Revising The Philippine Medical Care Act Of Nineteen Hundred And Sixty Nine

Case Overview and Summary

Summary of the Revised Philippine Medical Care Act

Declaration of Policy (Section 2):
- Provide comprehensive medical care based on the needs of patients.
- Coordinate the use of government and private medical facilities as public service.
- Achieve optimum health care by preserving relationships among physicians, patients, and hospitals.

Purpose and Objectives (Section 3):
- Provide medical care to residents within the nation's economic means.
- Provide a viable means for people to pay for adequate medical care.

Definitions (Section 4):
- Defines terms such as "Commission", "Philippine Medical Care Plan", "SSS", "GSIS", "Employee", "Beneficiary", "Employer", "Legal Dependent", "Medical Care Benefits", "Hospital", "Medical or Dental Practitioner", "Service Beds", "Single Period of Confinement", and "Medical or Dental Attendance".

Philippine Medical Care Commission (Section 5):
- Composition and appointment of the Commission members.
- Functions of the Commission members.

Functions of the Commission (Section 6):
- Formulate policies, administer, and implement the Philippine Medical Care Plan.
- Ensure medical care is provided to covered members.
- Organize offices, fix compensation, and appoint personnel.
- Establish provincial, city, and municipal medical care councils.
- Accredit medical and dental practitioners, hospitals, and facilities.
- Promulgate rules and regulations.
- Recommend contributions and benefits based on actuarial procedures.
- Fix and provide funds for operation of medical care councils.
- Ensure distribution of hospital accommodations and coordinate with the Department of Health.
- Acquire necessary property for the Commission.
- Enter into agreements or contracts.
- Adopt control measures to prevent abuses.
- Investigate and suspend or revoke accreditations after notice and hearing.
- Submit annual report to the President.
- Coordinate with agencies for development of medical manpower.
- Exercise necessary powers to attain the purposes and objectives.

Philippine Medical Care Plan (Section 10):
- Consists of Program I for SSS and GSIS members and their legal dependents.
- Consists of Program II for those not covered under Program I.

Program I (Section 11):
- Covers all SSS and GSIS members and their legal dependents.

Medical Care Benefits (Section 12):
- Allowance for hospital room and board up to ₱18 per day for 45 days per year for member and legal dependents.
- Allowance for necessary drugs and laboratory examinations up to ₱250.
- Surgeon's fee allowance up to ₱500 for major surgery.
- Operating room fee allowance up to ₱75 for major surgery.
- Anesthesiologist's fee allowance up to 30% of surgeon's fees.
- Allowance for medical and dental practitioner's fee up to ₱200 per single period of confinement.
- Allowance for sterilization expenses as determined by the Commission.

Participants in Delivery of Medical Care Services (Section 13):
- Hospitals, medical and dental practitioners, and drug stores duly accredited by the Commission.

Free Choice of Hospital and Practitioner (Section 14):
- Beneficiaries have the freedom to choose the hospital, medical or dental practitioner.

Entitlement to Medical Care Benefits (Section 15):
- An employee who has paid at least 3 monthly contributions during the last 12 months prior to the first day of the single period of confinement, and their legal dependents, are entitled to medical care benefits.

Supervision (Section 16):
- The Commission, SSS, and GSIS shall exercise supervision over confined beneficiaries.

SSS and GSIS Health Insurance Funds (Section 17):
- Payment for medical care benefits in Program I shall be borne by the SSS and GSIS Health Insurance Funds.
- The funds shall be kept separate from other funds administered by SSS and GSIS.
- The funds shall be deposited, invested, administered, and disbursed under the same conditions as other SSS and GSIS funds.
- SSS and GSIS may disburse up to 12% of total contributions and investment earnings for operational expenses.

Rates of Contributions for SSS and GSIS Health Insurance Funds (Section 18):
- Provides a schedule of monthly salary ranges and corresponding employer and employee contributions.

Collection of Contributions (Section 19):
- Employers shall deduct employee contributions from monthly compensation and remit to SSS or GSIS.
- Failure to remit contributions shall not deprive the employee of benefits.

Effects of Separation from Employment (Section 20):
- An employee who is no longer obliged to contribute may continue to enjoy medical care benefits under prescribed rules and regulations.

Payment of Medical Care Benefits (Section 21):
- Payment shall be made directly to the hospital, medical or dental practitioner, and retail drug store.
- Expenses incurred outside the country may be reimbursed under prescribed rules and regulations.

Limitation to Payment of Benefits (Section 22):
- Claims filed beyond 60 days after discharge or being declared well shall be barred from payment.
- Payment may be reduced or denied for furnishing false information or failing to comply with the Decree or regulations.
- Cost of medical care benefits for patients in service beds shall be limited to prescribed allowances.

Exclusions (Section 23):
- Benefits shall not cover expenses for cosmetic surgery or treatment, optometric services, psychiatric illness, normal obstetrical delivery, and purely diagnostic services.

Provincial, City, and Municipal Medical Care Councils (Sections 24-26):
- Establishes Provincial, City, and Municipal Medical Care Councils with specified compositions and terms.
- The Councils shall exercise powers and duties authorized by the Commission.

Records and Reports (Section 27):
- The Commission, Councils, SSS, and GSIS shall keep records of all operations relative to funds for financial management and research purposes.

Study and Research (Section 28):
- The Commission shall undertake continuous management study and research to ensure the viability of the Program.

Hearing Procedures (Section 29):
- The Commission may conduct inquiries and investigations into reported violations through a hearing committee.
- The committee shall not be bound by technical rules of evidence and may administer oaths, certify official acts, and issue subpoenas.

Penal Provisions (Section 30):
- Penalties for fraud, collusion, falsification, misrepresentation, or similar anomalies in securing benefits or documents.
- Penalties for failure or refusal to comply with the Decree or regulations.
- Penalties for failure to deduct and remit contributions.
- Penalties for misappropriation of contributions or funds by employers or employees.
- Liability of managing heads, directors, or partners of associations, partnerships, corporations, or institutions.
- Criminal actions may be commenced by SSS, GSIS, Commission, or the employee concerned.

Appropriations (Section 31):
- Funds necessary to finance the operation, programs, and projects of the Commission and Medical Care Councils shall be included in the Annual Appropriations Law.

Government Guarantee (Section 32):
- The Republic of the Philippines guarantees the benefits under this Decree and the solvency of the Community Health Insurance Funds.

Program II (Section 33):
- As soon as feasible, medical care benefits under Program II will be provided through a social insurance medical care service or public medical care service.
- Those not covered by Program I may seek medical attention from existing government hospitals.
- Program II shall be implemented upon approval by the President.

Separability Clause (Section 34):
- If any provision is declared invalid, the remainder of the Decree shall not be affected.

Repealing Clause (Section 35):
- Republic Act No. 6111 and other inconsistent laws, executive orders, administrative rules, and regulations are repealed or modified accordingly.

Effectivity (Section 36):
- The revised Medical Care Act shall be implemented 90 days after its approval.