WHEREAS, Republic Act Number Sixty-One Hundred Eleven entitled "An Act Establishing the Philippine Medical Care Plan and Creating the Philippine Medical Care Commission, Prescribing Its Duties and Powers and Functions and Appropriating Funds Therefor" enacted on August 4, 1969 requires revision in order to be responsive to the situation;

WHEREAS, such revision is a condition to the more effective implementation of the law and the achievement of its goals;

WHEREAS, the Medical Care Program is one of the vital Projects of the government in the New Society;

NOW, THEREFORE, I, FERDINAND E. MARCOS, President of the Philippines, by virtue of the powers vested in me by the Constitution, do hereby order and decree:

SECTION 1. Short Title. - This decree shall be known as the "Revised Philippine Medical Care Act."

SECTION 2. Declaration of Policy. - It is hereby declared to be the policy of the government to gradually provide total medical services to our people by adopting and implementing a comprehensive and coordinated medical care plan based on the following concepts of health care:

a) Commission - The Philippine Medical Care Commission created under R.A. No. 6111.

b) Philippine Medical Care Plan - The total Plan consisting of Programs I and II.

c) SSS - The Social Security System created under Republic Act Number Eleven Hundred Sixty One, as amended.

d) GSIS - The Government Service Insurance System created under Commonwealth Act Number One Hundred Eighty Six, as amended.

e) Employee - Any person compulsorily covered by either the GSIS or SSS.

f) Beneficiary - Any person entitled to medical care benefits under this Decree.

g) Employer - The employer of the employee.

h) Legal Dependent - Persons other than members and contributors who are entitled to benefits under this Decree in accordance with such terms and conditions as the Commission may prescribe.

i) Medical Care Benefits - Services relative to illness or injury, including major dental surgery or operation which needs hospitalization subject to reasonable limitations as will be imposed by the technical organization and finances of the Philippine Medical Care Plan.

j) Hospital - Any medical facility, government or private, accredited in accordance with rules and regulations promulgated by the Commission.

k) Medical or Dental Practitioner - Any doctor of medicine or doctor of dental medicine duly licensed to practice in the Philippines and who is accredited by the Commission in accordance with its rules and regulations. (As amended by Sec. 1, Executive Order 269) .

l) Service Beds - Private and government hospital beds set aside for beneficiaries of the Philippine Medical Care Plan as may be prescribed by the Commission.

m) Single Period of Confinement - A single confinement or series of confinements for the same illness, with intervals of not more than ninety (90) days.

n) Medical or Dental Attendance - Medical or dental care of a patient by a physician or medical staff or dentist or dental staff of the hospital.

SECTION 5. Philippine Medical Care Commission. - To carry out the purposes and objectives of this Act, the Philippine Medical Care Commission created by Republic Act No. 6111, hereinafter referred to as the Commission, shall be composed of the Secretary of Health as Chairman; an Undersecretary of Health designated by the former as Vice-Chairman; the Administrator of the Social Security System; the President and the General Manager of the Government Service Insurance System; the Secretary of Finance; the Secretary of Local Government; the Secretary of Labor and Employment; and four other members, one each representing the beneficiaries, the private employers, the physicians and the hospitals. The four other members shall be appointed by the President of the Philippines for a term of six (6) years.

The ex-officio members may designate their representatives who shall exercise the plenary powers of their principals as well as enjoy the same benefits available to the latter. (As amended by Sec. 2, Executive Order No. 269).

SECTION 6. Functions of the Commission. - The Commission shall have the following functions and powers:

a) To formulate policies, administer and implement the Philippine Medical Care Plan, consistent with the National Health Plan.

b) To ensure that medical care is provided to members covered by the Philippine Medical Care Plan.

c) To organize its offices, fix the compensation of and appoint its Secretary and such other personnel as may be deemed necessary, subject to pertinent budget and compensation laws, rules and regulations.

d) To accredit medical and dental practitioners, government and private hospitals and other facilities for participation in the Medical Care Plan under such terms and conditions as the Commission may set.

e) To promulgate or prescribe rules and regulations as may be necessary to carry out the provisions and purposes of this Act.

