Purpose
- Ensure quality services to the public by Health Maintenance Organizations.
- Promote the growth and development of HMOs.
Definition of Terms
- Association: The Association of Health Maintenance Organizations in the Philippines.
- Contract: Any agreement between an HMO and a member/group for pre-agreed health services.
- Department: Refers to the Department of Health.
- Health Maintenance Organization (HMO): A juridical entity providing or arranging designated health care services to enrolled members for a fixed prepaid fee.
- Investor-based HMO: Operates for profit.
- Community-based HMO: Non-profit for a specific community.
- Cooperative HMO: Operates under the Cooperative Code governed by the Cooperative Development Authority.
- Member: Individual contracted with an HMO.
- Provider: Licensed physician, hospital, or institution providing health care services.
Regulatory Authority
- The DOH through the Office for Health Facilities Standards and Regulations (OHFSR) exercises regulatory functions.
- Subject to powers granted to the Securities and Exchange Commission (SEC) and Cooperative Development Authority (CDA).
Clearance to Operate
- All HMOs, regardless of type, must secure a Clearance to Operate from the DOH via OHFSR.
- Existing HMOs expanding operations must also obtain clearance.
Application Requirements
- Standard application form provided by OHFSR.
- Must include:
- Statement of capitalization certified by SEC or CDA.
- List of providers owned, controlled or contracted by the HMO.
- Minimum facility requirements depending on HMO type:
- Investor-based HMO (stock corporation): Management of one tertiary hospital or affiliation with five tertiary hospitals; outpatient clinic with diagnostic facilities (ECG, X-rays, CBC, urinalysis, fecalysis).
- Community/cooperative-based HMO (non-stock/non-profit): One affiliated general hospital; one affiliated outpatient clinic.
- Copies of standard benefit packages and fee schedules.
- Forms of standard contracts with members.
- Brochures on procedures to avail benefits.
- Statement on differences in benefits and fees between Medicare members and non-members.
- Copies of agreements between HMO and providers.
Fees
- Non-refundable application processing fees:
- P25,000 for stock corporations.
- P5,000 for non-stock/non-profit community or cooperative HMOs.
Issuance and Denial of Clearance
- Clearance issued within 30 days from filing complete application and fee payment.
- Denial notified within 30 days from complete filing.
Renewal of Clearance
- Annual renewal required.
- Must comply with minimum requirements.
- Must submit:
- Financial reserves statement certified by external auditor.
- Audited financial reports (balance sheet, income statement, operating expenses).
- Operational reports with actuarial data on members and claims.
- Any amendments to original application documents.
- Documents certified by external auditor or actuary.
- Failure to submit documents on time may lead to cancellation of clearance.
- Renewal fees:
- P5,000 for stock corporations.
- P1,000 for community/cooperative HMOs.
Review of Requirements
- Periodic review by the Department in consultation with the industry association.
Arbitration of Complaints
- Member or provider complaints against HMOs first referred to the Association's grievance machinery (if HMO is a member).
- Complaints against non-member HMOs directed to the DOH.
- DOH assumes jurisdiction only after 30-day unsuccessful settlement via Association.
- DOH to settle complaints within 60 days of receipt.
- Contracts must inform members of this arbitration procedure.
Sanctions
- Suspension, cancellation, or revocation of Clearance for repeated violations.
- Re-application fee upon new clearance after cancellation:
- P5,000 for stock corporations.
- P1,000 for community/cooperative HMOs.
Publication
- DOH to periodically publish lists of HMOs with valid clearance and those suspended, cancelled or revoked.
- Copies to medical and employer organizations.
Transitory Provisions
- Existing HMOs prior to these rules must apply for clearance within one year.
- Clearance is contingent upon compliance with all requirements.
Effectivity
- Rules take effect 15 days after publication in the Official Gazette or a general circulation newspaper.