M a n i l a
PRESIDENTIAL DECREE No. 1519
REVISING THE PHILIPPINE MEDICAL CARE ACT OF NINETEEN HUNDRED AND SIXTY NINE
WHEREAS, Republic Act Number Sixty-One Hundred Eleven entitled "An Act Establishing the Philippine Medical Care Plan Creating the Philippine Medical Care Commission, Prescribing its Duties, 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 the policy of the government to gradually provide total medical service for our people by adopting and implementing a comprehensive and coordinated medical care plan based on the following concepts of health care:
(a) There shall be comprehensive medical care according to the needs of the patient.
(b) The use of government and private medical facilities shall be coordinated as public service instrumentalities for the people.
(c) Optimum health care shall be achieved by preserving and promoting a proper inter-relationship among physicians, patients and hospitals.
Section 3. Purpose and Objectives. The main purposes and objectives of this Decree are:
(a) To provide medical care to residents of the country in an evolutionary way within our economic means and capability as a nation.
(b) To provide our people with a viable means of helping themselves pay for adequate medical care.
Section 4. Definition of Terms. For the purpose of this Decree the following terms shall mean as follows:
(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 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 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 who is a member in good standing of the Philippine Medical Association or of the Philippine Dental Association and accredited in accordance with rules and regulations promulgated by the Commission.
(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 of 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 objective of this Decree, the Philippine Medical Care Commission created by Republic Act No. 6111, hereinafter referred to as the Commission, shall be composed of a Chairman, an Executive Director and the following members: the Administrator of the Social Security System, the General Manager of the Government Service Insurance System, the Secretary of Health, the Secretary of Finance, the Secretary of Local Governments and Community Development, the President of the Philippine Medical Association, the President of the Philippine Hospital Association, and two (2) members representing the private sector. The private sector representative 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.
When the Chairman is temporarily unable to perform his functions or in case of vacancy of the office, the Executive Director shall serve as the Acting Chairman.
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 establish when deemed necessary provincial, city and municipal medical care councils.
(e) 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 sent.
(f) To promulgate or prescribe rules and regulations as may be necessary to carry out the provisions and purposes of this Decree.
(g) To recommend to the President from time to time according to sound actuarial procedures the contributions as well as benefits under the Philippine Medical Care Plan as resources allow in order to insure adequate financing and effective delivery or medical care to all beneficiaries of the Plan.
(h) To fix and provide from its funds the necessary amount for the operation of Provincial Medical Care Councils, City Medical Care Councils and the Municipal Medical Care Councils so that they could carry out their respective functions under the Medical Care Plan. Council members shall be entitled to per diems for every meeting actually attended by them as well as actual and necessary travel expenses as the Commission may provide, subject to pertinent laws, rules and regulations on compensation honoraria and allowances. Ex-officio council members shall be provided with an honorarium in such amount as the Commission may approve subject to pertinent rules and regulations on honoraria.
(i) To ensure a homogenous distribution of adequate hospital accommodations for in-patient care through a 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.
(j) 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.
(k) To enter into agreement 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.
(l) To adopt control measures to prevent abuses of the Philippine Medical Care Plan.
(m) To investigate upon its own initiative or upon complaint in writing, any violation of this Decree or of the implementing rules and regulations and to suspend or revoke, after notice and hearing, the accreditation extended to any government or private hospital, drug store, medical and dental practitioner, who commits such violation: Provided, That any order or decision rendered by the Commission under this paragraph shall be appealable to the Office of the President in accordance with the procedure established under Executive Order No. 19, Series of 1966.
(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 and enforcement of this Decree during the preceding fiscal year.
(o) To coordinate with other appropriate government agencies in the development of medical and allied manpower based on the needs of the health care delivery system.
(p) Generally to exercise all powers necessary to attain the purposes and objectives of this Decree.
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, except the Chairman and the Executive Director, shall receive monthly commutable allowance subject to the aforementioned laws, rules and regulations on compensation.
