Law Summary
Declaration of Policy
- Policy to gradually provide total medical service.
- Adopt and implement a comprehensive, coordinated medical care plan.
- Health care based on comprehensive patient needs.
- Coordinate government and private medical facilities as public service.
- Promote proper inter-relationship among physicians, patients, and hospitals.
Purpose and Objectives
- Provide medical care to residents within national economic means.
- Provide a viable means to help people pay for adequate medical care.
Definitions
- Commission: The Philippine Medical Care Commission under RA No. 6111.
- Philippine Medical Care Plan: Total plan consisting of Programs I and II.
- SSS & GSIS: Social Security System and Government Service Insurance System.
- Employee: Persons compulsorily covered by SSS or GSIS.
- Beneficiary: Person entitled to medical care benefits.
- Employer: Employer of the employee.
- Legal Dependent: Persons entitled to benefits as prescribed.
- Medical Care Benefits: Services for illness/injury including major dental surgery needing hospitalization.
- Hospital: Accredited government/private medical facility.
- Medical/Dental Practitioner: Licensed and accredited doctors in the Philippines.
- Service Beds: Beds set aside for beneficiaries.
- Single Period of Confinement: One or series of hospitalizations for the same illness within 90 days.
- Medical/Dental Attendance: Care by qualified hospital or dental staff.
Philippine Medical Care Commission Composition
- Chairman, Executive Director, Administrator of SSS, GM of GSIS, Secretary of Health, Finance, Local Governments.
- Presidents of Philippine Medical and Hospital Associations.
- Two private sector members appointed by the President for six-year terms.
- Ex-officio members may designate representatives.
- Executive Director acts as Chairman if vacancy occurs.
Commission Functions and Powers
- Formulate policies and implement the Medical Care Plan.
- Ensure medical care for members.
- Organize offices; appoint staff; fix compensation.
- Establish local medical councils as needed.
- Accredit hospitals, practitioners, facilities.
- Promulgate necessary rules and regulations.
- Recommend contribution rates and benefits per actuarial procedures.
- Fund local councils; provide per diems and honoraria.
- Ensure adequate hospital accommodations nationwide.
- Acquire real or personal property for Commission purposes.
- Enter contracts for efficient administration.
- Prevent abuses; investigate violations, suspend/revoke accreditations.
- Submit annual reports to the President.
- Coordinate in medical manpower development.
- Exercise powers necessary to fulfill objectives.
Meetings and Attendance
- Meetings held as necessary.
- Quorum: six members.
- Members receive per diem and allowances, except Chairman and Executive Director.
Chairman of the Commission
- Appointed by the President for six years.
- Must be reputable and with 12 years medical practice experience.
- Full-time; removable only for cause.
- Receives salary determined by the Commission.
- Presides over meetings; supervises Commission operations.
Vice-Chairman and Executive Director
- Appointed by the President for six years.
- At least 10 years experience in business or medical practice.
- Full-time; removable only for cause.
- Assists Chairman in rules implementation.
- Performs functions assigned by Chairman.
Philippine Medical Care Plan and Programs
- Program I: For SSS/GSIS members and legal dependents.
- Program II: For others not covered under Program I; to be implemented per Presidential approval.
Program I Coverage
- Medical care benefits for SSS/GSIS members and legal dependents.
- If employee covered by both, GSIS employment prevails.
Medical Care Benefits
- Hospital room and board allowance of P12/day up to 45 days for member, plus 45 days shared with dependents.
- Commission may set rates up to P18/day.
- Drug and laboratory exams allowance capped at P150 per confinement; up to P250 for intensive care cases.
- Surgeon’s fees: up to P50 (minor), P250 (medium), P500 (major surgery).
- Operating room fees: P20 (minor), P50 (medium), P75 (major).
- Anesthesiologist fees max 30% of surgeon’s fee.
- Medical/Dental daily attendance fees: P10/visit, max P200 per confinement.
- Sterilization expenses for contributing member or spouse.
- Option to get drugs from hospital pharmacy or retail drugstore.
- Outpatient and domiciliary care by government health facilities.
- Expense allowances for ambulatory and domiciliary care when feasible.
Participants in Medical Service Delivery
- Accredited hospitals, medical/dental practitioners, and drugstores may participate.
Free Choice of Provider
- Beneficiaries may freely choose hospital and medical/dental practitioners.
- Private medical care arrangements at beneficiary’s expense are retained.
Entitlement to Benefits
- Requires at least 3 monthly contributions in last 12 months prior to confinement.
- Dependents covered accordingly.
- Those not meeting criteria covered under Program II until entitlement.
Supervision
- Commission, SSS, and GSIS supervise confined beneficiaries per regulations.
Health Insurance Funds
- Medical care payments under Program I funded by separate SSS and GSIS Health Insurance Funds.
- Funds managed under applicable laws and safeguards.
- Operational expenses capped at 12% of contributions and earnings.
Contribution Rates
- Schedule based on monthly salary with both employer and employee contributing equal amounts.
- Contributions compulsory.
Collection of Contributions
- Employer deducts employee’s share; remits both shares to SSS/GSIS.
- Employer contribution cannot be recovered from employee.
- Failure to remit contributions does not deprive employees of entitlement.
Effect of Employment Separation
- Former employees may continue medical benefits subject to Commission rules.
Payment Procedures
- Payments made directly to hospitals, practitioners, and drugstores as per rules.
- Additional charges beyond benefit limits to be borne by patient.
- Medical expenses incurred abroad may be reimbursed under Commission rules.
Limitations on Payment
- Claims must be filed within 60 days after discharge or declaration of wellness.
- Reduced or denied claims result from false information or failure to comply with rules.
- Payments for service bed patients limited to prescribed allowances.
- Reduced/denied amounts not charged to beneficiary unless caused by them.
Exclusions from Benefits
- Cosmetic surgery/treatment.
- Optometric services.
- Psychiatric illnesses.
- Normal childbirth delivery.
- Purely diagnostic services.
Local Medical Care Councils
- Provincial, City, and Municipal councils of seven members each, composed of health officers, treasurers, local government representatives, medical and hospital association reps, and private citizens.
- Members appointed by Commission for two-year terms.
- Councils elect officers annually and perform functions as authorized by the Commission.
Records and Reports
- Comprehensive recordkeeping by the Commission and local councils for management and research.
Management Study and Research
- Commission to continuously study program viability.
Hearing Procedures
- Hearings on violations conducted by Commission committees.
- Not bound by technical evidence rules.
- Power to administer oaths, issue subpoenas.
- Contumacy handled per Administrative Code.
Penal Provisions
- Fraud, collusion, falsification, or misrepresentation punishable under Revised Penal Code.
- Failure/refusal to comply with the Decree punishable by fines and/or imprisonment.
- Employer failing to remit contributions presumed to have misappropriated funds.
- Unauthorized recovery of employer contributions from employees punishable.
- Misappropriation of funds by SSS/GSIS employees punishable.
- Liability extends to responsible officials of entities committing offenses.
- Criminal actions may be filed locally or in Metro Manila.
Appropriation
- Necessary funds for Commission and local councils authorized in annual budget.
Government Guarantee
- Republic guarantees benefits and solvency of Health Insurance Funds.
Program II Implementation
- Will provide benefits via a social insurance or public medical care service.
- Coverage for non-Program I members.
- Implementation subject to presidential approval.
Separability Clause
- Invalid provisions do not affect remainder of the Decree or application to other persons/cases.
Repealing Clause
- Repeals RA No. 6111 and other inconsistent laws and rules.
Effectivity
- Implementation starts 90 days after approval.