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Date Filed: 30 August 2018

I.    BACKGROUND

One of the key strategies of the Philippine Development Plan 2016-2022 is covering all Filipinos against financial health risk. This shall be done through mobilizing, streamlining, and harmonizing access to various, discrete fund pools to avoid inefficient overlaps in financing health. These include funds from the Department  of  Health  (DOH),  Philippine  Health  Insurance  Corporation (PhilHealth), Philippine Charity Sweepstakes Office (PCSO), and Department of Social Welfare and Development (DSWD), among others.

From 2011-2014, PhilHealth set predetermined rates for essentially all inpatient conditions. The shift to case rates as the predominant payment mechanism enabled the implementation of the No Balance Billing Policy (NBB), which stipulates that indigent patients shall be provided with complete quality care  and  all  necessary  healthcare  services  to  attain  best  possible  health outcome, free of any other fees above and beyond the PhilHealth package rates during their confinement period. This is anchored on Section 2 of Republic Act

(RA) 10606, which declares that “the State shall provide comprehensive health care services to all Filipinos…and provide free health care services to indigents.” The coverage of the NBB policy was further expanded to sponsored and household help members through PhilHealth Circular No. 2014-0003, and senior citizens by virtue of Section 4 of the Expanded Senior Citizens Act of 2010 and PhilHealth Board Resolution No. 1924 which mandates the entitlement to NBB policy of PhilHealth by all senior citizen members including Lifetime Members and Kasambahays who are 60 years old and above.

The published case rate, however, is not always sufficient to cover actual costs incurred, thus, requires augmentation from other funding sources such as PCSO and DOH Medical Assistance to Indigent Patients Program for direct health  services.  Hence,  in  the  strengthened  NBB  Policy  as  espoused  in PhilHealth Circular No. 2017-0017, Section III.B, partner agencies were explicitly recognized as sources of financing to fully cover all facility charges in the event of an insufficiency.

II.   OBJECTIVES

This Order is being issued to (1) define the roles of DOH, PCSO, and DSWD in augmenting the financing provision of the NBB Policy for Case Rates and Z Benefits and (2) outline a streamlined process for accessing these funds by the members and dependents.

III.  SCOPE AND COVERAGE

This Order applies to all PhilHealth-accredited health care providers catering to  patients  in  non-private  or  service  settings  and  all  offices  of  the  DOH, PhilHealth, PCSO, and DSWD excluding full complementation packages.

IV.  DEFINITION OF TERMS

1.    Benefit Package – services that PhilHealth offers to members, subject to the classification and qualification in its Revised Implementing Rules and Regulations.

2.    Case  Rates  –  a  payment  scheme  where  a  standard,  pre-determined rate/amount with professional fee component is reimbursed to a health care facility for each episode of care provided to a patient.

3.    Endowment Fund Program (EFP) – funding assistance provided to DOH- licensed government hospitals to augment the NBB policy of PhilHealth.

4.   Total Charges – total medical bill including professional fee incurred by a patient in seeking care in a facility.

5.    Individual Medical Assistance Program (IMAP) – PCSO flagship program designed to augment the financial needs of individuals for the management of health-related concerns.

6.    Medical Assistance to Indigent Patients Program (MAIP) – program of the DOH providing medical assistance to poor and indigent patients in government hospitals.

7.    NBB Patients – patients covered under the No Balance Billing Policy of PhilHealth  (PhilHealth  Circular  No.  0003,  s.  2014),  who  are  admitted  in service accommodation.

8.    Non-medical  expenses – costs incurred by a patient in availing health services, outside of the actual costs of medical care, which may include transportation costs, accommodation, meals, etc.

9.    Quantified Free Service (QFS) – the cost of treatment subsidized by the maintenance and other operating expenses (MOOE) received from the National Budget and Income of the hospital.

10. Z Benefit Packages – PhilHealth benefit packages that cover a unique set of high-cost, catastrophic illnesses.

11. Malasakit Center – an area in which various payors (e.g., PCSO and DOH MAIP desks)  will be housed to streamline the process for patients in availing financial assistance.