Section 8. Chairman of the Commission. The Chairman of the Commission shall be appointed by the President of the Philippines for a term of six (6) years. He shall be a reputable member of the medical profession with at least twelve (12) years of experience in medical practice. He shall hold office on a full time basis and shall nor be removed except for cause. He shall receive such salary and remuneration as may be determined by the Commission, subject to provisions of P.D. No. 985.
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.
Section 9. The Vice-Chairman and Executive Director of the Commission. The Executive Director who shall also be the Vice-Chairman shall be appointed by the President of the Philippines for a term of six (6) years and shall have at least ten (10) years of experience in business undertaking or medical practice. 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 the provisions of P.D. No. 985.
The Executive Director shall advise and assist the Chairman in the formulation and implementation of rules and regulations necessary to carry out the policies established by the Commission. He shall perform such functions as may be assigned to him by the Chairman.
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 an employee is both covered by the SSS and GSIS, only his employment with the latter shall be considered for purposes of his coverage.
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) Allowance for hospital room and board at twelve (P12.00) pesos per day for a period not exceeding 45 days per year for each member of Program I and another 45 days per year to be shared by all his legal dependents. The Commission may, however, fix a higher rate not exceeding eighteen (P18.00) pesos per day in accordance with such standards that it may sent.
(b) Allowance for necessary drugs and laboratory examination including X-ray not exceeding one hundred fifty (P150.00) pesos per single period of confinement. However, amount not exceeding two hundred fifty (P250.00) pesos may be allowed for cases requiring intensive care as may be defined by the Commission.
(c) Surgeon's fee allowance not exceeding fifty (P50.00) pesos for minor surgery, two hundred fifty (P250.00) pesos for medium surgery and five hundred (P500.00) pesos for a major surgery, the exact amount of which shall be determined under a relative value scheme covering each kind of surgical procedure under rules and regulations to be promulgated by the Commission for this purpose, but not to exceed five hundred (P500.00) pesos for any listed operation. The fee shall cover two (2) days of pre-operative care and five (5) days of post-operative care.
(d) Operating room fee allowance not exceeding twenty (P20.00) for a minor surgery, fifty (P50.00) pesos for medium surgery, and seventy-five (P75.00) pesos for major surgery.
(e) Anesthesiologistís fee allowance shall not exceed thirty per cent (30%) of the surgeon's fees.
(f) Allowance for medical and dental practitioner's fee of ten (P10.00) pesos for each daily visit not to exceed two hundred (P200.00) pesos for a single period of confinement or for any sickness or injury provided that in determining the compensation daily visit occasioned by any one sickness or injury not more than one visit for any one day shall be counted.
(g) Allowance for sterilization expenses of a contributing member or his spouse as may be determined by the Commission.
The beneficiary 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 drug store 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 allowances 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 hospital, sanitaria, clinics, dispensaries and rural health units shall provide back-up services to the medical care plan especially for patients occupying service beds.
Section 13. Participants in the Delivery of Medical Care Services. Only the following may participate in the delivery of medical care 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) Drug stores 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 and dental practitioner or medical or dental attendance by whom he will be treated, under such rules and regulations as promulgated by the Commission.
The right of any beneficiary who so desires 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. An employee 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 until such time that such an employee becomes entitled to the benefits of Program I, he shall be covered by Program II.
Section 16. Supervision. The Commission, the SSS and GSIS shall exercise supervision over the confined beneficiaries under such rules and regulations as they may promulgate for the purpose. This authority may be exercised by the Commission through its intermediaries.
Section 17. The GSIS and the SSS Health Insurance Funds. Payment for medical care benefits in Program I shall be borne with the SSS and GSIS Health Insurance Funds which shall consist of all contributions and accruals thereto. These funds shall be kept distinct and separate from all other funds administered by the said agencies.
