Policy, purpose, and basis
- The Executive Order directs the increase of Medicare benefits because the need arises to make the Program responsive to members.
- The Executive Order states that the government desires to increase Medicare benefits to preserve the Program’s support level.
- The Executive Order cites actuarial studies showing the Health Insurance Fund administered by the SSS for private sector medicare beneficiaries and the Health Insurance Fund administered by the GSIS for government sector medicare beneficiaries can finance a 20% across-the-board increase in items of hospitalization compensable under the Medicare Program.
- The Executive Order relies on the Philippine Medical Care Commission’s recommendation for further enhancements of benefits under the Medicare Program.
Medicare hospitalization benefit limits
- Section 1 increases Medicare benefits for hospitalization items and provides benefit limits by hospital category: Primary, Secondary, and Tertiary.
- The Executive Order increases Hospital Charges under the following categories.
Room and board limits per year
- Section 1 sets Room and Board limits of not exceeding 45 days per year for each member of program 1, plus another 45 days per year to be shared by all dependents.
- Primary room and board is limited to PHP 55/Day.
- Secondary room and board is limited to PHP 100/Day.
- Tertiary room and board is limited to PHP 120/Day.
Medical expense benefit—ordinary cases
- Section 1 sets Medical Expense Benefit (per single period of confinement) for Ordinary Cases.
- For Primary, Drugs & Medicines are limited to PHP 720 and X-Ray/Lab/Other are limited to PHP 595.
- For Secondary, Drugs & Medicines are limited to PHP 1,090 and X-Ray/Lab/Other are limited to PHP 790.
- For Tertiary, Drugs & Medicines are limited to PHP 1,375 and X-Ray/Lab/Other are limited to PHP 845.
Medical expense benefit—intensive and catastrophic
Section 1 sets Medical Expense Benefit (per single period of confinement) for Intensive Cases.
For Primary intensive cases, Drugs & Medicines are limited to PHP 1,395 and X-Ray/Lab/Cases are limited to PHP 1,125.
For Secondary intensive cases, Drugs & Medicines are limited to PHP 2,040 and X-Ray/Lab/Cases are limited to PHP 1,350.
For Tertiary intensive cases, Drugs & Medicines are limited to PHP 3,480 and X-Ray/Lab/Cases are limited to PHP 2,430.
Section 1 sets Medical Expense Benefit (per single period of confinement) for Catastrophic Cases.
For Primary catastrophic cases, the Executive Order sets Drugs & Medicines at — and X-Ray/Lab/Other at —.
For Secondary catastrophic cases, Drugs & Medicines are limited to PHP 4,390 and X-Ray/Lab/Other are limited to PHP 3,040.
For Tertiary catastrophic cases, Drugs & Medicines are limited to PHP 6,680 and X-Ray/Lab/Other are limited to PHP 3,475.
Operating room fee and RUV limits
- Section 1 provides an Operating Room Fee based on the Commissions Relative Unit value (RUV) scheme.
- For RUV 5 & Below, Primary is limited to PHP 140, Secondary is —, and Tertiary is —.
- For RUV 5.1 to 10, Primary is —, Secondary is limited to PHP 245, and Tertiary is limited to PHP 420.
- For RUV 10.1 & Above, Primary is —, Secondary is limited to PHP 390, and Tertiary is limited to PHP 960.
Professional fees and capped amounts
- Section 1 establishes Professional Fees caps for Medicare hospitalization.
- A Medical/Dental practitioner’s fee is PHP 55 per day for general practitioners and PHP 80 per day for specialists, and is subject to the confinement caps below.
- For Ordinary Cases, Medical/Dental practitioner’s fee is capped at PHP 300 for general practitioners and PHP 450 for specialists per single period of confinement.
- For Intensive care/Catastrophic cases, Medical/Dental practitioner’s fee is capped at PHP 450 for general practitioners and PHP 750 for specialists per single period of confinement.
- A Surgeon’s fee is paid in accordance with the relative unit value scheme prescribed by the commission and is capped at PHP 7,080.
- An Anesthesiologist’s fee is set at 30% of the allowed surgeon’s fee and is capped at PHP 2,125.
- Fees for surgical family planning procedures are determined by the commission.
Repeal of inconsistent issuances
- Section 2 repeals or modifies any orders, issuances, rules and regulations, or parts thereof, that are inconsistent with Executive Order No. 501.
- Section 3 makes the Executive Order effective on January 1, 1992.
Effectivity date and signature
- Executive Order No. 501 is signed by Corazon C. Aquino as President of the Philippines on December 27, 1991.
- Franklin M. Drilon, Executive Secretary, signs for the Philippines.