c) Employee. Any person compulsorily covered by the SSS under Republic Act Numbered One thousand one hundred sixty-one, as amended; or by the GSIS under Commonwealth Act Numbered One hundred eighty-six, as amended, except members of the Armed Forces of the Philippines.
(d)
Employer. The employer of the employee.
(e) Benefit. The hospitalization, surgical and/or medical expense benefit provided for under this Act. ( f ) Hospital. Any hospital, government or private, licensed with the Bureau of Medical Services. (g) Medical Practitioner. Any Doctor of Medicine duly licensed to practice in the Philippines and an active member of good standing of the Philippine Medical Association. (h) Confinement. Confinement in a hospital defined in Section 35 (f), due to sickness or bodily injury. (i) Single Period of Confinement. A continuous period of confinement or periods of confinement for the same or any related illness, injury or condition not separated from each other by more than ninety days. ( j) Commission. Philippine Medical Care Commission created under this Act. (k) II. Service Beds. Beds reserved for beneficiaries under Program
(l) Community Mutual Health Funds. Funds accruing from the contributions of residents in each chartered city or municipality, plus the one hundred percent (100%) government counterpart funds.
(m) Administrator. Refers to the Commission, unless specified otherwise.
Administrator
of
the
SECTION 36. Study and Research. Immediately upon its organization, the Commission shall undertake actuarial studies for the purpose of determining the contributions necessary in order to insure adequate financing and disbursement of funds to all participants of the plan and the extent and scope of benefits of the beneficiaries of the plan.
Immediately upon completion of such study, the Commission shall submit to Congress a report with its recommendations as to the amount to be assessed from each resident or inhabitant covered by the plan for purposes of legislation by Congress.
SECTION 37.
Penal Provisions.
(a) Any person, who for the purpose of securing entitlement to any benefit or payment under this Act or the issuance of any certificate or document for any purpose connected with this Act, whether for him or for some other person, commits fraud, collusion, falsification, misrepresentation of facts or any other kind of anomaly shall be punished with a fine of not exceeding one thousand pesos or imprisonment not exceeding one year or by both such fine and imprisonment, at the discretion of the court; and (b) Any contribution or other amount collected by the treasurer, as provided for under Section 28 of this Act, shall not be used, appropriated or diverted for a purpose other than that authorized by this Act. Any person violating this provision shall be punished with imprisonment for not less than one year nor more than five years or with a fine of not less than one thousand pesos, nor more than five thousand pesos or by both such imprisonment and fine, at the discretion of the court. SECTION 38. Separability Clause. In the event any provision of this Act or the application of such provision to any person or circumstance is declared invalid, the remainder of the Act or the application of said provision to other persons or circumstances shall not be affected by such declaration.
SECTION 39. Repealing Clause. All laws, executive orders, and administrative rules and regulations or parts thereof which are inconsistent with the provisions of this Act are hereby repealed or modified accordingly: Provided, however, That nothing in this Act shall be construed to remove or eliminate the present powers and functions of existing agencies involved. SECTION 40. Appropriation. The sum of one million pesos is hereby appropriated out of any funds in the National Treasury not otherwise appropriated for the initial organizational expenses of the Commission and the Medical Care Councils, as provided for in Sections 29, 30 and 31. Thereafter, the necessary funds for the yearly operation of the above-mentioned agencies shall be incorporated in the General Appropriations Act.
SECTION 41. Effectivity. Program I shall be implemented immediately and upon the effectivity of this Act. Program II shall be implemented in the manner and time to be determined by Congress upon recommendation of the Commission. Approved: August 4, 1969
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: (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 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 promulgation 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. (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. (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 services on an out-patient and inpatient basis, duly licensed by the Department of Health, member in good standing of a national association of government and privatelyowned 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. (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 privatelyemployed 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) (w) 1) 2) 3) 4) 5) SYSTEM The GSIS or SSS as the case may be. VIOLATION Any act or omission constituting infraction of: the provisions of P.D. 1519, as amended; and/or the Medicare implementing rules and regulations; and/or the warranties of accreditation; and/or administrative orders of the Commission; and/or 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. 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 outpatient 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 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 members; and b) 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 MEMBERSHIP SSS GSIS HOSPITAL CATEGORY PRIMARY SECONDARY TERTIARY P30 20 P35 24 EXPENSE P45 33 PER SINGLE
(b) ALLOWANCE FOR MEDICAL PERIOD OF CONFINEMENT FOR SSS BENEFICIARIES MEDICAL EXPENSE BENEFITS 1. ORDINARY CASES: Drugs & Medicines X-ray/Lab./Others 2. INTENSIVE CARE CASES: Drugs & Medicines X-ray/Lab./Others 3. CATASTROPHIC CASES: Drugs & Medicines X-ray/Lab./Others 375 125 P175 75
HOSPITAL CATEGORY PRIMARY SECONDARY TERTIARY
P200 150
P300 350
400 200
500 500
800 400
1,000 1,000
FOR GSIS BENEFICIARIES MEDICAL EXPENSE BENEFITS 1. ORDINARY CASES: Drugs & Medicines X-ray/Lab./Others 2. INTENSIVE CARE CASES: Drugs & Medicines X-ray/Lab./Others 3. CATASTROPHIC CASES: Drugs & Medicines X-ray/Lab./Others 400 150 450 300 250 100 300 125 350 250 P150 50 P175 75 P250 100 HOSPITAL CATEGORY PRIMARY SECONDARY TERTIARY
