REPUBLIC ACT NO. 6111 - Chan Robles and Associates Law Firm

(b) Program II — For those not covered in program I.Beneficiaries under Program I shall be entitled to medical carebenefits specifically provided for in subsequent sections of this Act.The Commission shall, within three years after the effectivity of thisAct, formulate an integrated program for the proper implementationof program II as envisioned in this Act. Likewise, it shall, within thesame period, recommend to Congress who shall be entitled toMedical Care benefits under Program II and the amount ofcontributions they shall make.PROGRAM ISECTION 10. Medical Care for SSS and GSIS Members. — TheSSS and the GSIS shall set up their respective medical care funds andshall administer the same in accordance with the following provisionsof this Act, and the policies and implementing rules and regulationspromulgated by the Commission. chanroblespublishingcompanyWithin five years from the approval of this Act, the SSS and the GSISshall, with the approval of the Commission, respectively adopt asupplementary plan designed to take over the medical care needs ofthe legal dependents of their members from Program I for which theSSS and the GSIS may require additional premiums.SECTION 11. Compulsory Coverage. — Coverage under this Actshall be compulsory and automatic upon all employees entitled underSection 35 of this Act: Provided, That in the case of an employee whois both covered by the SSS and GSIS, only his employment with thelatter shall be considered for purposes of his coverage.SECTION 12. Effect of Separation from Employment. — Subject tosuch rules, regulations and/or conditions as the SSS or GSIS mayprescribe, an employee who is no longer obliged to contribute underSection 22 hereof by separation from employment, may elect tocontinue paying contributions representing the contribution of theemployer as well as that of the employee only within sixty daysfollowing the date of such separation: Provided, That an employee

shall be entitled to the benefits under this Act if he has satisfied thecontribution requirements specified in Section 21 of this Act.SECTION 13. Hospitalization Expense Benefit. — Under suchrules, regulations and/or conditions as the SSS and GSIS mayprescribe, subject to the approval of the Commission, an employeewho is confined in a hospital on account of sickness or bodily injuryrequiring hospitalization, shall be entitled to confinement notexceeding forty-five days annually to: chanroblespublishingcompany(a) Room and board expense benefit for each day of confinement ina hospital not exceeding twelve pesos (P12.00) a day; and(b) Special charge expense benefit for charges necessary for thecare of the employee, such as laboratory examination fees, drugs, X-ray, operating room and the like, not to exceed one hundred fiftypesos (P150.00).For drugs and medicines that may be essential under this sub-section,the employee shall have the option to secure the same from either thehospital pharmacy wherein he is confined or from any retail drugstore of his own choice, subject only to the rules and regulations or asprovided for in Section 18 hereof.SECTION 14. Surgical Expense Benefit. — Under such rules,regulations, and/or conditions as the SSS or the GSIS may prescribe,subject to the approval of the Commission, an employee who shallhave undergone surgical procedure in a hospital shall be entitled to asurgical expense benefit as may be determined by the SSS or GSIS, asthe case may be, taking into account the nature and complexity of theprocedure: Provided, That the amount of benefit shall not exceed fiftypesos for a minor operation, one hundred fifty pesos for a mediumoperation and three hundred fifty pesos for a major operation. chanroblespublishingcompanySECTION 15. Medical Expense Benefit. — Under such rules,regulations and/or conditions as the SSS or the GSIS may prescribe,subject to the approval of the Commission, an employee who shallhave received necessary professional medical treatment by a medicalpractitioner while confined shall be entitled to a medical expensebenefit of P5.00 for each daily visit: Provided, That the maximum

enefit shall not exceed one hundred pesos for a single period ofconfinement or for any one sickness or injury: Provided, further, Thatin determining the compensable daily visit occasioned by any onesickness or injury not more than one visit for any one day shall becounted: Provided, finally, That specialists who are properly certifiedby the Philippine Medical Association shall be entitled to collect tenpesos for each daily visit.SECTION 16. Free Choice of Hospital or Medical Practitioner. —Any employee who becomes sick or is injured shall be free to choosethe hospital in which he will be confined and the medical practitionerby whom he will be treated.SECTION 17. Notification of Illness, Confinement andSupervision. — When an employee becomes sick or is injured andconfined in a hospital, his confinement as well as the nature of hissickness or injury shall be communicated by said hospital to the SSSor GSIS, as the case may be. The SSS or GSIS may exercisesupervision over the confined employee and, at its expense, requirehim to be examined by a medical practitioner of his choice.SECTION 18. Payment of Claims. — Benefits provided under thisAct shall be payable directly to the hospital, the medical practitionerand the retail drug store, if any, under such rules, regulations and/orconditions as the SSS or GSIS may prescribe, subject to the approvalof the Commission: Provided, That when the charges and fees agreedupon between the employee and the hospital and/or medicalpractitioner are in excess of the amount of the benefits provided forunder this Act, such employee shall be liable only for the payment ofthat portion of such fees and charges as are in excess of the benefitspayable under this Act. chanroblespublishingcompanySECTION 19. Limitation on the Right to Benefits. —(a) No employee shall be entitled to the benefits herein grantedunless he shall have paid at least three monthly contribution duringthe last twelve months prior to the first day of the single period ofconfinement: Provided, That in case of sickness on which surgery maybe deferred at the election of the employee in such cases ashermictomy, hemorrhoidectomy, tonsillectomy, adenoidectomy and

