Pursuant to E.O. No. 195 and D.O. No. 37, Series of 1994 providing compulsory Medical Care Coverage to Filipino OCWs, the following guidelines are hereby issued:

I.
General Statement

The provision of this memorandum Circular shall apply to all departing OCWs under the following classifications:

1. Workers recruited and placed by licensed/manning agencies;

2. Workers recruited and placed by the Administration on a government to government hiring arrangements;

3. Name Hires;

4. Workers recruited and placed through the Administration for Foreign employers in such sectors as policy may dictate; and

5. Balik Manggagawa (vacationing OCWs).

II
Exemptions

The provision on the M.C. shall not apply to the following:

1. Seafarers with active SSS coverage; and

2. Land-based workers of active status under the GSIS/SSS Voluntary Membership Program.

III
Beneficiaries

The beneficiaries of the Program are the OCW Medicare Members and their legal dependents:

The legal dependents of a member are:

1. The legitimate spouse who is not Medicare member.

2. The unmarried and unemployed legitimate, legitimated acknowledged children as appearing in the birth certificate, legally adopted or stepchildren below 21 years of age.

3. Children who are suffering from congenital disability, either physical or mental, or any disability acquired below the age of 21 than renders them totally dependent upon the member for support.

4. The parents who are 60 years old and above whose income is P 1,000.00 or less a month.

IV
Benefits

A. Entitlement to Benefits. A beneficiary shall be entitled to benefits if he meets the following conditions:

1. He is confined in a hospital due to illness or injury requiring hospitalization, or undergoes a surgical procedure in the operating room complex on an out-patient basis or received chemotherapy, radiotherapy, or hemodialysis similarly on an out-patient basis.

2. The member has paid at least one (1) annual contribution within the immediate three (3) month period prior to the first day of confinement.

3. The 45-day room and board allowance for the year has not been consumed.

B. Types of Benefits. A beneficiary of the Program who is confined in a hospital on account of sickness or injury requiring hospitalization i.e. entitled to confinement days per year as follows: 1) Maximum of forty-five (45) days for members. 2). Maximum of forty-five (45) days for all dependents. Any unused benefits for any prior year shall not be carried over to the succeeding year. The benefits for such confinement shall not exceed the following:

a. ALLOWANCE FOR HOSPITAL ROOM AND BOARD PER DAY:

HOSPITAL CATEGORY
PRIMARY		SECONDARY		TERTIARY
	P 55/day		P100/day		P145/day

b. ALLOWANCE FOR MEDICAL EXPENSE PER SINGLE PERIOD OF CONFINEMENT:

MEDICAL EXPENSE BENEFITS	HOSPITAL CATEGORY
	PRIMARY		SECONDARY		TERTIARY
1. ORDINARY CASES:
Drugs & Medicine	P 595.00		P790.00		P 1,015.00
X-ray/Lab/Others	150.00		360.00		635.00
2. INTENSIVE CARE CASES:
Drugs & Medicines	P 1,350.00		P1,620.00		P 2,915.00
X-ray/Lab/Others	325.00		830.00		1,260.00
3. CATASTROPHIC CASES:
Drugs & Medicines			P 3,650.00		P 4,170.00
X-ray/Lab/Others			1,620.00		3,845.00

CATASTROPHIC CASES shall include the following:

1. Illnesses or injuries such as cancer cases requiring cases requiring chemotherapy and/or radiotherapy, meningitis, encephalitis, cirrhosis of the liver, myocardial infraction, cerebrovascular attack, rheumatic heart disease - Grade III, renal conditions requiring dialysis or transplant, massive hemorrhage;

2. Surgical procedures or multiple surgical procedures done in one sitting with a total Relative Unit Value of 20 and above such as coronary bypass, open heart surgery, neurosurgery shall be construed catastrophic.

INTENSIVE CARE CASES shall include the following:

1. All confinement in an intensive care unit other than those classified as catastrophic;

2. Other similar serious illnesses or injuries such as cancer, pneumonia, moderately and for advanced pulmonary tuberculosis including its complications, cardiovascular attack, diseases of the heart chronic obstructive pulmonary disease, liver disease, typhoid fever, H-fever, kidney diseases, septicemia, diarrhea with severe dehydration, severe injuries, black water fever.

3. Surgical procedures or multiple surgical procedures done in one sitting with a total Relative Unit Value of 8 and above but not exceeding 19:99 shall be considered as intensive care cases.

ORDINARY CASES are illnesses or injuries other than those included in the above enumeration.

For purposes or reimbursement of medicines, a mark-up of not more than 50% of the price bases on the latest and updated issue of Philippine Index of Medical Specialties (PTMS) shall be adopted.