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; 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. (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. 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 05 5.1 10 10.1 above (e) SURGICAL FAMILY (STERILIZATION BENEFITS): P30 P35 120 170 P65 165 225 PROCEDURES
PLANNING
The following procedures are compensable under Medicare: 1. Vasectomy Hospital services & medicines Professional fees Tubal Ligation Hospital services & medicines Professional fees P200.00 P120.00 80.00 P300.00 P180.00 120.00
2.
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) (c) Optometric services; 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. SECTION 4. Benefits: (a) Members: Requirements for Availment of MEDICARE
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. 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. (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. 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. 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 MONTHLY SALARY CONTRIBUTION EMPLOYERS EMPLOYEES BRACKET WAGE OR EARNING BASE CONTRIBUTION CONTRIBUTION NUMBER 1 Below - P49.99 P25.00 P0.30 P0.30 2 50.00 - 99.99 75.00 0.95 0.95 3 100.00- 149.99 125.00 1.55 1.55 4 150. - 199.99 175.00 2.20 2.20 5 200.00- 249.99 235.00 2.80 2.80 6 250.00-349.99 300.00 3.75 3.75 7 350.00-499.99 425.00 5.35 5.35 8 500.00-699.99 600.00 7.50 7.50 9 700.00-899.99 800.00 10.00 10.00 10 900.00-Over 1,000.00 12.50 12.50
TOTAL P0.60 1.90 3.10 4.40 5.60 7.50 10.50 15.00 20.00 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. 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. 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. 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.
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. 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. 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. 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: (a) (b) (c) (d) (f) the provision of P.D. 1519 as amended; its Implementing Rules and Regulations; the warranties of accreditation; administrative orders of the Commission; 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. 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 15day 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.
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: 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. 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. (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. 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. 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 propio 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. 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: (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: (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. 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: 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. (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: 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. 5. 6. Willful operation without license and/or accreditation; Machinations; and 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. (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. (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. 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. 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. PART II Violations and Penalties SECTION 6. (a) Fraudulent Practices.
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 noncompensable 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 twentyfour (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. 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 twentyfour (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. 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.
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: 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 twentyfour (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. 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. 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.
(d)
Violations and penalties shall prescribe as follows:
1. Violations punishable by revocation of accreditation with nonaccreditation 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 filling 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. 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 Resolution Number 87-1987.
Meeting
under
Medicare
MEDICARE SCHEDULE OF CONTRIBUTIONS I. The following shall take effect on January 1, 1991:
CONTRIBUTION BASE EMPLOYEES SHARE EMPLOYERS P125.00 175.00 225.00 300.00 425.00 600.00 800.00 1,000.00 1,250.00 1,500.00 2,000.00 P1.55 2.20 2.80 3.75 5.35 7.50 10.00 12.50 15.65 18.75 25.00 P1.55 2.20 2.80 3.75 5.35 7.50 10.00 12.50 15.65 18.75 25.00
SALARY BRACKET SHARE P less than P149.99 150 199.99 200 249.99 250 349.99 350 499.99 500 699.99 700 899.99 900 1,099.99 1,100 1,399.99 1,400 1,749.99 1,750 OVER II.
The following shall take effect on January 1, 1992: CONTRIBUTION BASE P125.00 175.00 225.00 300.00 425.00 600.00 800.00 1,000.00 1,250.00 1,500.00 2,000.00 2,500.00 EMPLOYEES SHARE EMPLOYERS P1.55 2.20 2.80 3.75 5.35 7.50 10.00 12.50 15.65 18.75 25.00 31.25 P1.55 2.20 2.80 3.75 5.35 7.50 10.00 12.50 15.65 18.75 25.00 31.25
SALARY BRACKET SHARE P less than P149.99 150 199.99 200 249.99 250 349.99 350 499.99 500 699.99 700 899.99 900 1,099.99 1,100 1,399.99 1,400 1,749.99 1,750 2,249.99 2,250 OVER III.
The following shall take effect on January 1, 1993: CONTRIBUTION BASE P125.00 EMPLOYEES SHARE EMPLOYERS SHARE P1.55 P1.55
SALARY BRACKET P less than P149.99
150 199.99 200 249.99 250 349.99 350 499.99 500 699.99 700 899.99 900 1,099.99 1,100 1,399.99 1,400 1,749.99 1,750 2,249.99 2,250 2749.99 2,750 OVER
175.00 225.00 300.00 425.00 600.00 800.00 1,000.00 1,250.00 1,500.00 2,000.00 2,500.00 3,000.00
2.20 2.80 3.75 5.35 7.50 10.00 12.50 15.65 18.75 25.00 31.25 37.50
2.20 2.80 3.75 5.35 7.50 10.00 12.50 15.65 18.75 25.00 31.25 37.50

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Ra 6111 - Medicare

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REPUBLIC ACT NO.

To devise control measures to prevent abuses of the Plan;

Program II For those not covered in program I.

Limitation on the Right to Benefits.

Cosmetic surgery or treatment;

SECTION 22. Collection Contribution.

Community Mutual Health Fund.

Employer. The employer of the employee.

(m) Administrator. Refers to the Commission, unless specified otherwise.

HOSPITAL CATEGORY PRIMARY SECONDARY TERTIARY

Violations and penalties shall prescribe as follows:

during the 758th Regular Resolution Number 87-1987.

SALARY BRACKET P less than P149.99

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