Legal basis, policy, and purpose
- The Order implements coverage strategies aligned with the Philippine Development Plan 2016-2022 to cover all Filipinos against financial health risk by mobilizing, streamlining, and harmonizing access to health financing funds.
- The Order recognizes the No Balance Billing Policy (NBB) as the mechanism that ensures indigent patients receive complete quality care and all necessary healthcare services free of any other fees above and beyond PhilHealth package rates during their confinement period.
- The Order anchors NBB on Section 2 of Republic Act No. 10606, which declares the State shall provide comprehensive health care services to all and provide free health care services to indigents.
- The Order strengthens NBB financing by recognizing partner agencies as sources of financing to fully cover facility charges when PhilHealth case rates are insufficient, consistent with the NBB expansion approach in PhilHealth Circular No. 2017-0017, Section III.B.
- The Order defines agency roles for DOH, PCSO, and DSWD in augmenting NBB-related financing and outlines a streamlined process for accessing those funds by members and dependents.
Scope, coverage, and who is covered
- The Order applies to all PhilHealth-accredited health care providers that cater to patients in non-private or service settings.
- The Order applies to all offices of the DOH, PhilHealth, PCSO, and DSWD involved in implementing the streamlined medical assistance process.
- The Order excludes full complementation packages from its operational coverage as a specified exclusion category.
Key definitions and program terms
- Benefit Package refers to services offered by PhilHealth subject to classification and qualification in its Revised Implementing Rules and Regulations.
- Case Rates refers to a payment scheme where a standard, pre-determined amount with a professional fee component is reimbursed to a health care facility for each episode of care.
- Endowment Fund Program (EFP) refers to funding assistance provided to DOH-licensed government hospitals to augment the NBB policy of PhilHealth.
- Total Charges refers to the total medical bill including professional fee incurred by a patient in seeking care in a facility.
- Individual Medical Assistance Program (IMAP) refers to PCSO’s flagship program designed to augment individuals’ financial needs for health-related concerns.
- Medical Assistance to Indigent Patients Program (MAIP) refers to DOH’s program providing medical assistance to poor and indigent patients in government hospitals.
- NBB Patients refer to patients covered under PhilHealth’s No Balance Billing Policy who are admitted in service accommodation.
- Non-medical expenses refer to costs incurred outside actual medical care, such as transportation costs and accommodation-related costs.
- Quantified Free Service (QFS) refers to the cost of treatment subsidized by hospital maintenance and other operating expenses (MOOE) from the National Budget and Income of the hospital.
- Z Benefit Packages refer to PhilHealth benefit packages covering high-cost, catastrophic illnesses.
- Malasakit Center refers to an area housing various payors (e.g., PCSO and DOH MAIP desks) to streamline processes for patients availing financial assistance.
- Individual-based Intervention refers to health care goods/services definitively traceable to a singular person, including public health (e.g., vaccines) and personal care (e.g., primary care consultation and hospital services).
- Full complementation packages refers to benefit packages which PhilHealth and PCSO have agreed to jointly finance.
General operational rules for agencies and providers
- All classified indigent patients in non-private or service settings in PhilHealth-accredited government health care providers are entitled to No Balance Billing.
- All direct medical expenses must be augmented by PCSO and DOH MAIP, while non-direct medical expenses such as transportation must be covered by DSWD.
- All medical assistance funds must be coursed through the health care providers; patients must no longer file separate applications to obtain support from PCSO and DOH MAIP.
- PhilHealth-accredited health care providers must establish a Malasakit Center where funding sources (e.g., PCSO ASAP and DOH MAIP desks) are housed in one area for patients admitted in service accommodation.
- All agencies must jointly develop an effective communication strategy and ensure IEC materials are made available to inform patients about the harmonized medical assistance program and the streamlined availment process.
- All agencies must establish a joint mechanism to resolve grievances and meet regularly to discuss implementation progress, including results of exit surveys and availability of funds.