The Health Insurance Funds administered under the GSIS and SSS shall be deposited, invested, administered and disbursed in the same manner and under the same conditions, requirements, and safeguards as provided by Republic Act Number Eleven Hundred Sixty-One, as amended, and Commonwealth Act Number One Hundred Eighty-six as amended, with regard to such other funds as are administered by the SSS or GSIS respectively: Provided, That the SSS and GSIS may disburse each for operational expenses not more than 12 per cent of the total contributions and investment earnings collected during the year.
Section 18. Rates of Contributions for SSS and GSIS Health Insurance Funds. Contributions for the Health Insurance Funds by members of the SSS and GSIS shall be compulsory in accordance with the following schedule:
|Monthly Salary Wage of Earnings
|P1.00 - P49.99||P25.00||P0.30||P0.30|
|50.00 - 99.99||75.00||0.95||0.95|
|100.00 - 149.99||125.00||1.55||1.55|
|150.00 - 199.99||175.00||2.20||2.20|
|200.00 - 249.99||225.00||2.80||2.80|
|250.00 - 349.99||300.00||3.75||3.75|
|350.00 - 499.99||425.00||5.35||5.35|
|500.00 - Above||600.00||7.50||7.50|
Section 19. Collection of Contributions to the SSS and GSIS Health Insurance Funds. The employer shall deduct from his employee's monthly compensation the employee's contribution. The employee's contribution and the employer's counterpart thereof shall be remitted by the employer directly to the GSIS and SSS, as the case may be, in the same manner as other SSS and GSIS contributions and shall be subject to the same penalties for late payment. The employer's counterpart contribution shall not in any manner be recovered from the employee. Failure of the employer to remit to the GSIS or the SSS the corresponding employee's and employer's contributions shall not be a reason for depriving the employee of the benefits of this Decree.
Section 20. Effects of Separation from Employment. An employee who is no longer obliged to contribute 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 for medical care service 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 chooses to occupy a bed more expensive than a service bed, and the provider of the service exceed the amount of benefits provided for under this Decree, the difference shall be borne personally by the patient. Medical Care expenses incurred while outside the country may be reimbursed to the beneficiary under such rules, regulations and/or conditions as the Commission may prescribe.
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 or 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 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) Physchiatric illness;
(d) Normal obstetrical delivery; and
(e) Services which are purely diagnostic.
Section 24. Provincial Medical Care Council. The Commission shall establish in each province a Provincial Medical Care Council of seven (7) members, to be composed of: (1) the Provincial Health Officer or in his absence his authorized representative; (2) a representative of the Provincial Governor chosen from his official staff and confirmed by the Commission; (3) the Provincial Treasurer, or in his absence, his duly authorized representative; (4) a duly designated representative of the Philippine Medical Association who is a member of the Association's component society; (5) a duly designated representative of the Philippine Hospital Association preferably the chief of one of the private hospitals in the province, if any; and (6 and 7) two private citizens of the province representing the beneficiaries of the Philippine Medical Care Plan.
The last four (4) mentioned members shall be appointed by the Commission and shall hold office for a period of two (2) years unless sooner removed for cause by the Commission. The Council shall elect annually its Chairman and such other officers as may be deemed necessary. The Provincial Medical Care Council shall exercise such power and duties as may be authorized by the Commission.
Section 25. City Medical Council. The Commission shall establish in each chartered city a Medical Care Council of seven (7) members, to be composed of: (1) the City Health Officer or in his absence his authorized representative; (2) City Treasurer or in his absence his authorized representative; (3) a representative of the City Mayor chosen from his official staff and confirmed by the Commission; (4) a duly designated representative of the Philippine Medical Association who is a member of the Association's components society, (5) a duly designated representative of the Philippine Hospital Association preferably the chief of a private hospital in the City, if any; and two private citizens from the city representing the beneficiaries of the Philippine Medical Care Plan. The last four (4) mentioned members shall be appointed by the Commission and shall hold office for a period of two (2) years unless sooner removed for cause by the Commission.