f) To recommend to the President from time to time according to sound actuarial procedures the contributions and benefits under the Philippine Medical Care Plan as well as alternative system in order to insure adequate financing and effective delivery of medical care to all beneficiaries of the plan.

g) To ensure a homogenous distribution of adequate hospital accommodations for inpatient care through national network of government and private medical care facilities; and to coordinate with the Department of Health in the implementation of the Hospital Licensure Act.

h) To acquire in behalf of the Republic of the Philippines, real or personal property which may be necessary or expedient for the attainment of the purposes of the Commission

i) To enter into agreements or contracts in the manner and under such terms and conditions as the Commission may deem proper for the efficient and effective administration of the Commission.

j) To adopt control measures to prevent abuses of the Philippine Medical Care Plan.

k) To render decisions, orders or resolutions on any investigation conducted upon its own initiative or upon complaint in writing for any violation of this law or its rules and regulations, and after notice and hearing, impose administrative fines of not less than P5,000 but not more than P10,000 against any person, natural or juridical, found guilty of such violation: Provided, That should the violation be committed by a hospital, drugstore, medical or dental practitioner, the accreditation so extended shall, in addition, be suspended for a period not exceeding six months: Provided, furthermore, That any decision, order or resolution rendered by the Commission shall be appealable to the Office of the President in accordance with the procedure established under Administrative Order No. 18, Series of 1987: Provided, finally, That the administrative sanctions provided herein shall be without prejudice to the penal provisions under Section 28 hereof.

l) To issue as soon as the decision, order or resolution has become final and executory, writs of execution enforceable in accordance with the Rules of Court of the Philippines.

m) To deputize any law enforcement agency or official in the execution of its final decisions, orders or resolutions and to serve such other processes of the Commission.

n) To submit to the President of the Philippines annually within the first ten days of each year, a report covering its activities in the administration of this Act during the preceding fiscal years.

o) To coordinate with other appropriate government agencies in the development of the medical and allied manpower based on the needs of the health care delivery system.

p) To approve rules and regulations to ensure uniform evaluation of claims as may be elevated by the beneficiary hospitals or practitioners.

q) Generally to exercise all powers necessary to attain the purposes and objectives of this Act. (As amended by Sec. 3, Executive Order No. 269).

SECTION 7. Meetings and Hearings of the Commission. - The meetings and hearings of the Commission shall be held as often as necessary at the discretion of the Chairman or at the request of the majority of the members of the Commission. The presence of six (6) members of the Commission shall constitute a quorum. The members of the Commission shall receive a per diem for every meeting and hearing attended subject to pertinent budget laws, rules and regulations on compensation, honoraria and allowances. Each member of the Commission shall receive a monthly commutable allowance subject to the aforementioned laws, rules and regulations, except those who are already receiving the same from the government offices they are appointed to. (As amended by Sec. 4, Executive Order No. 269).

SECTION 8. Chairman and Vice-Chairman of the Commission. - (a) The Chairman shall preside over the meetings of the Commission and shall implement its decisions. He shall exercise supervision and control over all operations of the Commission.

(b) When the Chairman is temporarily unable to perform his functions or in case of vacancy of the Office of the Chairman, the Vice-Chairman shall serve as Acting Chairman. He shall perform such other functions as may be assigned to him by the Chairman. (As amended by Sec. 5, Executive Order No. 269).

SECTION 9. Executive Director of the Commission. - The Commission shall have an Executive Director who shall be appointed by the President of the Philippines for a term of six (6) years. The Executive Director shall have at least ten (10) years experience in technical and administrative fields related to the purposes and objectives of this Act. He shall hold office on a full-time basis and shall not be removed except for cause. He shall receive such salary and remuneration as may be determined by the Commission, subject to pertinent laws, rules and regulations on compensation, honoraria and allowances.

The Executive Director shall be responsible for the general conduct of the operations and administration of the Commission. (As amended by Sec. 6, Executive Order No. 269).

SECTION 10. The Philippine Medical Care Plan. - The Philippine Medical Care Plan shall consist of the following which shall provide medical care benefits:

a) Program I - for members of the SSS and the GSIS including their legal dependents.

b) Program II - for those not covered under Program I. This shall be in accordance with Section 33 hereof.

