Law Summary

Introduction

This Circular outlines the conditions under which a hospital that has not been operational for at least three years may qualify for initial accreditation under the Implementing Rules and Regulations (IRR) of the National Health Insurance Act of 1995 (RA 7875, as amended by RA 9241).

General Accreditation Requirements

The Circular specifies that a health care provider may be eligible for initial accreditation despite not meeting the three-year operational requirement if it satisfies particular conditions.

Qualifications of the Managing Health Care Professional

• Legal Principle: The managing health care professional must possess relevant experience in an accredited facility.
• Key Definitions:
  • Managing Health Care Professional: The individual responsible for overseeing hospital operations.
  • Accredited Health Care Institution: A facility recognized by PhilHealth for compliance with standards.
• Requirements:
  • At least three years of experience as a medical director or hospital administrator in an accredited tertiary hospital or equivalent.
  • The previous institution must have been accredited with PhilHealth for three years during the professional's tenure.
  • Documentary proof is required to verify experience, including:
    • Service Record (for government hospitals)
    • Certification from the Board or Hospital Owner (for private hospitals)
    • Certification from the Board (for Corporations or Foundations).
• Replacement Clause: If the managing professional leaves within three years of operation, a qualified replacement must be provided.

Facility Classification

• Legal Principle: The health care provider must function as a tertiary facility or its equivalent.
• Key Definitions:
  • Tertiary Facility: A hospital providing specialized consultative healthcare, typically requiring advanced medical technology.
  • Secondary Care Hospital: A facility providing additional support to primary care services.
• Requirements:
  • The provider must operate as a tertiary facility or equivalent, as classified by the Department of Health (DOH).

Local Government Unit (LGU) Considerations

• Legal Principle: The health care provider must operate in an LGU with inadequate health service provision.
• Requirements:
  • For primary hospitals: PhilHealth records indicating no accredited facility in the LGU.
  • For secondary hospitals: PhilHealth records demonstrating the absence of similar accredited facilities.

Waiver of the Three-Year Requirement

• Legal Principle: Certain providers may waive the three-year operational requirement.
• Specific Providers:
  • Outpatient Primary Care Benefits (OPB)
  • TB-DOTS Benefits
  • Non-hospital Maternity Care Benefits

Effective Date

• The Circular shall take effect 15 days after its publication.

Key Takeaways

• A hospital can qualify for initial accreditation without three years of operation if it meets specific criteria regarding management experience, facility classification, and local health service adequacy.
• Documentation proving the managing professional’s experience is critical for qualification.
• Certain health service providers are exempt from the three-year operational requirement to promote access to essential health services.
• Compliance with this Circular is required for effective operation and accreditation under PhilHealth.