The Council shall elect annually its Chairman and such other officers as may be deemed necessary, and shall perform such functions as may be directed by the Commission.
Whenever it is deemed necessary, the Commission may organize District Medical Care Councils of not more than five (5) members whose functions shall be to assist the City Medical Care Council in implementing the Medical Care Plan for the City in accordance with rules and regulations that the Commission may promulgate.
Section 26. Municipal Medical Care Council. The Commission may establish in each municipality a Municipal Medical Care Council of seven (7) members to be composed of (1) The Municipal Health Officer or in his absence his authorized representative; (2) the municipal treasurer or in his absence his authorized representative; (3) a representative of the Municipal Mayor chosen from his official staff and confirmed by the Commission; (4) a duly designated representative of the Philippine Medical Association; (5) a representative of the Philippine Hospital Association preferably the chief of a private hospital in the town; or in the absence of one, the highest public school official in the town; and (6 and 7) two private citizens of the municipality representing the beneficiaries of the Philippine Medical Care Plan. The last four (4) mentioned members shall be appointed by the Commission and shall hold office for a period of two (2) years unless sooner removed for cause by the Commission. The Council shall elect annually its Chairman and such other officers as may be deemed necessary, and shall perform such functions as may be directed by the Commission.
The Council shall perform such functions as may be authorized by the Commission.
Section 27. Records and Reports. The Commission, the Provincial, the City and Municipal Medical Care Councils, the SSS and GSIS shall keep records of all operations relative to any and all funds. Such records shall be for purposes of financial management as well as research.
Section 28. Study and Research. The Commission shall undertake a continuous management study and research to insure the viability of the Program.
Section 29. Hearing Procedures. Whenever the Commission deems it necessary, inquiries and investigations into reported violations of the provision of this Decree or the implementing rules and regulations shall be conducted by a hearing committee created by the Commission, and for this purpose, the committee shall not be bound by technical rules of evidence. The Commission 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 Decree. Any case of contumacy shall be dealt with in accordance with the provisions of Section 580 of the Administrative Code.
Section 30. 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 penalties provided for in Article 172 of the Revised Penal Code.
Whoever fails or refuses to comply with the provisions of this Decree or with the rules and regulations promulgated by the Commission, shall be punished by a fine of not less than five hundred pesos nor more than five thousand pesos, or imprisonment for not less than six months nor more than one year, or both, at the discretion of the counter: Provided, That, where the violation consist in failure or refusal to deduct contributions from employee's compensation and remit the same to the SSS and GSIS, the penalty shall be a fine of not less than five hundred pesos nor more than five thousand pesos and imprisonment for not less than six months nor more than one year.
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 and indirectly from the compensation of the covered employee or otherwise recover from them his own contribution on behalf of such employees shall be punished with a fine not exceeding one thousand pesos for imprisonment not exceeding one year or by both fines and imprisonment at the discretion of the court.
Any employee of the SSS or GSIS who receives or keeps funds or property belonging, payable or deliverable to the SSS and GSIS 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 a violation of the provisions of this Decree may be commenced by the SSS, the GSIS or the Commission, or the employee 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 31. Appropriations. Funds as may be necessary to finance the operation, programs, and projects of the Commission and the Medical Care Councils, as provided for in Sections 24, 25 and 26, in carrying out the purposes and objectives of this Decree are hereby authorized to be included in the Annual Appropriations Law.
Section 32. Government Guarantee. The Republic of the Philippines guarantees the benefits under this Decree and the solvency of the Community Health Insurance Funds.
Section 33. 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 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 34. 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 35. 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 36. Effectivity. The revised Medical Care Act shall be implemented 90 days after its approval.
Done in the City of Manila, this 11th day of June, in the year of Our Lord, nineteen hundred and seventy-eight.
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