Revised Philippine Medical Care Act

Policy, purpose, and objectives

Section 2 declares the government policy to gradually provide total medical service through a comprehensive and coordinated medical care plan.
Section 2 requires a plan that follows these concepts of health care: (1) comprehensive medical care according to the needs of the patient; (2) coordination of government and private medical facilities as public service instrumentalities; and (3) optimum health care through a proper inter-relationship among physicians, patients, and hospitals.
Section 3 sets the main purposes and objectives: (1) provide medical care in an evolutionary way within national economic means and capability; and (2) provide a viable means for people to help themselves pay for adequate medical care.

Core definitions and named institutions

Section 4 defines the Philippine Medical Care Commission as the commission created under Republic Act No. 6111.
Section 4 defines the Philippine Medical Care Plan as the total plan consisting of Programs I and II.
Section 4 defines the Social Security System (SSS) as created under Republic Act No. 1161 (as amended).
Section 4 defines the Government Service Insurance System (GSIS) as created under Commonwealth Act No. 186 (as amended).
Section 4 defines an employee as any person compulsorily covered by either GSIS or SSS.
Section 4 defines a beneficiary as any person entitled to medical care benefits under the Decree.
Section 4 defines legal dependents as persons other than members and contributors entitled to benefits under the Decree under terms and conditions the Commission prescribes.
Section 4 defines Medical Care Benefits as services relative to illness or injury, including major dental surgery or operation needing hospitalization, subject to reasonable limitations imposed by the technical organization and finances of the Philippine Medical Care Plan.
Section 4 defines a Hospital as any government or private medical facility accredited under rules and regulations promulgated by the Commission.
Section 4 defines a Medical or Dental Practitioner as a duly licensed doctor of medicine or doctor of dental medicine, a member in good standing of the Philippine Medical Association or Philippine Dental Association, and accredited under Commission rules and regulations.
Section 4 defines Service Beds as private and government hospital beds set aside for beneficiaries of the plan, as prescribed by the Commission.
Section 4 defines Single Period of Confinement as a single confinement or series of confinements for the same illness with intervals of not more than 90 days.
Section 4 defines Medical or Dental Attendance as medical or dental care by a physician or medical staff or dentist or dental staff of the hospital.

Coverage, programs, and eligibility

Section 10 provides that the Philippine Medical Care Plan consists of Program I and Program II, which provide medical care benefits.
Section 10 provides Program I for members of the SSS and GSIS, including their legal dependents.
Section 10 provides Program II for those not covered under Program I, in accordance with Section 33.
Section 11 provides that all SSS and GSIS members and all their legal dependents receive medical care benefits under Program I.
Section 11 provides that if an employee is covered by both SSS and GSIS, only employment with the GSIS counts for coverage purposes.
Section 15 provides entitlement to medical care benefits if the employee has paid at least three monthly contributions during the last twelve months prior to the first day of the single period of confinement, and also provides that the employee’s legal dependents are entitled.
Section 15 provides that until an employee becomes entitled to benefits of Program I, the employee is covered by Program II.
Section 33 provides that Program II will be implemented upon approval by the President and will be provided through (1) a social insurance medical care service similar to Program I or (2) the public medical care service under Commission rules and regulations.
Section 33 provides that persons not covered at present by Program I may seek medical attention from existing government hospitals.

