[ PhilHealth Circular No. 001-2015, February 13, 2015 ]

PHILHEALTH COVERAGE FOR CONFIRMED CASES OF MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS (MERS-COV)



Adopted: 13 February 2015
Date Filed: 12 March 2015

I. RATIONALE

Recent developments make it of utmost importance for the corporation to align its efforts with other agencies to safeguard the Filipino from both foreign and domestic threats to public health, especially from emerging and re-emerging infectious diseases defined as œInfections that have newly appeared in [a] population or have existed but are rapidly increasing in incidence or geographic range  (S.S. Morse. Factors in the Emergence of Infectious Diseases. Emerging Infectious Diseases, 1996; 1(1): 7-15).

In a globalized world, transient population visiting other countries can easily become unwitting carriers of public health threats from these diseases; and this may only be rationally contained within boundaries of the same to protect the more vulnerable ones, like our own, only by concerted effort of all civilized nations acting with proportional response to the potential threat.

The Corporation has consistently and proactively responded to prevent the potential spread of the aforementioned threats (such as SARS and Novel Virus A H1N1) when faced by the same challenges in the recent past.

The potential outbreak of any emerging and re-emerging infectious disease must be met with equal resolve and the same meticulous strategic planning as pioneered by the corporation when faced with said threats that unequivocally resulted in prevention of loss of life and disruption of economic growth.

The Department of Health thru Department Memorandum No. 2013-0205 recognizes the potential spread of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in the country if left unchecked.

Hence, the following are the guidelines for the coverage of confirmed cases of MERS-CoV.

II. SCOPE AND COVERAGE

  1. This policy shall cover the Confirmed cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV).
  2. It shall cover members and their dependents as defined in Section V, Rule I, Title III of the Revised IRR of the National Health Insurance Act of 2013 (RA 7875 as amended by RA 9241 and 10606).
  3. This benefit may be availed in an accredited HCI that has the capabilities and facilities to manage MERS-CoV as required by the DOH MERS-CoV strategic plans (i.e. for MERS-CoV: negative isolation room, respirators, etc).

III. GUIDELINES

  1. The œConfirmed  cases of MERS-CoV as defined in the DOH Department Memorandum No. 2013-0205 must have their confirmatory tests done by the RITM. The official result of this positive test must be submitted together with the claim.
  2. ICD-10 code œJ12.8, B97.2  shall be the designated code for this particular MERS-CoV-related benefit and must be written in PhilHealth Claim Form 2 item 9 as the First Case rate being claimed.
  3. The benefits shall cover non-health workers and health workers up to a maximum of Php50,000 and Php100,000, respectively.

    Benefit Items
    Non-Health Workers Members/Dependents
    Health Workers
    Room and Board
    Php1,500/day maximum of Php10,000
    Php1,500/day Maximum of Php10,000
    Drugs and Medicines
    Php25,000
    Php60,000
    Screening Test for MERS-CoV, Xray, Laboratory and Others (including Supplies, and Personal Protective Equipments; Transfer Services (Ambulance)
    Operating Room Fee (if necessary)
    Professional Fee
    Php1,000/day Maximum of Php15,000
    Php1,000/day Maximum of Php30,000

  4. The aforementioned amounts shall cover for the management of co- morbidities treated during the same confinement.
  5. A œhealth worker  shall be limited to an employee or institutional worker of an HCI whether located in the Philippines or abroad and that cared for, or had close contact with, a MERS-CoV patient and may have had contracted the infection while performing his or her duty.
  6. Claims shall undergo medical evaluation and shall be paid following the fee- for-service mechanism.
  7. Compliance to the required qualifying contribution and 45 days benefit limit shall be waived for availment of this benefit.
  8. The No Balance Billing policy shall be applied to MERS-CoV claims.
  9. All MERS-CoV benefits shall be subjected to post audit.

IV. CLAIMS FILING

  1. PhilHealth Benefit Eligibility Form (PBEF) and/ or Completely and properly filled out and signed PhilHealth Claim Form 1
  2. Completely and properly filled out and signed PhilHealth Claim Form 2
  3. Completely and properly filled out and signed PhilHealth Claim Form 3
  4. For non-members availing of the benefit, PhilHealth Membership Registration Form (PMRF) must be properly accomplished and submitted. Those who qualify shall be enrolled under point of care as provided in PhilHealth Circular No. 32, s-2013.
  5. The Statement of Account (SOA) shall be required.
  6. Positive confirmatory test result for MERS-CoV by RITM.

V. MONITORING AND EVALUATION

The health care provider shall be subjected to the rules on monitoring and evaluation of performance as provided for in PhilHealth Circular No. 54, s-2012: Provider Engagement through Accreditation and Contracting for Health Services (PEACHeS) and PhilHealth Circular No. 031-2014 re: Health Care Provider Performance Assessment System (HCP PAS).

Violations shall be dealt with accordingly and the Corporation reserves the right to rectify any prejudicial financial charges of the hospital to ultimately redound back to the patient.

This Circular shall be reviewed annually and as necessary.

VI. REPEALING CLAUSE

All provisions of previous issuances, circulars, and directives that are inconsistent with any of the provisions of this Circular for this particular circumstance wherein the same is exclusively applicable, are hereby amended, modified or repealed accordingly.

VII. SEPARABILITY CLAUSE

In the event that a part or provision of this Circular is declared unauthorized or rendered invalid by any Court of Law or competent authority, those provisions not affected by such declaration shall remain valid and effective.

VIII. EFFECTIVITY

This Circular shall take effect for all admissions starting January 1, 2015. It shall be published in any newspaper of general circulation and shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.


(SGD) ALEXANDER A. PADILLA
President and CEO