(NAR) VOL. 29 NO. 3/ JULY - SEPTEMBER 18
1. Benefit Package – services that PhilHealth offers to members, subject to the classification and qualification in its Revised Implementing Rules and Regulations.V. GENERAL GUIDELINES
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.
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.VI. SPECIFIC GUIDELINES
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.
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 Individual Medical Assistance | 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 |
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 |
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.2. The health care provider shall be responsible for recording all the services rendered to the patient during confinement.
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.
3. The medical social worker shall facilitate tapping of carious financial assistance for patients admitted in service or non-private setting.C. Special Cases for Admitted Patients
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.
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.
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.
1. Provide funds to support this Orders, as specified in the guidelines;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.
2. Partner with all PhilHealth-accredited health care providers for the implementation of the PCSO ASAP desk.
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.XI. SEPARABILITY CLAUSE
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.
(SGD) FRANCISCO T. DUQUE III, MD, MSc Secretary Department of Health | (SGD) ROY B. FERRER, MD, MSc, FPSMS, FPSD | |
(SGD) ALEXANDER F. BALUTAN General Manager Philippine Charity Sweepstakes Office | (SGD) VIRGINIA N. OROGO Acting Secretary Department of Social Welfare and Development |