QuestionsQuestions (PRESIDENTIAL DECREE NO. 1519)
It is known as the “Revised Philippine Medical Care Act.” The policy is to gradually provide total medical service through a comprehensive and coordinated medical care plan: (1) comprehensive care based on patients’ needs; (2) coordination of government and private facilities as public service instrumentalities; and (3) achieving optimum care by preserving proper inter-relationship among physicians, patients, and hospitals.
To provide medical care to residents in an evolutionary manner within the nation’s economic means and capability; and to provide a viable means for the people to help themselves pay for adequate medical care.
“Commission” is the Philippine Medical Care Commission created under RA 6111. “Employee” is any person compulsorily covered by either the SSS or GSIS. “Beneficiary” is one entitled to medical care benefits under the Decree. “Hospital” is any accredited government or private medical facility. “Medical Care Benefits” are services relative to illness or injury including major dental surgery/operation needing hospitalization, subject to limitations imposed by the Plan’s technical organization and finances.
It includes a Chairman, Executive Director, and members: Administrator of SSS, General Manager of GSIS, Secretary of Health, Secretary of Finance, Secretary of Local Governments and Community Development, President of the Philippine Medical Association, President of the Philippine Hospital Association, and two private sector members. Private sector representatives are appointed by the President for a term of six (6) years.
Among others: formulate policies and administer the Plan; ensure medical care for covered members; organize its offices and personnel; establish provincial/city/municipal medical care councils; accredit practitioners and facilities; promulgate rules; recommend contribution/benefit levels using actuarial procedures; fund operation of councils; ensure hospital accommodation distribution and coordinate with DOH on licensure; prevent abuses; investigate violations and suspend/revoke accreditation with notice and hearing; and submit annual reports to the President.
Quorum is six (6) members. Members receive per diem for every meeting/hearing attended, subject to budget laws and regulations on compensation, honoraria, and allowances. Each member except the Chairman and Executive Director also receives a monthly commutable allowance under the same constraints.
The Chairman is appointed by the President for six (6) years, must be a reputable medical professional with at least 12 years of medical practice experience, holds office full-time, and is removable only for cause. The Executive Director is also Vice-Chairman, appointed by the President for six (6) years, must have at least 10 years experience in business undertaking or medical practice, holds office full-time, and is removable only for cause.
Program I covers SSS and GSIS members and their legal dependents. Program II is for those not covered under Program I, to be provided either through a social insurance medical care service similar to Program I or through public medical care service, subject to implementation upon President’s approval.
If an employee is both covered by SSS and GSIS, only the employment with the GSIS is considered for purposes of coverage.
The employee must have paid at least three (3) monthly contributions during the last twelve (12) months prior to the first day of the single period of confinement, and his legal dependents are also entitled (subject to the Decree’s rules/conditions).
PD 1519 lists: (1) allowance for hospital room/board at P12/day for up to 45 days/year per member, with another 45 days/year shared by dependents (Commission may increase up to P18/day); (2) drugs/laboratory/X-ray not exceeding P150 per single period (up to P250 for intensive care cases as defined); (3) surgeon’s fee allowance by surgery type (minor P50, medium P250, major P500, not exceeding P500 per listed operation) covering specified pre- and post-operative days; (4) operating room fees (minor P20, medium P50, major P75); (5) anesthesiologist fee up to 30% of surgeon’s fees; (6) medical/dental practitioner daily visit allowance P10 per daily visit up to P200 per confinement episode/sickness/injury with counting rules; (7) sterilization expenses for a contributing member or spouse as determined by the Commission.
It is a single confinement or series of confinements for the same illness, with intervals of not more than 90 days. It is relevant because certain allowances (e.g., drugs/laboratory/X-ray up to a per-single-period amount) are keyed to the “single period of confinement.”
The beneficiary is free to choose the accredited hospital and the medical/dental practitioner/attendance, subject to Commission rules. The right to arrange privately at one’s own expense is not prejudiced.
Payment is made directly to the hospital, practitioner, and retail drug store. If the charges/fees agreed for a bed more expensive than a service bed exceed the amount of benefits, the difference must be borne personally by the patient.
Excluded are: cosmetic surgery/treatment; optometric services; psychiatric illness; normal obstetrical delivery; and services that are purely diagnostic.
Claims filed beyond sixty (60) days after discharge or when the patient is declared well are barred. Payment may also be reduced or denied for false/incorrect information, failure to comply without good cause/legal ground, and limitations for service-bed costs. Denied/reduced amounts generally cannot be charged to the beneficiary unless the beneficiary is directly responsible for the cause.
Fraud, collusion, falsification, misrepresentation, or similar anomalies to secure entitlement lead to penalties under Article 172 of the Revised Penal Code. Failure/refusal to comply with the Decree or rules results in a fine of not less than P500 nor more than P5,000 or imprisonment of not less than 6 months nor more than 1 year, or both (with specific presumptions and corresponding penalties for employers who fail to deduct/remit and for misappropriation-related acts).
The Republic guarantees the benefits under the Decree and the solvency of the Community Health Insurance Funds. It is implemented 90 days after its approval.