SECTION 11. Program I. - All members of the SSS and GSIS and all their legal dependents as defined under Section 4 hereof shall be provided with medical care benefits.

In case a person is covered by both the SSS and the GSIS, he may choose under which system he shall be covered for Medicare purposes, under such rules as the Commission may prescribe. (As amended by Sec. 7, Executive Order No. 269).

SECTION 12. Medical Care Benefits. - Under such rules, regulations and/or conditions as the SSS or the GSIS may prescribe, subject to the approval of the Commission, a beneficiary under Program I who suffers from sickness or injury requiring hospitalization/surgical operation shall be entitled to the following benefits:

a) The medical care benefits to Medicare beneficiaries covered by the Social Security System (SSS) shall not exceed the rates indicated below:
 

                        HOSPITAL CATEGORY
                BENEFIT                                                        PRIMARY     SECONDARY     TERTIARY

    2.2. Intensive Care Cases
        2.2.1. Drugs & Medicines                                                             350              1,620                  2,915
        2.2.2 . X-Ray/Laboratory/Others                                                    325                 830                  1,260
    2.3. Catastrophic Cases
        2.3.1. Drugs and Medicines                                                                             3,650                  4,170
        2.3.2. X-Ray/Laboratory/Others                                                                         1,620                  3,845

3. Medical/Dental Practitioner’s Fee shall be P55.00
    per day for a General Practitioner and P80.00 for a
    Specialist but not to exceed:
    3.1. For Ordinary Cases
          (Per Single Period of Confinement)
          For General Practitioner                                                                                   300
          For Specialist                                                                                                  450
    3.2. For Intensive Care/Catastrophic Cases
          (Per Single Period of Confinement)
          For General Practitioner                                                                                   450
          For Specialist                                                                                                  750

4. Surgeon’s Fee shall be in accordance with the
    Relative Value Scheme prescribed by the
    Commission not to exceed P7,080.00.

5. Anesthesiologist’s Fee not to exceed 30% of the
    allowable Surgeon’s Fee.

6. Operating Room Fee for Surgical Procedures
    under the following brackets of Relative Unit Value
    (RUV):
            1. RUV of 5.0 and below -                                                       170                 295                  470
            2. RUV 5.1 to 10.0 units -                                                                               505                  600
            3. RUV above 10 units -                                                                                 960               1,550

7. Fees for Surgical Family Planning Procedures
    (For members and spouses only):
            1. Vasectomy -                                                                                             400
            2. Tubal Ligation                                                                                           500

b) The Medical Care benefits of Medicare beneficiaries covered by Government Service Insurance System (GSIS) shall not exceed the rates indicated below:
 

                        HOSPITAL CATEGORY
                BENEFIT                                                        PRIMARY     SECONDARY     TERTIARY

2. Medical Expense Benefit
    (Per Single Period of Confinement)
    2.1. Ordinary Cases
        2.1.1. Drugs & Medicines                                                             595                  790                 845
        2.1.2. X-Ray/Laboratory/Others                                                     125                  300                 530
    2.2. Intensive Care Cases
        2.2.1. Drugs & Medicines                                                          1,125               1,350               2,430
        2.2.2. X-Ray/Laboratory/Others                                                     270                  690               1,050
    2.3. Catastrophic Cases
        2.3.1. Drugs & Medicines                                                          3,040               3,475
        2.3.2. X-Ray/Laboratory/Others                                                  1,350               3,205

3. Medical/Dental Practitioner’s Fee shall be P55.00
per day for a General Practitioner and P80.00 for a
Specialist but not to exceed:
    3.1. For Ordinary Cases
    (Per Single Period of Confinement)
    For General Practitioner                                                                                          300
    For Specialist                                                                                                         450
    3.2. For Intensive Care/Catastrophic Cases
    (Per Single Period of Confinement)
    For General Practitioner                                                                                          450
    For Specialist                                                                                                         750

4. Surgeon’s Fee shall be in accordance with the
    Relative Value Scheme prescribed by the
    Commission not to exceed P7,080.00.