- All complaints must be lodged through the Citizens Complaint Hotline, 8888, and only complaints containing: (a) name and address of the complainant; (b) name of the offender and/or institutions; (c) direct and concise statement of the offense; and (d) name of the agency (PhilHealth, DOH, PCSO, DSWD) to which relief is sought will be acted upon.
- PhilHealth and PCSO must publish the list of full complementation packages annually.
- Health care providers must bill all agencies according to existing guidelines and procedures.
Charging order, funding limits, and billing method
- The health care provider’s billing section must coordinate with the Medical Social Worker to tap financing sources in the following order:
- 1) PhilHealth: based on published case rates per PhilHealth Circular No. 0031, s. 2013 and other circulars pertinent to Z benefits.
- 2) Private Health Insurance: based on the patient’s insurance plan/policy with the private insurance or health management organization, if applicable.
- 3) Mandatory Discounts and Benefits: discounts for senior citizens, PWDs, SSS members, DOH employees, and other authorized discounts must apply in billing.
- 4) PCSO: sourced from EFP if applicable; once EFP is consumed or if there is no EFP, IMAP must be tapped.
- For Case Rates, PCSO maximum support must equal 100% of prevailing PhilHealth case rates.
- For Z Benefits, PCSO support must focus on services excluded in the package.
- No professional or room and board fees may be charged to the patients, the PCSO, or the DOH MAIP funds.
- For DOH or LGU hospitals, room and board and professional fees are covered by DOH or LGU subsidy as MOOE and personal services.
- All government hospitals must establish PCSO ASAP (At Source Ang Processing) desks.
- All government hospitals must receive periodic DOH MAIP sub-allotment.
- 5) DOH MAIP: maximum support must be based on MAIP guidelines, subject to availability of funds.
- 6) PhilHealth-accredited health care providers: all remaining expenses must be charged to the provider’s MOOE or income as QFS for patients in service or non-private settings.
- The charging order for direct medical expenses follows:
- First: PhilHealth (National Health Insurance Fund) using published PhilHealth case rates and Z benefits.
- Second: Private health insurance (if applicable).
- Third: Mandatory discounts and benefits based on existing guidelines.
- Fourth: PCSO using EFP (if applicable) and IMAP with maximum = 100% of PhilHealth case rates, and Z benefit exclusions cannot be used to pay room and board and professional fees.
- Fifth: DOH using MAIP fixed rates based on MAIP guidelines.
- Last: Hospital MOOE/Income charged as QFS, covering 100% of the remaining balance.
- The charging order for non-direct medical expenses provides:
- First: DSWD through Assistance to individual in crisis situations (AICS) based on existing guidelines.
Availment procedure and patient-facing process
- Before services are availed, the health care provider must assess a patient’s PhilHealth and NBB eligibility and provide complete information on: (1) financial implications if the patient is availing services as a service or private patient; and (2) the streamlined availment of financial assistance from various funding sources.
- If the patient is PhilHealth and NBB eligible, the provider must ensure the patient will not incur out of pocket payment and must facilitate provision of services.
- If the patient is a non-PhilHealth member, the provider must endorse the patient to the medical social worker.
- Once the patient is classified as C3 or D, the provider must enroll the patient under PhilHealth’s Point of Care or Point of Service program.
- After enrollment under point-of-care/point-of-service, the hospital must ensure zero out-of-pocket payment and facilitate service provision.
- The health care provider must record all services rendered to the patient during confinement.
- The medical social worker must facilitate tapping of financial assistance for patients admitted in service or non-private settings.
- The health care provider’s billing section must facilitate settlement of the provider’s bill outlined in the charging provisions.
- No reimbursement for medical services may be directly given to the patient.
- A Statement of Account (SOA) that clearly accounts for contributions from various fund sources must be provided to the patient.
- Copies of SOA must be submitted in encoded, editable format following the template in Annex A.