12. Individual-based Intervention – health care goods and services that can be definitively traced back to a singular person, can be public health (e.g. vaccines) or personal care (e.g. primary care consultation, hospital services). 13. Full complementation packages – benefit packages which PhilHealth and PCSO have agreed to jointly finance.

V.   GENERAL GUIDELINES

1.   All  classified  indigent  patients  in  non-private  or  service  settings  in  all PhilHealth-accredited government health care providers shall be entitled to No Balance Billing.

2.    All direct medical expenses shall be augmented by PCSO and DOH MAIP while  all  non-direct  medical  expenses  such  as  transportation  shall  be covered by DSWD.

3.    All funds for medical assistance shall be coursed through the health care providers. Patients shall no longer need to file separate application to obtain support from PCSO and DOH MAIP.

4.    All  PhilHealth-accredited  health  care  providers  shall  establish  “Malasakit Center” in which the various funding sources (e.g. PCSO ASAP and DOH MAIP desks) will be housed in one area to streamline the availment of funding assistance of patients admitted in service accommodation.

5.    All  agencies  shall  jointly  develop  an  effective  communication  strategy. Specifically, all government health care providers shall make available clear Information, Education and Communication (IEC) materials to inform patients regarding the harmonized medical assistance program and streamlined process of availment.

6.    All agencies shall establish a joint mechanism to resolve grievances and meet regularly to discuss the progress of the implementation of this Order, specifically results of exit surveys of patients and availability of funds.

7.    All complaints shall be lodged through the Citizen’s Complaint Hotline, 8888. Only complaints with all the following information will be acted upon: a) name and address of the complainant; b) name of the offender and/or institutions; c) direct and concise statement of the offense; and d) name of the agency (PhilHealth, DOH, PCSO, DSWD) to which the relief is sought.

8.    PhilHealth and PCSO shall publish the list of full complementation packages annually.

9.    The  health  care  providers  shall  bill  all  agencies  according  to  existing guidelines and procedures.

VI.  SPECIFIC GUIDELINES

A.   Order of Charging

The health care provider’s billing section shall coordinate closely with the Medical Social Worker to tap the sources of financing for the patient’s bill in the following order:

1. PhilHealth: Support shall be based on the published case rates per PhilHealth Circular No. 0031, s. 2013 and other circulars pertinent to Z benefits.

2.  Private  Health  Insurance: Support  shall  be  based  on  insurance plan/policy  with  the  private  insurance  or  health  management organization, if applicable.

3.  Mandatory Discounts and Benefits: Discounts for Senior Citizens, Persons with Disabilities (PWDs), SSS members, DOH employees and other  authorized  discounts  shall  apply  in  the  billing  of  the  service patient/s.

4.   PCSO: Funds shall be sourced from the Endowment Fund Program (EFP), if applicable. In cases where there is no EFP or once EFP has been consumed, the Individual Medical Assistant Program (IMAP) shall be tapped.

a.    For  Case  Rates,  maximum  support  shall  be  equal  to  100%  of prevailing PhilHealth case rates.

b.    For  Z  Benefits,  support  will  focus  on  services  excluded  in  the package.

c.    No professional or room and board fees may be charged to: the patients, the PCSO or DOH MAIP funds. For DOH or LGU hospitals, the room and board and professional fees are covered by DOH’s or LGU’s subsidy as maintenance and other operating expenditures (MOOE) and personal services.

d.    All government hospitals shall establish PCSO ASAP (At Source Ang Processing) desks and all government hospitals shall receive periodic DOH MAIP sub-allotment.

5.   DOH MAIP. Maximum support shall be based on its guidelines, subject to availability of funds.

6.   PhilHealth-Accredited Health Care Providers. All remaining expenses shall be charged to the health care provider’s MOOE or income as Quantified Free Services (QFS) for patients in service or non-private settings.

