Policy and program intent
- The OHAT Package is established to support United Nations Millennium Development Goal Number 6 to halt or reverse the incidence of HIV/AIDS by 2015.
- The benefit is designed to increase the proportion of the population with access to effective HIV/AIDS treatment and patient education measures.
- The implementation follows Department of Health (DOH) guidelines on anti-retroviral therapy among adults and adolescents with HIV infection.
Definition of who qualifies as cases
- The OHAT Package covers confirmed HIV/AIDS cases requiring treatment.
- PhilHealth pays only for cases confirmed by STD/AIDS Central Cooperative Laboratory (SACCL) or Research Institute for Tropical Medicine (RITM).
- Covered treatment requires that the case has an indication for anti-retroviral therapy and meets the laboratory confirmation requirement.
What the package covers
- The OHAT Package covers drugs and medicines, laboratory examinations, and professional fees of providers.
- Laboratory examinations include Cluster Difference 4 (CD4) level determination test.
- Laboratory examinations include tests for monitoring of anti-retroviral drugs (ARV) toxicity.
- The benefit is structured as a set of reimbursable service items under the OHAT package logic and DOH treatment guidelines followed by accredited hubs.
Payment amounts and quarterly structure
- PhilHealth reimbursement for the OHAT Package is set at an annual reimbursement of PHP 30,000 per year.
- Payment uses four (4) quarterly payments, with each sub-package worth PHP 7,500.
- A maximum of four (4) treatment sub-packages per year may be claimed by the treatment hub.
- Only quarters where services were actually provided in a year are reimbursed.
Timing, single-period rule, and limits
- Each quarterly claim is covered by the rule on single period of confinement, computed from the date of consultation.
- Additional claims filed within the same single period for the same reason are denied.
- Each quarterly claim is charged one (1) day against the 45-day annual limit, equivalent to 4 days per year.
- Claims for entitlements follow the entitlement period based on consultation date (e.g., October 15, 2010 covers October 15, 2010 to December 31, 2010), with the amount aligned to the PHP 7,500 quarterly sub-package.
Transfers between treatment hubs
- PhilHealth continues reimbursement in cases of transfer from one treatment hub to another if:
- The receiving facility is also PhilHealth accredited; and
- A referral letter from the referring facility to the receiving facility is accomplished; and
- PhilHealth reimburses the facility prior to the transfer.
- Fees for OHAT Package claims are payable to the provider who filed the initial claim.
- If transfer occurs, the claim is processed according to where the patient transfer is situated for payment handling (including treatment hub transfer within the same quarter).
Inclusion and exclusion rules for coverage
- The OHAT Package includes only confirmed HIV/AIDS cases requiring treatment and confirmed by SACCL or RITM.
- The OHAT Package excludes:
- Diagnosis of HIV/AIDS with no laboratory confirmation;
- HIV/AIDS cases with no indication for anti-retroviral therapy;
- Management of patients with pulmonary tuberculosis co-infection through the OHAT Package; a separate TB-DOTS package may be reimbursed in accredited TB-DOTS facilities; and a member may avail of both OHAT and TB-DOTS packages simultaneously;
- Illness (opportunistic infections) secondary to HIV/AIDS that requires hospitalization.
- HIV/AIDS cases requiring confinement are covered under the regular inpatient benefit of PhilHealth.
Claims filing, deadlines, and required documents
- OHAT Package claims must be submitted to PhilHealth within sixty (60) days from the first day of treatment.
- Claims with incomplete requirements are returned to the facility for completion.
- For all claims, the claim forms must be duly accomplished revised PhilHealth Claim Form 1 by the member and employer, and revised PhilHealth Claim Form 2 by the health care providers.
- The claim forms must follow specific filling rules, including:
- Category of Facility (Annex C): Item No. 4 must state “Outpatient HIV/AIDS Treatment Package” or “OHAT”;
- Dates/times: Item No. 10 must use the date corresponding to the day of consultation as the date of admission and date of discharge, while “NA” is used for Time of Admission and Time of Discharge;
- Amount fields: Item No. 11 must write PHP 7,500 in the Total Actual Charges and Total PhilHealth Benefit columns;
- Admission diagnosis: Part II Item No. 14 must write “HIV/AIDS” as the admission diagnosis;
- Final diagnosis: Part II Item No. 15 must write “Human Immunodeficiency Virus - Acquired Immune Deficiency Syndrome” as the complete final diagnosis;
- OHAT package notation: The physician portion must reflect “OHAT PACKAGE” in the drugs and medicines portion and in the spaces for x-ray, laboratories, supplies and others;
- Provider institutional portion must include the authorized representative’s signature over printed name, official designation, and date; and
- Patient portion must include signature with date, relationship indication if the patient is represented, and the reason for signing on behalf of the patient.
Confidentiality, filing format, and evaluation rules
- To protect patient confidentiality, all OHAT claims must be enclosed in a sealed envelope marked “CONFIDENTIAL” and submitted to the PhilHealth Regional Office.
- PhilHealth employees directly involved in processing OHAT claims must sign a confidentiality agreement.
- Claims for the OHAT Package undergo regular claims processing, using appropriate office orders for processing guidelines.
- PhilHealth uses the Relative Value Scale (RVS) code for claims evaluation, including RVU 99246 with description “OUTPATIENT HIV/AIDS PACKAGE Package”.
Eligibility of members and dependents
- Sponsored and Overseas Workers Program members are entitled when the treatment period falls within the membership validity periods shown in the ID card.
- Retirees and pensioners are entitled upon presentation of a PhilHealth ID.
- Employed members, including KASAPI and the Individually Paying Program (IPP) members, must have at least 3 months of contribution within the immediate 6 months prior to availment of the claim.
Accredited hubs and provider requirements
- Only DOH-designated treatment hubs in accredited facilities may file for reimbursement for the OHAT Package.
- Treatment hubs do not need separate OHAT accreditation; the hospital’s current PhilHealth accreditation governs OHAT hub eligibility.
- If there are gaps between facility accreditation, claims for the sub-package are not paid.
- Accredited providers designated as treatment hubs must create a trust fund for OHAT Package reimbursement.
- PhilHealth payment disposition for hubs is allocated as:
- 80% as a revolving fund for delivering required services, including drugs, supplies, laboratory reagents, equipment, site improvement, and referral fee; and
- 20% for administrative costs including staff training and incentive, divided among the HIV/AIDS Core Team (HACT) and other staff directly providing services, including doctors, dentists, nurses, medical social workers, and medical technologists.
- OHAT Package fees are payable to the provider who filed the initial claim, and in the event of transfer from one treatment hub to another, the claim is processed under the hub transfer rules described.
Exceptions, special cases, and transitional rules
- HIV/AIDS members with pulmonary tuberculosis co-infection may receive the OHAT Package and a separate TB-DOTS package simultaneously, with TB-DOTS reimbursed in accredited TB-DOTS facilities.
- Illnesses that require hospitalization due to opportunistic infections secondary to HIV/AIDS are treated under the regular inpatient benefit, not the OHAT outpatient package.
- Claims submission and treatment entitlement mechanics operate through the quarterly structure, with denial applying to multiple claims filed within the same single period for the same reason.
Effectivity, repeals, and continuity
- The circular takes effect for all claims starting October 1, 2010.
- All other provisions of previous Circulars, Office Orders, and other related issuances inconsistent with the circular are superseded, while all other provisions that are not inconsistent remain in full force and effect.
- The circular is signed by (SGD.) DR. REY B. AQUINO, President and CEO.