5. Anesthesiologist’s Fee not to exceed 30% of the
    allowable Surgeon’s Fee.

6. Operating Room Fee for Surgical Procedures
    under the following brackets of Relative Unit Value
    (RUV):
        1. RUV of 5.0 and below -                                                            140                  245                 390
        2. RUV 5.1 to 10.0 units -                                                                                     420                 500
        3. RUV above 10 units -                                                                                      960               1,290

7. Fees for Surgical Family Planning Procedures
    (For members and spouses only):
    1. Vasectomy -                                                                                                       400
    2. Tubal Ligation -                                                                                                   500

The beneficiaries shall have the option to secure the drugs and medicines used for his treatment from either the hospital pharmacy wherein he is confined or from any retail drugstore of his own choice subject to the rules and regulations promulgated by the Commission or as provided for in Sections 21 and 22 thereof.

Out-patient and domiciliary care shall be carried out by existing government hospitals, rural health units, other government clinics and all clinics under the supervision of various government entities.

As soon as feasible, the Commission shall provide expense allowance for ambulatory and domiciliary care benefits rendered in/by government or private hospitals or clinics to beneficiaries of this Medical Care Act subject to rules and regulations promulgated by the Commission.

All government hospitals, sanitaria, clinics, dispensaries and rural health units shall provide back-up services to the medical care plan, especially for patients occupying service beds. (As amended by Executive Order No. 106).

SECTION 13. Participants in the Delivery of Medical Care Services. - Only the following may participate in the delivery of medical services in the Philippine Medical Care Plan under such rules and regulations as the Commission may set:

a) Hospitals duly accredited by the Commission.

b) Medical and dental practitioners duly accredited by the Commission.

c) Drugstores duly accredited by the Commission.

SECTION 14. Free Choice of Hospital, Medical or Dental Attendance. - Any beneficiary who becomes sick or is injured shall be free to choose the hospital in which he will be confined and the medical or dental practitioner or medical or dental attendance by whom he will be treated, under such rules and regulations as may be promulgated by the Commission.

The right of any beneficiary who so desire to arrange privately for medical care at his own expense shall not be prejudiced by any provision of this Decree.

SECTION 15. Entitlement to Medical Care Benefits. - A member who shall have paid at least three monthly contributions during the last twelve months prior to the first day of the single period of confinement, as well as his legal dependents, shall be entitled to medical care benefits: Provided, That when he commits any violation of this law or its rules and regulations, he and his legal dependents shall not be allowed to avail of these benefits by the Commission subject to Section 6(K) hereof. The member shall continue to pay his contributions during the period of suspension of availment of benefits. (As amended by Sec. 3, Executive Order No. 105).

SECTION 16. Supervision. - The Commission, the SSS and the GSIS shall exercise supervision over the confined beneficiaries under such rules and regulations as may be promulgated for the purpose. This authority may be exercised by the Commission through its intermediaries.

SECTION 17. Health Insurance Fund. - Payments for medical care benefits under Program I shall be borne by the Health Insurance Fund which shall consist of all contributions of Medicare members and all accruals thereto collected by the SSS and GSIS from the members under the Act. It shall be kept distinct and separate from all other funds administered by the said agencies.

The Health Insurance Fund shall be deposited, invested, administered, and disbursed in the same manner and under the same conditions, requirements, and safeguards as provided by Republic Act Numbered Eleven Hundred Sixty-One, as amended, and Presidential Decree Numbered Eleven Hundred Forty-Six, as amended, with regard to such other funds as are administered by the SSS and GSIS, respectively: Provided, That the deposit, investment, administration, and disbursement of the funds conform with the policies established by the Commission: Provided, further, That the SSS and GSIS may disburse each for operational expenses not more than twelve percent (12%) of the total contributions and investment earnings collected during the year. (As amended by Sec. 8, Executive Order No. 269).

SECTION 18. Contributions to the Health Insurance Fund. - The compulsory contributions of members to the Health Insurance Fund shall be in accordance with the schedule of rates established by the Commission and approved by the President. (As amended by Sec. 9, Executive Order No. 269).
 