Table 1. Sources, Uses and Limitations of Funds for Direct Medical Expenses

Order of Charging	Agency	Fund Source/ Program	Amount and Restrictions, if any
First	PhilHealth	National Health Insurance Fund	Published PhilHealth case rates and Z Benefits
Second	Private health insurance, if applicable	Various private health insurance funds	Insurance Plan/Policy
Third	Mandatory Discounts and Benefits	Discounts for Senior Citizens, PWDs, DOH employees, SSS members, etc.	Based one existing guidelines
Fourth	PCSO	Endowment Fund Program (EFP), if applicable Individual Medical Assistance   Program (IMAP)	Maximum = 100% of PhilHealth case rates; Z Benefits exclusions cannot be used to pay for room and board and professional fees
Fifth	DOH	Medical Assistance to Indigents Program (MAIP)	Fixed rates based on MAIP guidelines
Last	Hospital	MOOE/Income (charged as QFS)	100% of remaining balance

Table 2. Sources, Uses and Limitations of Funds for Non-Direct Medical Expenses

Order	Agency	Fund Source/ Program	Basis for Amount
First	DSWD	Assistance to individual in crisis situations (AICS)	Based on existing guidelines

B.   Availment Procedures

1.   Prior to availment of services, the health care provider shall assess patient’s PhilHealth and NBB eligibility and provide the patient with complete information on the (1) financial implications of availment as service or private patient and (2) streamlined availment of financial assistance from various funding sources.

a.    If patient is PhilHealth and NBB eligible, the health care provider staff shall ensure the patient will not incur out of pocket payment and facilitate provision of services.

b.    If patient is non-PhilHealth member, the health care provider staff shall endorse the patient to the medical social worker. Once the patient is classified as C3 or D, the health care provider shall enroll patient under PhilHealth’s Point of Care or Point of Service program. The hospital staff shall then ensure the patient of zero out-of-pocket payment and facilitate provision of service.

2.  The  health  care  provider  shall  be  responsible  for  recording  all  the services rendered to the patient during confinement.

3.  The medical social worker shall facilitate tapping of carious financial assistance for patients admitted in service or non-private setting.

4.   The health care provider’s billing section shall facilitate settlement of the patient’s health care provider’s bill outlined in VI.A. No reimbursement for medical services shall be directly given to the patient. A statement of account (SOA) clearly accounting for contributions from various fund sources shall be provided to the patient. Copies of these shall be submitted in encoded, editable format following the template in Annex A.

C.   Special Cases for Admitted Patients

1.   In  instances  where  a  patient  in  a  PhilHealth-accredited  health  care provider  could  not  be  admitted  to  a  non-private  or  service accommodation because all beds are already occupied, the patient shall

be admitted to the next available private accommodation but still be charged to hospital’s service rates.

2.   In instances where services are not available in the hospital, government health  care  providers  shall  be  responsible  to  assist  the  patient  in obtaining the said service, either through contracting out of service or partnership with another facility, and/or transferring the patient to the said facility, without the patient incurring out-of-pocket payment.

3.   Patients who can no longer avail of PhilHealth benefits due to exhausted number of days or single period of confinement, unpaid premiums non- emergency confinement of less than 24 hours shall still be eligible for coverage from the other fund sources.

4.  If the patient decides to transfer in a private accommodation, then the guidelines shall no longer apply to him/her.

D.   Grievance Mechanism

Each agency shall resolve all complaints within their jurisdiction according to their respective citizens’ charter.

VII. MONITORING AND EVALUATION

An interagency monitoring and evaluation mechanism including a shared database shall be created to support the implementation of this policy. This shall leverage on existing accountability measures and monitoring mechanisms of all involved agencies, to detect and capture incidents of fraud, for implementation of necessary sanctions and penalties. Cooperating agencies shall enter into non- disclosure agreements (NDAs) in cases of necessary sharing of sensitive and/or confidential  data.  Likewise,  PhilHealth  shall  provide  a  summary  of  the  exit surveys to all agencies on a regular basis.