C. ALLOWANCE FOR PROFESSIONAL FEES:

1. Medical/Dental Practitioner's fee of P55.00 per day for a General Practitioner and P800.00 for a Specialist but not to exceed:

a. For Ordinary Cases (per single period of Confinement)

For General Practitioner	P300.00
For Specialist	450.00

b. For Intensive/Catastrophic Cases (per single period of confinement)

For General Practitioner	P450.00
For Specialist	750.00

2. Surgeon's Fee not exceeding P 7,080.00 shall be paid in accordance with the Relative Unit Value promulgated by the Commission.

The surgeon's fee shall include two (2) days of pre-and five (5) days of post-operative care.

Surgical procedures without any assigned Relative Unit Value shall be evaluated taking into consideration its similarly to existing procedures.

Two or more surgical procedures done through the same incision shall be considered as a single procedure and shall be paid based on the highest Relative Unit Value.

A qualified beneficiary who undergoes surgical procedure in the hospital operating undergoes surgical procedure in the hospital operating room complex on an out-patient basis is entitled to benefits provided that one (1) day is deducted from his forty-five (45) day room and board benefits.

All claims for surgical expense shall be made by listing the operation as appearing in the Standard Nomenclature of International Classification of Surgical Procedure.

3. Anesthesiologist's fee not exceeding thirty percent (30%) of the allowable Surgeon's fee.

To be entitled to the above fee, the following must be observed:

1. Only one anesthesiologist shall be compensated for each operation.

2. Local anesthesia is not compensable except when it is a regional nerve block anesthesia.

3. When the operating surgeon administers anesthesia himself, no separate anesthesiologist's fee shall be allowed.

D. ALLOWANCE FOR OPERATING ROOM FEE

SURGICAL PROCEDURE WITH RELATIVE		HOSPITAL CATEGORY
UNIT VALUE OF:		PRIMARY		SECONDARY		TERTIARY
___________________________________________________________________________________________
	0-5		P170.00	P295.00		P470.00
	5.1 - 10		-	505.00		600.00
	10.1 - above		-	960.00		1550.00

e. SURGICAL FAMILY PLANNING PROCEDURES (STERILIZATION BENEFITS):

The Following Procedures are compensable under Medicare:

1. Vasectomy	P400.00
2. Tubal Ligation	P500.00

V
Requirements for Availment of Medicare Benefits

1. A member or his legal dependent must present the original and true copy of the Medicare Eligibility Certificate to the hospital, the latter to be authenticated by the Hospital and attached to the claim form.

2. The member shall furnish the OWWA with an updated list of his legal dependents as defined herein whenever necessary. In the case of a newly born dependent, a certified true copy of the birth certificate shall be submitted.

VI
Benefits of Members While Abroad

1. A member, including his legal dependents, who is abroad shall be eligible to Medicare benefits while outside the country provided the conditions for entitlement are met.

2. The medicare benefits to be granted shall be in accordance with the schedule provided for in these rules and regulations.

VII
Payment of Medicare Benefits While Abroad

1. Requirements - The requirements shall include the following documents (in addition to the pertinent requirements for settlement of claims):

1. Statement of Account and Official Receipt of payment from the foreign hospital where the patient was confined;

2. Certification of the attending physician as to the final diagnosis, period of confinement, and services rendered.

2. Manner of Payment - Payment shall be made to the beneficiary in Philippine Currency.

VIII
Premium Rate and Payment

The Premium shall be a maximum of P900.00 per member for a year's coverage. The cost of premium for Medicare Coverage shall be paid by the workers.

The departing OCW or licensed agency shall pay the premium at the Medicare Registration Center established for this purpose. A corresponding proof of payment shall be issued.

No refund of premium contribution shall be allowed in whole or in part once the Medicare Eligibility Certificate is issued. However, a worker can avail of all benefits under this program during its validity.

IX
Functions of the Medicare Registration Center;

1. Evaluate the OCW Medicare Eligibility Information Sheet and verify Certificate of exemption, if applicable;

2. Accept premium payments and issue corresponding receipts; and

3. Issue individual certificate of coverage, the Medical Eligibility Certificate.

X
Documentation Requirements

All OCWs shall be required to fill up the OCW Medicare Information Sheet (MIS) provided for the purpose. Those workers seeking for exemptions from Compulsory Medical Coverage are required to attach Certificate of active SSS/GSIS Voluntary Membership Status. OCW applicants with at least two (2) months of unexpired OCW Medicare Coverage shall attach a copy of their Medicate Eligibility Certificate to the MIS to quality for exemption.

XI
Distribution of Medicare Information Sheet

Medicare Information Sheet shall be made available to all OCW-applicants and landbased licensed agencies/concerned manning agencies for reproduction.

XII
Effectivity

This Memorandum Circular shall take effect fifteen (15) days from the date of publication.

For strict compliance.

Adopted: 14 Dec. 1994

(SGD.) FELICISIMO O. JOSON
Administrator