Administration: Commission and local councils

Section 5 requires the Philippine Medical Care Commission to carry out the purposes and objectives of the Decree and to administer the plan.
Section 5 requires the Commission to be composed of: a Chairman, an Executive Director, and the following members—(1) Administrator of SSS; (2) General Manager of GSIS; (3) Secretary of Health; (4) Secretary of Finance; (5) Secretary of Local Governments and Community Development; (6) President of the Philippine Medical Association; (7) President of the Philippine Hospital Association; and (8) two (2) members representing the private sector.
Section 5 provides that the private sector representative is appointed by the President of the Philippines for a term of six (6) years.
Section 5 provides that ex-officio members may designate representatives who exercise the plenary powers and enjoy the same benefits as their principals.
Section 5 provides that when the Chairman is temporarily unable or if there is a vacancy, the Executive Director serves as Acting Chairman.
Section 6 grants the Commission functions including policy formulation, plan administration and implementation consistent with the National Health Plan, accreditation of practitioners and facilities, rulemaking, actuarial recommendations for contributions and benefits, creation of provincial/city/municipal councils when necessary, and adoption of control measures to prevent abuses.
Section 6 requires the Commission, after notice and hearing, to suspend or revoke accreditation of any accredited government or private hospital, drug store, or medical and dental practitioner that violates the Decree or implementing rules.
Section 6 provides that orders or decisions by the Commission under its suspension/revocation power are appealable to the Office of the President under the procedure of Executive Order No. 19, Series of 1966.
Section 6 requires the Commission to submit an annual report to the President, within the first ten days of each year, covering activities during the preceding fiscal year.
Section 6 requires the Commission to coordinate with other government agencies for the development of medical and allied manpower based on health care delivery system needs.
Section 24 requires the Commission to establish in each province a Provincial Medical Care Council of seven (7) members with specified official representatives and appointed private beneficiaries, and provides a two (2) years term for appointed members unless sooner removed for cause.
Section 25 requires the Commission to establish in each chartered city a Medical Care Council of seven (7) members, and provides that appointed members hold office for two (2) years unless sooner removed for cause; it also authorizes District Medical Care Councils of not more than five (5) members.
Section 26 provides that the Commission may establish in each municipality a Municipal Medical Care Council of seven (7) members, with appointed members holding office for two (2) years unless sooner removed for cause.

Commission meetings, chairman, and executive director

Section 7 provides that Commission meetings and hearings occur as often as necessary at the discretion of the Chairman or upon request of the majority of Commission members.
Section 7 provides that six (6) Commission members constitute a quorum.
Section 7 provides for per diem for members for every meeting and hearing attended, subject to budget and compensation rules.
Section 7 provides monthly commutable allowance for each member except the Chairman and the Executive Director, subject to compensation laws and rules.
Section 8 provides that the Chairman is appointed by the President of the Philippines for a term of six (6) years.
Section 8 requires the Chairman to be a reputable medical professional with at least twelve (12) years of medical practice experience, and provides that the Chairman holds office full time and shall not be removed except for cause.
Section 8 requires the Chairman to preside over meetings and implement Commission decisions and exercise supervision and control over Commission operations; compensation is subject to P.D. No. 985.
Section 9 provides that the Executive Director, who is also Vice-Chairman, is appointed by the President for a term of six (6) years with at least ten (10) years of experience in business undertaking or medical practice.
Section 9 provides that the Executive Director holds office full time and shall not be removed except for cause; compensation is subject to P.D. No. 985.
Section 9 requires the Executive Director to advise and assist the Chairman in formulating and implementing rules and regulations, and to perform functions assigned by the Chairman.