VIII.    RESPONSIBILITIES

A.  DOH shall:

1.  Lead and coordinate with other participating agencies and offices in the effective implementation of this Order in DOH-licensed hospitals;

2. Promote  NBB  compliance  among  DOH-licensed  hospitals  by implementing stringent monitoring and using compliance rate as one of the criteria to assess hospital performance; and

3. Train, supervise and monitor all medical social workers involved in implementing this Order.

B.   PhilHealth shall:

1.   Provide  explicit  guidelines  in  identifying  NBB  eligible  patients  and ensuring their enrolment to the NHIP;

2.   Furnish all participating agencies a copy of prevailing case rates and Z benefit package rates;

3.   Consolidate data from Statement of Account (SOA) and regularly provide reports (i.e. membership, reimbursement, etc.) to all participating agencies;

4.   Undertake costing and share costing data to update the current case rates;

5.   Deploy PhilHealth CARES to all government health care providers and selected private health care providers with MOA to implement NBB;

6.   Enhance the NBB exit survey to include monitoring and evaluation of this Order.

C.   PCSO shall:

1.   Provide funds to support this Orders, as specified in the guidelines;

2.   Partner  with  all  PhilHealth-accredited  health  care  providers  for  the implementation of the PCSO ASAP desk.

D.  DSWD shall provide assistance to eligible patients/beneficiaries through the AICS in accordance to the existing policy/guidelines of the Department to support the NBB policy as specified in Section V.B of this Order.

E. All PhilHealth-accredited health care providers shall ensure 100% compliance to the NBB policy, such that all NBB-eligible patients are given adequate health service and guaranteed zero out-of-pocket payments.

IX.  GOVERNING CLAUSE

Issues arising from the implementation of this Order shall be resolved jointly by DOH, PhilHealth, PCSO and DSWD. The provisions of this Order shall be transitory until policies on full streamlining of all fund sources for health is institutionalized.

X.   PENALTY CLAUSE

1.    Patient  who  provides  false  information  or  engages  in  misrepresentation resulting in unjust availment of benefits, all future requests for assistance and/or claims shall be denied without prejudice to the filing of appropriate criminal or administrative charges.

2.    PhilHealth-accredited  private  and  government  health  care  providers  that violate any provision of this Order and related rules and regulations of each participating agency, resulting in filing of unjustified claims, shall be subject to the appropriate administrative, civil or criminal charges.

3.    Late filing or non-compliance to claims rules as prescribed by each of the participating agencies shall merit sanctions/penalties following existing rules and policies.

XI.  SEPARABILITY CLAUSE

In the event that any provision or part of this Order is declared unauthorized or rendered invalid by any Court of Law or competent authority, those provisions not affected by such declaration shall remain valid and effective.

XII. REPEALING CLAUSE

All other provisions on Administrative Order 2017-0003 on the Guidelines for the Implementation of the 2017 Medical Assistance Program (MAP) in DOH Hospitals   and   Other   Selected   Government   Health   Facilities  which  are inconsistent with this Order are hereby repealed, amended, or modified accordingly. All provisions of existing issuances which are not affected by this

Order shall remain valid and in effect. In the event that any provision or part of this Order is declared unauthorized or rendered invalid by any court of law or competent authority, those provisions or parts not affected by such declaration shall remain valid and in effect.

XIII. TRANSITORY CLAUSE

The virtual pooling of health funds from different agencies will be an interim guideline towards a long-term measure which is to make Philippine Health Insurance Corporation a national single purchaser of individual-based interventions.

XIV.   EFFECTIVITY

This Order shall take effect 15 days after its publication in a newspaper of nationwide circulation.

Done in the City of Manila on July 13, 2018.

(SGD) FRANCISCO T. DUQUE III, MD, MSc Secretary Department of Health		(SGD) ROY B. FERRER, MD, MSc, FPSMS, FPSD Acting President and CEO Philippine Health Insurance Corporation
(SGD) ALEXANDER F. BALUTAN General Manager Philippine   Charity Sweepstakes Office		(SGD) VIRGINIA N. OROGO Acting Secretary Department of Social Welfare and Development