Special case rules for admissions
- If all beds are occupied and a PhilHealth-accredited health care provider cannot admit a patient to a non-private or service accommodation, the patient must be admitted to the next available private accommodation but must still be charged to the hospital’s service rates.
- If services are not available in the hospital, government health care providers must assist the patient in obtaining the service through contracting out, partnership with another facility, and/or transferring the patient, without the patient incurring out-of-pocket payment.
- Patients who can no longer avail of PhilHealth benefits due to exhausted number of days or a single period of confinement, unpaid premiums, or non-emergency confinement of less than 24 hours must still receive coverage from other fund sources.
- If a patient decides to transfer to private accommodation, the streamlined guidelines on availment and charging must no longer apply to that patient.
Grievance resolution and monitoring system
- Each agency must resolve complaints within its jurisdiction according to its respective citizen’s charter.
- An interagency monitoring and evaluation mechanism must be created with a shared database to support implementation and detect fraud, enabling necessary sanctions and penalties.
- Participating agencies must enter non-disclosure agreements (NDAs) when sharing sensitive and/or confidential data is necessary.
- PhilHealth must provide summaries of exit surveys to all agencies on a regular basis.
Agency duties and provider compliance
- DOH must lead and coordinate effective implementation in DOH-licensed hospitals.
- DOH must promote NBB compliance among DOH-licensed hospitals through stringent monitoring and by using compliance rate as a criterion in assessing hospital performance.
- DOH must train, supervise, and monitor medical social workers implementing the Order.
- PhilHealth must provide explicit guidelines for identifying NBB-eligible patients and ensuring their enrolment to the NHIP.
- PhilHealth must furnish participating agencies a copy of prevailing case rates and Z benefit package rates.
- PhilHealth must consolidate SOA data and regularly provide reports (including membership and reimbursement) to participating agencies.
- PhilHealth must undertake costing and share costing data to update case rates.
- PhilHealth must deploy PhilHealth CARES to all government health care providers and selected private providers with MOA to implement NBB.
- PhilHealth must enhance the NBB exit survey to include monitoring and evaluation of the Order.
- PCSO must provide funds to support implementation as specified in the guidelines.
- PCSO must partner with all PhilHealth-accredited health care providers for implementation of the PCSO ASAP desk.
- DSWD must provide assistance to eligible patients/beneficiaries through AICS in accordance with existing DSWD policy/guidelines to support NBB.
- All PhilHealth-accredited health care providers must ensure 100% compliance with NBB so that all NBB-eligible patients are given adequate health services and guaranteed zero out-of-pocket payments.
Penalties, sanctions, and liability
- Patients who provide false information or engage in misrepresentation resulting in unjust availment of benefits must have all future requests for assistance and/or claims denied, without prejudice to filing appropriate criminal or administrative charges.
- PhilHealth-accredited private and government health care providers that violate any provision of the Order and related rules and regulations of each participating agency, resulting in unjustified claims, must be subjected to appropriate administrative, civil, or criminal charges.
- Late filing or non-compliance with claims rules prescribed by each participating agency must merit sanctions/penalties following existing rules and policies.
Transitory, separability, repealing, and governing provisions
- Issues arising from implementation must be resolved jointly by DOH, PhilHealth, PCSO, and DSWD.
- The provisions are transitory until policies for full streamlining of all fund sources for health are institutionalized.
- If any provision or part of the Order is declared unauthorized or invalid by a court or competent authority, unaffected provisions remain valid and effective.
- Administrative Order No. 2017-0003 on the Guidelines for the Implementation of the 2017 Medical Assistance Program (MAP) in DOH Hospitals and Other Selected Government Health Facilities is repealed, amended, or modified only to the extent inconsistent with this Order.
- Provisions of existing issuances not affected by this Order remain valid and in effect.
- The virtual pooling of health funds from different agencies is treated as an interim guideline toward a long-term measure making PhilHealth a national single purchaser of individual-based interventions.