Legal basis and related issuances
- The circular is issued to implement Republic Act No. 9257, known as the “Expanded Senior Citizens Act of 2003.”
- The circular is also implemented pursuant to Administrative Order No. 177, s. 2004.
- The circular cross-references the accreditation breach consequences under Republic Act No. 7875, as amended, and R.A. 9257.
- The circular uses R.A. 9257 as the substantive statutory basis for senior citizens’ health service privileges through discounts and free/subsidized services.
Purpose and policy statement
- The circular establishes PhilHealth operational guidelines to apply senior citizens’ health services privileges under R.A. 9257.
- The circular standardizes how PhilHealth benefits reimbursement and the 20% senior citizens’ discount must be applied in government and private health facilities and in professional fees.
- The circular adds accreditation warranty requirements so accredited facilities and professionals implement senior citizen discounts properly.
Coverage: who and what it applies to
- The circular applies to all PhilHealth members and dependents who are 60 years old and above.
- The circular applies to all accredited PhilHealth institutional health facilities.
- The circular applies to all health care professionals accredited under PhilHealth.
Senior citizens benefits on health services
- Medical (including surgical) and dental services, including diagnostic and laboratory fees, for senior citizens confined in service wards of government facilities must be provided for free.
- Free provision applies only when services are in accordance with available Clinical Practice Guidelines or Hospital Treatment Protocols, and are therefore medically necessary.
- For senior citizens confined in pay sections of government health facilities (including inpatient and outpatient pay sections), medical and dental services plus diagnostic and laboratory fees must be granted a 20% discount.
- For senior citizens confined in private hospitals and medical facilities, medical and dental services including diagnostic and laboratory fees must be granted a 20% discount, including services such as x-rays, computerized tomography scans and blood tests.
- The 20% discount in private facilities includes the use of specialized treatment rooms and equipment such as those for hemodialysis and radiotheraphy.
- For health care professional fees in private hospitals and medical facilities, attending health care professionals rendering medical, surgical and dental services to senior citizens must grant a 20% discount.
How discounts and PhilHealth benefits must be applied
When senior citizens are in settings where the facility provides subsidized care in government facilities, PhilHealth benefit reimbursement must be applied first to PhilHealth covered services (drugs/medicines, laboratories and supplies) that are not subsidized by the government facility.
Accredited facilities must compute total expenses for services/items not subsidized incurred by the patient, and must deduct the appropriate PhilHealth Benefit from those total expenses.
The facility must attach Official Receipts of the purchases for services/items not subsidized to the Claims applications for appropriate reimbursement.
After applying PhilHealth benefits to non-subsidized items, any remaining PhilHealth benefits (including professional fees) must be applied to the cost of services/items subsidized by the facility and covered by PhilHealth.
For requests for adjustments of reimbursements for health expenses on the same admission, payment to the requesting party (member/hospital) must be made if the expenses claimed are not included in the claim application earlier submitted and benefits balances are available.
No adjustment for reimbursement must be made without a corresponding request and necessary documentation.
When the facility provides the 20% discount for hospital services (i.e., in pay sections of government health facilities and in private health facilities), the facility must first deduct the amount representing 20% discount from the total hospital charges.
Only the remaining 80% (or a portion chargeable correspondingly to PhilHealth) is chargeable to PhilHealth as reimbursement basis.
When the facility provides the 20% discount for health care professional services, the professional must first deduct the amount representing the 20% discount before PhilHealth benefit application.
For professional fees reimbursement, only the remaining 80% (or a portion thereof) is chargeable to PhilHealth, subject to the following operating rules:
- In computing PhilHealth reimbursement of professional fees, the professional must deduct the 20% discount first; only the remaining 80% (or portion thereof) is chargeable to PhilHealth.
- If the senior citizen member pays the professional fees in full and opts to claim reimbursement of professional fees directly to PhilHealth through direct filing, the original Official Receipt (OR) must be attached to the claim.
- If there is under-deduction of PhilHealth benefit, the difference must be paid to the member provided the original OR is attached.
- Accredited health care professionals must issue an Official Receipt (OR) to the member showing the 20% senior citizen’s discount and the PhilHealth expected reimbursement or counter-part explicitly written.
The receipt issuance requirement includes that the OR must show the total charges, the 20% senior citizen’s discount deducted, the professional fee net of 20% discount, the PhilHealth reimbursement deducted, and the remaining professional fee net of PhilHealth.
Accreditation warranty requirements
Accredited health facilities must comply with accreditation warranties under Administrative Order No. 177, s. 2004, including the following operational requirements:
- Facilities must post in conspicuous places near or at the main entrance: hospital room rates, laboratory and diagnostic tests fees, medicine prices, professional fees for private patients, and all other fees and rates.
- Facilities must submit the above-described price lists as attachments for all applications for initial accreditation or renewal of accreditation to PHIC.
- Facilities must issue Official Receipts for every paid medical and dental service, laboratory and diagnostic tests, and medicines, and the receipts must state the usual rates or fees and the discounted price.
- Private health facilities must set up grievance mechanisms for senior citizens to entertain questions regarding discounts on professional fees.
- Facilities must establish health facility-level guidelines on disciplinary and reportorial procedures for health professionals who refuse to grant the proper discount.
Failure to comply with these accreditation requirements is treated as a breach of warranties that may result in:
- Non-approval or non-renewal of accreditation, or
- Any other sanction provided for in the implementing rules and regulations of Republic Act No. 7875, as amended, and R.A. 9257.
Accredited health care professionals must comply with accreditation warranties under Administrative Order No. 177, s. 2004, including the following:
- A schedule of professional fees must be posted in a conspicuous place in the office of the accredited physician or other health care professional.
- Professionals must issue to the member an OR indicating the 20% senior citizen’s (SC) discount and the PhilHealth expected reimbursement or counterpart.
- Both the patient’s and the accredited health care professional’s copies of the OR for covered services must be made available to PhilHealth upon request.
Effectivity rule
- The circular takes effect 15 days after publication.