Objectives
- Define the roles of DOH, PCSO, and DSWD in augmenting financing for NBB Policy case rates and Z Benefits.
- Outline a streamlined fund access process for members and dependents.
Scope and Coverage
- Applicable to all PhilHealth-accredited non-private or service-setting healthcare providers.
- Covers all offices of DOH, PhilHealth, PCSO, and DSWD.
- Excludes full complementation packages.
Definition of Key Terms
- Benefit Package: Services offered by PhilHealth per Revised IRR.
- Case Rates: Predetermined reimbursement amounts per care episode.
- Endowment Fund Program (EFP): PCSO funding to augment NBB policy.
- Total Charges: Complete medical bill including professional fees.
- Individual Medical Assistance Program (IMAP): PCSO program for individual financial aid.
- Medical Assistance to Indigent Patients Program (MAIP): DOH program providing aid to indigents.
- NBB Patients: Indigent patients covered under PhilHealth NBB policy admitted in service accommodations.
- Non-medical Expenses: Costs like transport, meals, accommodation outside direct medical care.
- Quantified Free Service (QFS): Cost subsidized by hospital maintenance and income.
- Z Benefit Packages: Coverage for high-cost catastrophic illnesses under PhilHealth.
- Malasakit Center: Centralized area housing various payors for streamlined financial assistance.
- Individual-based Intervention: Traceable healthcare services targeting an individual.
- Full Complementation Packages: Jointly financed packages by PhilHealth and PCSO.
General Guidelines
- Indigent patients in non-private accommodations are entitled to NBB.
- Direct medical costs augmented by PCSO and DOH MAIP; non-medical costs by DSWD.
- Medical assistance accessed through healthcare providers; no separate patient applications needed.
- Malasakit Centers to be established in accredited facilities to streamline assistance.
- Agencies to develop communication strategies and IEC materials.
- Joint grievance mechanisms and regular inter-agency meetings for implementation progress.
- Complaints processed through Citizen's Complaint Hotline 8888 with specific information requirements.
- Annual publication of full complementation packages by PhilHealth and PCSO.
- Healthcare providers must bill agencies per established guidelines.
Specific Guidelines: Order of Charging
- PhilHealth: Case rates and Z benefits.
- Private Health Insurance: As per plan/policy.
- Mandatory Discounts: Senior Citizens, PWDs, SSS members, etc.
- PCSO: Endowment Fund Program (EFP) or IMAP.
- Case rates: max 100% of PhilHealth rates.
- Z benefits: focus on exclusions; no fee charges to patients.
- DOH's MAIP: According to guidelines and fund availability.
- Remaining expenses charged as hospital MOOE or QFS.
Sources and Uses of Funds for Direct and Non-Direct Medical Expenses
- Direct medical expenses funded first by PhilHealth, then insurance, discounts, PCSO, DOH MAIP, and lastly hospital resources.
- Non-direct medical expenses funded by DSWD's Assistance to Individuals in Crisis Situations (AICS).
Availment Procedures
- Healthcare providers assess patient PhilHealth and NBB eligibility before service.
- Ensure zero out-of-pocket payment for eligible patients.
- Non-members classified and enrolled under PhilHealth's Point of Care or Service program.
- Record all services rendered.
- Medical social workers facilitate financial assistance claims.
- Billing department coordinates settlement; no direct reimbursement to patients.
- Provide statement of account detailing contributions from fund sources.
Special Cases for Admitted Patients
- If no service accommodation beds, admit patient to private accommodation with service rates.
- Providers must assist with unavailable services without out-of-pocket patient payment.
- Patients exhausted of PhilHealth benefits remain eligible for other funds.
- Transferring to private accommodation negates NBB policy guidelines.
Grievance Mechanism
- Each agency resolves complaints within its jurisdiction as per citizens' charter.
Monitoring and Evaluation
- An interagency mechanism and shared database shall monitor implementation and detect fraud.
- NDAs required for sharing sensitive data.
- PhilHealth to provide regular exit survey summaries to agencies.
Responsibilities of Participating Agencies
- DOH: Lead, coordinate, monitor NBB compliance, train social workers.
- PhilHealth: Define eligibility guidelines, furnish case rate data, consolidate reports, update cost data, deploy CARES, enhance exit surveys.
- PCSO: Provide funds, implement ASAP desks.
- DSWD: Provide crisis assistance through AICS.
- Healthcare Providers: Ensure full NBB compliance and guarantee zero out-of-pocket payments.
Governing Clause
- DOH, PhilHealth, PCSO, and DSWD jointly resolve issues.
- Provisions are transitory pending institutionalization of full fund streamlining.
Penalty Clause
- False information by patients leads to denial of future assistance and possible charges.
- Health care providers making unjustified claims face administrative, civil, or criminal sanctions.
- Sanctions apply for late or non-compliance in claims filing.
Separability Clause
- Invalidity of any provision does not affect remainder of the Order.
Repealing Clause
- Inconsistent provisions of AO 2017-0003 are repealed, amended, or modified.
- Unaffected provisions of existing issuances remain valid.
Transitory Clause
- Current pooling of funds is interim, moving towards PhilHealth as single national purchaser.
Effectivity
- The Order takes effect 15 days after publication in a nationwide newspaper.