Salary             Monthly Salary
Bracket             Wages or         Contribution         Employer’s         Employee’s
Number             Earnings             Base             Contributions        Contributions

    1.             Below - P 49.99     P 25.00             P 0.30                   P 0.30

    2.             50.00 -     99.99        75.00                 0.95                      0.95

    3.             100.00 - 149.99       125.00                1.55                       1.55

    4.             150.00 - 199.99       175.00               2.20                        2.20

    5.             200.00 - 249.99       255.00               2.80                        2.80

    6.             250.00 - 349.99       300.00               3.75                         3.75

    7.             350.00 - 499.99       425.00              5.35                          5.35

    8.             500.00 - 599.99      600.00               7.50                          7.50

    9.             700.00 - 899.99      800.00              10.00                       10.00

    10.           900.00 - over       1,000.00              12.50                       12.50

SECTION 20. Effects of Separation from Employment. - An employee who is no longer obliged under Section 19 hereof by separation from employment may continue to enjoy medical care benefits, subject to such rules and regulations and/or conditions as the Commission may prescribe.

SECTION 21. Payment of Medical Care Benefits. - Payment of medical care services shall be made directly to the hospital, the medical or dental practitioner, and the retail drug store according to rules, regulations and/or conditions which the Commission may set: Provided, that when the charges and fees agreed upon between the beneficiary, who choose to occupy a bed more expensive than a service bed, and the provider of the service, exceed the amount of benefits provided under this Decree, the difference shall be borne personally by the patient. Medical care expense incurred while outside the country may be reimbursed to the beneficiary under such rules, regulations and/or conditions as the Commission may prescribe and research to improve the program. (As amended by Sec. 11, Executive Order No. 269).

SECTION 22. Limitation to Payment of Benefits. - Claims for payment of services rendered under this Decree which are filed beyond sixty (60) days after the discharge of the patient from the hospital or from the time a patient has been declared well, shall be barred from payment.

Payment for services rendered may be reduced or denied when the claimant:

(a) Furnishes false of incorrect information concerning any matter required by this Decree or the rules and regulations promulgated by the Commission.

(b) Fails without good cause or legal ground to comply with any provision of this Decree or the implementing rules and regulations of the Commission.

The cost of medical care benefits of patients confined in service beds shall be limited to the prescribed medical care benefit allowances.

When a claim is reduced or denied, the amount thus reduced or denied shall not be charged directly or indirectly to the beneficiary involved unless the latter is directly responsible for the cause of such reduction or denial.

SECTION 23. Exclusion. - The benefits granted under the Medical Care Plan shall not cover any expenses for:

(a) Cosmetic surgery or treatment;

(b) Optometric services;

(c) Psychiatric illness;

(d) Normal obstetrical delivery; and

(e) Services which are purely diagnostic.

SECTION 24. Records and Reports. - The Commission, the SSS and GSIS, shall keep records of all operations relative to the Program.

SECTION 25. Program Monitoring, Study and Research. - The Commission shall undertake a continuing monitoring study and research to improve the Program. (As amended by Sec. 11, Executive Order No. 269).

SECTION 26. Hearing Procedures. - There is hereby created a Hearing Committee composed of nine (9) members who shall be designated by the Commission for the purpose of conducting inquiries and investigations into reported violations of this law or its implementing rules and regulations. The Committee may sit in three (3) divisions, each division composed of three (3) members. The Committee shall not be bound by the technical rules of evidence. The Committee may administer oaths, certify to official acts, and issue subpoena and subpoena duces tecum to compel the attendance of witnesses, and the production of books, papers and other records deemed necessary in connection with any question arising under this law. The Commission shall have the same powers to punish direct and indirect contempts granted to superior courts under Rule 71 of the Rules of Court. (As amended by Sec. 4, Executive Order No. 105).

SECTION 27. Preventive Suspension. - The Hearing Committee may preventively suspend any beneficiary, duly accredited practitioner, hospital or other facility from participation in the Program if any of the following circumstances is present:

a. When the respondent has been found guilty of a violation of this Act or of its rules and regulations at least twice and there is reasonable ground to believe that the respondent is guilty of the present charge.

b. When the respondent, at the time of the inspection, has committed or is committing a violation.

The preventive suspension order shall be for a period of not exceeding three (3) months from the date of its issuance. The order: (a) shall specify the violation charged, supported by the evidence of the violation; (b) shall require the respondent to answer the charges within a period of ten (10) days from receipt thereof; and (c) shall require the respondent to appear on the date set for hearing the case. (As amended by Sec. 12, Executive Order No. 269).