Plan benefits, hospitals, practitioners, and provider participation

Section 12 entitles a Program I beneficiary who suffers sickness or injury requiring hospitalization/surgical operation to specified allowances and fees, subject to rules and regulations the SSS or GSIS may prescribe and subject to approval of the Commission.
Section 12 provides the following benefit rates/limits under Program I:
- Hospital room and board: P12.00 per day for not exceeding 45 days per year for each member, and another 45 days per year shared by all legal dependents; the Commission may set a higher rate not exceeding P18.00 per day.
- Drugs and laboratory examination (including X-ray): not exceeding P150.00 per single period of confinement; up to P250.00 may be allowed for cases requiring intensive care as defined by the Commission.
- Surgeon’s fee allowance (with exact amount under a relative value scheme, not to exceed limits): minor surgery not exceeding P50.00, medium surgery not exceeding P250.00, major surgery not exceeding P500.00, and in all cases the fee is capped at P500.00 for any listed operation; surgeon’s fee covers 8 days pre-operative care and 5 days post-operative care.
- Operating room fee allowance: minor surgery not exceeding P20.00, medium surgery not exceeding P50.00, major surgery not exceeding P75.00.
- Anesthesiologist’s fee: not exceeding 30% of the surgeon’s fees.
- Medical and dental practitioner’s fee: P10.00 per daily visit, not to exceed P200.00 for a single period of confinement, or for any sickness or injury; in counting compensable daily visits, not more than one visit for any one day for any one sickness or injury is counted.
- Sterilization expenses: as may be determined by the Commission for a contributing member or spouse.
Section 12 gives the beneficiary the option to secure drugs and medicines from either the hospital pharmacy or a retail drug store of the beneficiary’s choice, subject to Commission rules or Sections 21 and 22.
Section 12 provides that out-patient and domiciliary care shall be carried out by existing government hospitals, rural health units, other government clinics, and all clinics under supervision of government entities.
Section 12 directs that, as soon as feasible, the Commission shall provide expense allowances for ambulatory and domiciliary care rendered in/by government or private hospitals or clinics under Commission rules.
Section 12 requires all government hospitals, sanitaria, clinics, dispensaries, and rural health units to provide back-up services to the medical care plan, especially for patients occupying service beds.
Section 13 limits participation in delivery of medical care services to only accredited: (1) hospitals; (2) medical and dental practitioners; and (3) drugstores.
Section 14 requires free choice of hospital and practitioner: any beneficiary who becomes sick or injured is free to choose the hospital for confinement and the practitioner/attendance for treatment, under Commission-promulgated rules.
Section 14 provides that a beneficiary who arranges privately for medical care at personal expense is not prejudiced by any provision of the Decree.
Section 16 provides that the Commission, the SSS, and the GSIS supervise confined beneficiaries under rules and regulations they promulgate and may exercise this authority through intermediaries.
Section 17 requires Program I medical care benefit payments to be borne by the SSS and GSIS Health Insurance Funds, which must be kept distinct and separate from other funds.
Section 17 requires GSIS Health Insurance Funds to be deposited, invested, administered, and disbursed in the same manner and under the same conditions, requirements, and safeguards as provided by Republic Act No. 1161 and Commonwealth Act No. 186.
Section 17 limits operational expenses: the SSS and GSIS may disburse operational expenses not more than 12% of total contributions and investment earnings collected during the year.

Contributions: amounts, collection, and effects of separation

Section 18 makes contributions to the Health Insurance Funds compulsory and sets the schedule based on monthly salary wage or earnings:
- P1.00–P49.99: contribution base P25.00; employer P0.30; employee P0.30
- P50.00–P99.99: base P75.00; employer P0.95; employee P0.95
- P100.00–P149.99: base P125.00; employer P1.55; employee P1.55
- P150.00–P199.99: base P175.00; employer P2.20; employee P2.20
- P200.00–P249.99: base P225.00; employer P2.80; employee P2.80
- P250.00–P349.99: base P300.00; employer P3.75; employee P3.75
- P350.00–P499.99: base P425.00; employer P5.35; employee P5.35
- P500.00–Above: base P600.00; employer P7.50; employee P7.50
Section 19 requires the employer to deduct the employee’s contribution from monthly compensation.
Section 19 requires the employer to remit both the employee’s contribution and the employer’s counterpart directly to the GSIS or SSS, in the same manner as other SSS/GSIS contributions and subject to the same penalties for late payment.
Section 19 prohibits recovery of the employer’s counterpart contribution from the employee.
Section 19 provides that failure of the employer to remit the corresponding contributions is not a reason to deprive the employee of medical care benefits under the Decree.
Section 20 provides that an employee separated from employment who is no longer obliged to contribute under Section 19 may continue to enjoy medical care benefits, subject to Commission rules and conditions.

