I. COVERAGE AND SCOPE

This Circular shall apply to all PhilHealth members and dependents who are 60 years old and above; and to all accredited PhilHealth institutional health facilities and health care professionals.

The circular provides the guidelines for benefits availment of PhilHealth members and dependents and additional accreditation rules for institutional health facilities and health care professionals.

II. APPLICATION OF SENIOR CITIZENS' PRIVILEGE FOR HEALTH SERVICES

With regard to the implementation of R.A. 9257 and pursuant to Administrative Order No. 177, s. 2004, the following are the application of senior citizens discount for health and dental services.

A. Subsidized Services in In-patient and Out-patient Sections of Government Health Facilities:

Medical (includes surgical) and dental services, including diagnostic and laboratory fees for all senior citizens confined in service wards of government facilities shall be provided for free as long as these are in accordance with available Clinical Practice Guidelines or Hospital Treatment Protocols, and therefore, medically necessary.

B. Non-Subsidized Services in Pay Sections of Government Health Facilities

Medical and dental services, including diagnostic and laboratory fees for all senior citizens confined in pay section (both and out patient sections) of government health facilities shall be granted twenty percent (20%) discount, provided that these are in accordance with available Clinical Practice Guidelines or Hospital Treatment Protocols, and therefore, medically necessary.

C. Twenty Percent (20%) Discount on Services in Private Health Facilities

Medical and dental services, including diagnostic and laboratory fees such as, but not limited to, x-rays, computerized tomography scans and blood tests for all senior citizens confined in private hospitals and medical facilities shall be given a 20% discount. The services shall include the use of specialized treatment rooms and equipment such as those for hemodialysis and radiotheraphy.

D. Twenty Percent (20%) Discount on Services of Health Care Professionals

Professional fees of attending health care professionals in all private hospitals and medical facilities for medical, surgical and dental services rendered to senior citizens shall also be given of twenty percent (20%) discount.

III. RULES on the APPLICATION of the SENIOR CITIZENS PRIVILEGES to the AVAILMENT of PHILHEALTH BENEFITS

A. Subsidized Services in In-patient and Out-Patient Sections of Government Health Facilities

In any setting where the PhilHealth member or dependent will be provided subsidized care, the rules for the availment of PhilHealth benefits are as follows:

1. PhilHealth benefit reimbursement shall first be applied to all PhilHealth covered services (drugs/medicines, laboratories and supplies) that are not subsidized by the government facility. To facilitate this, the accredited facility shall compute for the total expenses (for services and items not subsidized) incurred by the patient and from therein deduct the appropriate PhilHealth Benefit. The facility must also ensure that all Official Receipts of such purchases are attached to the Claims applications for appropriate reimbursement.


2. After the above deductions are made, the remaining PhilHealth benefits (including professional fees), if there will still be, shall be applied to the cost of services/items subsidized by the said facility and covered by PhilHealth.


3. In case of requests for adjustments of reimbursements for health expenses on the same admission, payment shall be made to the requesting party (member/hospital) provided expenses being claimed are not included in the claim application earlier submitted and that there are benefits balances available. No adjustment shall be made on any claim without the corresponding request and necessary documentation.

To illustrate,

                                                                               

SAMPLE CALCULATION	AMOUNT
Total charges incurred for services provided to a senior citizen	P 25,000
Deduct Charges for services that is expected to be shouldered by the senior citizen (PhilHealth benefits should be APPLIED FIRST on these charges)	less   P _5,000
Balance are Charges for services mandated to be provided free or fully subsidized to the senior citizen AND all 20% discounts	P 20,000
(PhilHealth benefits may NOW be APPLIED on the balance provide the benefit limits for the particular has not been fully applied to the charges that was supposed to be shouldered by the senior citizen)

B. Twenty Percent (20%) discount on services in Pay Sections of Government Health Facilities and in Private Health Facilities

In a setting where the PhilHealth member or dependent will be provided the 20% discount for hospital services, the health facility must first deduct from the total hospital charges, the amount representing the 20% thereof. Only the remaining 80% or a portion of which, chargeable correspondingly to PhilHealth. To illustrate,

SAMPLE CALCULATION
  for HEALTH FACILITY (HOSPITAL) CHARGES

                                                                                       

	AMOUNT
Applicable health facility charges	P10,000
less
Deduct 20% discount of senior citizen privilege	(P20,000)
Applicable charges for Philhealth reimbursement	P 8,000
less
Deduct PhilHealth benefit coverage	_(5,000)
Co-payment of senior citizen	P 3,000

