QuestionsQuestions (ADMINISTRATIVE ORDER NO. 2018-0001)
AO 2018-0001 aims to streamline and harmonize access to government medical assistance funds to avoid inefficient overlaps in financing health. It defines the roles of DOH, PCSO, and DSWD in augmenting PhilHealth’s No Balance Billing (NBB) policy for case rates and Z benefits and provides a unified process for patients to avail financial assistance through health care providers.
The AO references 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.
The AO explains that NBB is anchored on Section 2 of RA 10606, which declares that the State shall provide comprehensive health care services and free health care services to indigents. It further notes that NBB coverage was expanded through subsequent PhilHealth issuances and legal entitlements.
“Case Rates” are a payment scheme where a standard, pre-determined rate/amount with a professional fee component is reimbursed to a health care facility for each episode of care provided to a patient. The AO uses case rates as the basis for PhilHealth support and the benchmark for PCSO maximum support (up to 100% of prevailing PhilHealth case rates).
“Z Benefit Packages” are PhilHealth benefit packages that cover unique sets of high-cost, catastrophic illnesses. For Z benefits, the AO provides that PhilHealth is the first source, and PCSO support focuses on services excluded in the Z benefit package rather than paying room and board/professional fees.
It requires that all NBB-eligible patients be given adequate health service and be guaranteed zero out-of-pocket payments. It also states that patients should not need to file separate applications for PCSO and DOH MAIP, because funds should be coursed through the health care providers.
All classified indigent patients in non-private or service settings in PhilHealth-accredited government health care providers are entitled to No Balance Billing.
The AO’s order for direct medical expenses is: (1) PhilHealth (published case rates and Z benefits), (2) private health insurance if applicable, (3) mandatory discounts/benefits, (4) PCSO (EFP if applicable; otherwise IMAP), and (5) DOH MAIP (subject to availability). Any remaining expenses are charged to the hospital’s MOOE or income as Quantified Free Services (QFS).
It states that no professional or room and board fees may be charged to the patients, the PCSO, or the DOH MAIP funds. For DOH or LGU hospitals, room and board and professional fees are covered by DOH or LGU subsidy as MOOE and personal services.
DSWD is responsible for covering non-direct medical expenses such as transportation, which the AO contrasts with direct medical expenses that are augmented by PCSO and DOH MAIP.
A Malasakit Center is an area in which various payors (e.g., PCSO and DOH MAIP desks) are housed to streamline the process for patients in availing financial assistance. The AO requires PhilHealth-accredited providers to establish one to integrate funding sources in one location.
Before services, the health care provider assesses the patient’s PhilHealth and NBB eligibility and provides complete information on financial implications if availed as service/private patient and on streamlined financial assistance. If PhilHealth and NBB eligible, provider staff ensure the patient will not incur out-of-pocket payment and facilitate provision of services. During confinement, the provider records all services rendered.
The provider endorses the patient to the medical social worker. If classified as C3 or D, the hospital enrolls the patient under PhilHealth’s Point of Care or Point of Service program and ensures zero out-of-pocket payment while facilitating provision of service.
No reimbursement for medical services shall be directly given to the patient. The hospital must provide a Statement of Account (SOA) that clearly accounts for contributions from various fund sources and submit copies in encoded, editable format following the template in Annex A.
If non-private/service beds are unavailable, the patient may be admitted to the next available private accommodation, but must still be charged to the hospital’s service rates—meaning the patient remains under service-rate charging rather than private billing conditions.
Even if PhilHealth benefits are exhausted (including cases of unpaid premiums or non-emergency confinement of less than 24 hours), the patient remains eligible for coverage from other fund sources under the AO’s harmonized financing approach.
If the patient decides to transfer in a private accommodation, the AO’s guidelines no longer apply to him/her.
Complaints must be lodged through the Citizen’s Complaint Hotline, 8888. Only complaints containing the following will be acted upon: (a) name and address of complainant; (b) name of offender and/or institution; (c) direct and concise statement of the offense; and (d) agency (PhilHealth, DOH, PCSO, or DSWD) to which relief is sought.
If a patient provides false information or engages in misrepresentation resulting in unjust availment of benefits, all future assistance requests and/or claims are denied without prejudice to filing appropriate criminal or administrative charges. For PhilHealth-accredited private and government providers that violate any provision and file unjustified claims, they may be subject to appropriate administrative, civil, or criminal charges. Late filing or non-compliance to claims rules may lead to sanctions/penalties under existing rules.
The AO takes effect 15 days after its publication in a newspaper of nationwide circulation.