Payment procedures, claim limits, and exclusions

Section 21 requires payment for medical care services to be made directly to the hospital, the medical or dental practitioner, and the retail drug store according to Commission rules, regulations, and conditions.
Section 21 provides that if charges exceed the amount of benefits under the Decree because a beneficiary chooses a bed more expensive than a service bed, the difference is borne personally by the patient.
Section 21 provides that medical care expenses incurred outside the country may be reimbursed to the beneficiary under Commission rules, regulations, and conditions.
Section 22 bars claims filed beyond sixty (60) days after the patient’s discharge from the hospital or after the patient is declared well.
Section 22 authorizes reduction or denial of payment when the claimant: (1) furnishes false or incorrect information required under the Decree or Commission rules; or (2) fails without good cause or legal ground to comply with any provision of the Decree or implementing rules.
Section 22 limits service-bed medical care benefit costs to prescribed benefit allowances.
Section 22 prohibits charging the reduced or denied amount directly or indirectly to the beneficiary unless the beneficiary is directly responsible for the cause of the reduction or denial.
Section 23 excludes medical care plan benefits for: cosmetic surgery or treatment; optometric services; psychiatric illness; normal obstetrical delivery; and services purely diagnostic.

Fraud controls and hearings

Section 29 authorizes the Commission to conduct inquiries and investigations through a hearing committee when necessary.
Section 29 provides that the hearing committee is not bound by technical rules of evidence.
Section 29 empowers the Commission to administer oaths, certify official acts, and issue subpoenas and subpoenas duces tecum to compel attendance of witnesses and production of books, papers, and records needed under questions arising under the Decree.
Section 29 requires any contumacy to be dealt with in accordance with Section 580 of the Administrative Code.

Penal provisions and criminal liability

Section 30 imposes penalties under Article 172 of the Revised Penal Code on any person who commits fraud, collusion, falsification, misrepresentation, or any similar anomaly, for the purpose of securing entitlement to any benefit or payment under the Decree or issuance of any certificate or document connected with the Decree for himself or for another person.
Section 30 penalizes failure or refusal to comply with the Decree or Commission rules and regulations with: a fine of not less than PHP 500 nor more than PHP 5,000, or imprisonment of not less than six months nor more than one year, or both, at the discretion of the court.
Section 30 provides that for violations consisting in failure or refusal to deduct contributions and remit the same to the SSS and GSIS, the penalty is the same fine range (PHP 500 to PHP 5,000) and imprisonment range (six months to one year).
Section 30 provides that an employer who fails to remit deducted contributions to the SSS and GSIS within 30 days from the date they became due is presumed to have misappropriated the contributions and is punished under Article 315 of the Revised Penal Code.
Section 30 penalizes an employer who deducts directly and indirectly from the covered employee’s compensation or otherwise recovers his contribution on behalf of employees with a fine not exceeding PHP 1,000 or imprisonment not exceeding one year, or both, at the discretion of the court.
Section 30 imposes penalties under Article 217 of the Revised Penal Code on an employee of the SSS or GSIS who appropriates, takes, misappropriates, consents to, or through abandonment or negligence permits misappropriation of funds or property belonging to, payable or deliverable to, the SSS or GSIS.
Section 30 provides entity liability: if the penalized act is committed by an association, partnership, corporation, or other institution, its managing head, directors, or partners are liable to the penalties provided in the Decree for the offense.
Section 30 provides that criminal actions arising from violations may be commenced by the SSS, the GSIS, or the Commission, or by the employee concerned under the Decree or, where appropriate, under the Revised Penal Code.
Section 30 provides venue options for prosecutions commenced by the SSS, GSIS, or Commission: in the city or municipality where the violation was committed or in Metro Manila at their option.

Funds, guarantees, appropriations, and implementation of Program II

Section 31 authorizes inclusion in the Annual Appropriations Law of funds necessary to finance the Commission’s and Medical Care Councils’ operation, programs, and projects under Sections 24, 25, and 26.
Section 32 guarantees benefits under the Decree and the solvency of the Community Health Insurance Funds by the Republic of the Philippines.
Section 33 provides that Program II becomes effective upon President approval, and requires that applicable provisions of the Decree govern Program II.

Separability, repeals, and effectivity

Section 34 provides a separability rule: invalidity of any provision or application does not affect remaining provisions or other applications.
Section 35 repeals or modifies Republic Act No. 6111 and all inconsistent laws, executive orders, administrative rules and regulations, or parts thereof.
Section 36 provides the effectivity implementation timeline of 90 days after its approval.