C. Twenty Percent (20%) Discount on Services of Health Care Professionals

In a setting where the Philhealth member or dependent will be provided the 20% discount for health care professional services, the amount representing the 20% discount must first be deducted prior to the application of the PhilHealth benefit. Only the remaining 80% or a portion thereof, is chargeable to PhilHealth, subject to the following rules:

1) In calculating the PhilHealth reimbursement of professional fees, the health professional must first deduct the amount representing the 20% discount from the applicable fees. Only the remaining 80% or a portion thereof, is chargeable to PhilHealth. To illustrate,

SAMPLE CALCULATION
for PROFESSIONAL FEES

                                                                               

	AMOUNT
Applicable professional fees (PF)	P 5,000
less
Deduct 20% discount of senior citizen privilege	(P1,000)
Applicable charges for PhilHealth reimbursement	P4,000
less
Deduct PhilHealth benefit coverage	(P1,500)
Co-payment of senior citizen	P2,500

2) If the PhilHealth member pays for the professional fees in full and opts to claim reimbursement of professional fees directly to PhilHealth through direct filing, the original of the OR must be attached to the claim.

3) In case of under-deduction of the PhilHealth benefit, the difference shall be paid to the member provided that the original OR is attached.

4) Accredited health care professionals shall issue to the member an official receipt (OR) with the 20% senior citizen's (SC) discount and the PhilHealth expected reimbursement or counter-part explicitly written.

SAMPLE of the OR (or what should appear in the OR)

Bobby Cruz, MD
Rm. 1904 State Hospital, Pasig City
TIN number: 123-456-789

OFFICIAL RECEIPT

                                                                                                                                         

		No. 101
		Date: February 16, 2005
RECEIVED from Mr. Leo Balisi 73/M   Address Kapitolyo, Pasig City   the SUM of Two thousand five hundred pesos (P2,500)   in full/partial payment of professional fees (PF)
	Total charges	5,000
	20% Senior citizens' discount	less 1,000
	PF net of 20% SC Discount	4,000
	PhilHealth reimbursement	less 1,500
PF net of PhilHealth	2,500
		By: SIGNED
		_________________
		Authorized Signature

All other rules in benefit payment/reimbursement shall apply.

IV. RULES on ADDITIONAL WARRANTIES of ACCREDITATION to ENSURE the IMPLEMENTATION of RA 9257

A. All Accredited Health Facilities

Consistent with the warranties of accreditation that mandates all accredited health facilities to comply with all pertinent and applicable laws and regulations, all accredited health facilities are required to comply with the following requirements set in Administrative Order No. 177, s. 2004:

1) The posting of hospital room rates, laboratory and diagnostic tests fees, medicine prices, professional fees for private patients, and all other fees and rates in conspicuous places near or at the main entrance of their respective facility.

2) The submission of the above-described price lists as an attachment for all application for initial accreditation, or renewal of accreditation to PHIC;

3) The issuance of official receipts for every paid for medical and dental services, laboratory and diagnostic tests, and medicines provided. The receipts shall state the usual rates or fees and the discounted price;

4) The setting up of grievance mechanisms for senior citizens in private health facilities to entertain questions with regards to discounts on professional fees;

5) The health facility-level guidelines on the disciplinary and reportorial procedures for health professionals who refuse to grant the proper discount; and

Non-compliance with the aforesaid accreditation requirements shall be considered breach of warranties and may result in non-approval or application of non-renewal of accreditation or any other sanction provided for in the implementing rules and regulations of Republic Act 7875, as amended and RA 9257.

B. ALL ACCREDITED HEALTH CARE PROFESSIONALS

Consistent with the warranties of accreditation that mandates all accredited health care professionals to comply with all pertinent and applicable laws and regulations, they shall be required to comply with the following requirements set in Administrative Order No. 177, s. of 2004:

1) Schedule of professional fees shall be posted in a conspicuous place in the office of the accredited physician or other health care professional.

2) The accredited health care professionals shall issue to the member an official receipt (OR) indicating there with 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 shall be made available to PhilHealth upon request.

V. EFFECTIVITY

These guidelines shall take effect 15 days after publication.

Adopted: 08 Feb. 2005

(SGD.) FRANCISCO T. DUQUE III, MD, MSc
Secretary
President and CEO