SECTION 28. Penal Provisions. - Any person who, for the purpose of securing entitlement to any benefit or payment under this Decree or the issuance of any certificate or document for any purpose connected with this Decree, whether for himself or for some other person, shall commit fraud, collusion, falsification, misrepresentation or any similar anomaly, shall suffer the penalties provided for in Article 172 of the Revised Penal Code.

Whoever fails or refuses to comply with the provisions of this law or with the rules and regulations promulgated by the Commission, including failure or refusal to deduct contributions from the employee’s compensation and to remit the same to the Social Security System (SSS) or the Government Service Insurance System (GSIS), shall be punished by a fine of not less than Ten thousand pesos (P10,000.00) but not more than Forty thousand pesos (P40,000.00) or imprisonment for not less than six (6) months nor more than six (6) years, or both, at the discretion of the court. (As amended by Par. 1, Sec. 5, Executive Order No. 105).

Any employer who, after deducting the monthly contributions from his employee’s compensation, fails to remit the said deductions to the SSS and GSIS within thirty days from the date they become due shall be presumed to have misappropriated such contributions and shall suffer the penalties provided in Article 315 of the Revised Penal Code.

Any employer who shall deduct, directly or indirectly, from the compensation of the covered employees or otherwise recover from them his own contribution on behalf of such employees shall be punished by a fine of not less than Ten thousand pesos (P10,000.00) but not more than Forty thousand pesos (P40,000.00) or imprisonment of not less than six (6) months nor more than six (6) years, or both, at the discretion of the court. (As amended by Par. 2, Sec. 5, Executive Order No. 105).

Any employee of the SSS or GSIS who receives or keeps funds or property belonging, payable or deliverable to the SSS or GSIS and who shall appropriate the same, or shall take or misappropriate or shall consent, or through abandonment or negligence, shall permit any other person to take such property or funds, wholly or partially, or shall otherwise be guilty of misappropriation of such funds or property, shall suffer the penalties provided in Article 217 of the Revised Penal Code.

If the act or omission, penalized by this Decree, be committed by an association, partnership, corporation or any other institution, its managing head, directors or partners shall be liable to the penalties provided in this Decree for the offense.

Criminal actions arising from violation of the provisions of this Decree may be commenced by the SSS, the GSIS or the Commission, or the employees concerned either under this Decree or, in appropriate cases, under the Revised Penal Code: Provided, That criminal actions may be filed by the SSS, the GSIS or the Commission in the city or municipality where the violation was committed or in Metro Manila, at their option.

SECTION 29. Appropriation. - Funds as may be necessary to finance the operations, programs, and projects of the Commission in carrying out this Decree are hereby authorized to be included in the Annual Appropriation Law. (As amended by Sec. 13, Executive Order No. 269).

SECTION 30. Government Guarantee. - The Republic of the Philippines guarantees the benefits under this Decree and the solvency of the Community Health Insurance Funds.

SECTION 31. Program II. - As soon as feasible, medical care benefits under Program II will be provided either through a social insurance medical care service similar to that of Program I or through the public medical care service under the rules and regulations to be promulgated by the Commission. All provisions of this Decree as may be applicable to Program II shall so apply. Those not covered at present by Program I may seek medical attention from existing government hospitals.

Program II shall be implemented upon its approval by the President.

SECTION 32. Separability Clause. - In the event any provision of this Decree or the application of such provision to any person or circumstances is declared invalid, the remainder of the Decree or the application of said provision to other persons or circumstances shall not be affected by such declaration.

SECTION 33. Repealing Clause. - Republic Act No. 6111, and all laws, executive orders, administrative rules and regulations or parts thereof which are inconsistent with the provisions of this Decree are hereby repealed or modified accordingly.

SECTION 34. Effectivity. - The Revised Medical Care Act shall be implemented 90 days after its approval.

Done in the City of Manila, this 11th of June in the year of our Lord, nineteen hundred and seventy-eight.

(Sgd.) JUAN C. TUVERA
Presidential Assistant

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