the like, the required monthly contributions paid immediately priorto the operation shall be at least for twelve consecutive monthlyinstallments: And, provided, further, That until such time that suchan employee is entitled to the benefits under Program I, he shall becovered by Program II; chanroblespublishingcompany(b) When the SSS or GSIS, as the case may be, has not been dulynotified by the hospital in the manner prescribed under Section 17 ofthis Act, no claim for any of the benefits of the Act shall be paid to thehospital concerned and said hospital shall further pay to the medicalpractitioner damages equivalent to the benefits which said medicalpractitioner would have received had there been due notification:Provided, That in no case may a claim for benefit filed after the lapseof sixty days from the last day of confinement be paid;(c) The SSS or GSIS may deny or reduce any benefits providedunder Program I of this Act when an employee, hospital or medialpractitioner, as the case may be:(1) Fails without good cause or legal ground to comply with theadvice of the medical practitioner with respect to hospitalization;(2) Furnishes false or incorrect information concerning any matterrequired by this Act or the rules and regulations of the SSS or theGSIS;(3) Is guilty during his confinement or illness of gross negligencewith regard to his health;(4) Refuses to be examined by or fails to comply with the advice ofthe medical practitioner appointed for supervision purposes by theSSS or GSIS; and(5) Fails to comply with any provision of Program I of this Act orrules and regulations of the SSS or GSIS required for entitlement tothe benefits provided in this Act.SECTION 20. Exclusion. — The benefits granted under this Actshall not cover any expense for:

(a)Cosmetic surgery or treatment;(b) Dental Service, except major dental surgery or operation whichneeds hospitalization;(c)Optometric service or surgery;(d) Services related to the case of psychiatric illness or of diseasestraceable to such illness; and(e)Services which are purely diagnostic.SECTION 21. Rates of Contributions. — For employees covered bythe GSIS and the SSS, the initial monthly contributions shall be inaccordance with the following schedule:Monthly Salary Covered Employer’s Employee’sWage or Earnings Wage Contribution ContributionBelow P49.99 P25.00 P0.30 P0.30P50.00 — 99.00 75.00 0.95 0.95100.00 — 149.99 125.00 1.55 1.55150.00 — 199.99 175.00 2.20 2.20200.00 — 249.99 225.00 2.80 2.80250.00 — over 300.00 3.75 3.75SECTION 22. Collection of Employee’s and Employer’sContribution. —(a) Within such time and manner as the SSS or GSIS mayprescribe, the employer shall deduct and withhold from hisemployee’s monthly compensation the employee’s contribution; and(b) Within such time and manner as the SSS or GSIS mayprescribe, but not beyond twenty days from the date due, theemployer shall remit directly to the GSIS or the SSS, as the case maybe, his corresponding contributions together with the employee’scontribution. No employer shall deduct, directly or indirectly, fromthe compensation of the covered employees or otherwise recover fromthem his own contributions in behalf of such employees: Provided,

That failure of the employer to remit to the GSIS or the SSS thecorresponding employee’s and employer’s contributions shall not be areason for depriving the employee of the benefits of this Act. chanroblespublishingcompanySECTION 23. Health Insurance Fund. — The Health InsuranceFunds of the SSS and the GSIS are hereby created which shall consistof all contributions and all accruals thereto and shall be kept separateand distinct from all other funds paid to and collected by saidagencies to be utilized for the purpose of meeting claims for benefitsunder this Act.SECTION 24. Administration and Disbursement of Funds. —Subject to Section 25 hereof, the Health Insurance Funds of the SSSor GSIS shall be administered and disbursed in the same manner andunder the same conditions, requirements and safeguards as providedby Republic Act Numbered One thousand one hundred sixty-one, asamended, and Commonwealth Act Numbered One hundred eightysix,as amended, with regard to such other funds as are thereunderbeing paid to or collected by the SSS and the GSIS, respectively:Provided, That they conform with the policies, rules and regulationsestablished by the Commission.SECTION 25. Deposit of Contributions. — All the contributionscollected by and remitted to the GSIS and the SSS under this Actshall, within thirty days of receipt be deposited in interest bearinggovernment deposit banks doing business in the Philippines, havingan unimpaired paid-up capital and surplus equivalent to one millionfive hundred thousand pesos or over. chanroblespublishingcompanySECTION 26. Records and Reports. — The Philippine MedicalCare Commission, the provincial, city and municipal Medical CareCouncils, the SSS and the GSIS shall keep and cause to be keptrecords of the operation of their respective funds and of disbursementthereof, and all accounts or payments made out of said funds. Theyshall also cause to be kept such records as may be required for thepurpose of making actuarial valuations including such data necessaryin the computation of the rate of morbidity in the Philippines and anyother information that may be useful for the adjustment of benefits.

PROGRAM IISECTION 27. Hospitalization, Out-Patient and Domiciliary Care.— Subject to the provisions of Section 13 hereof, for purposes ofhospitalization under this Act, private hospitals and clinics dulylicensed by the Bureau of Medical Services shall set aside at leasttwenty percent (20%) of their total bed capacity as service beds to besubsidized at the rate of P10.00 per bed per day to be paid by themonth not later than the tenth day of the following month, from anyspecial fund appropriated for this purpose: Provided, That saidservice beds shall remain such only when payments of these monthlysubsidies do not become delinquent for more than three consecutivemonths.Hospital loans shall be given priority by government financinginstitutions, especially in the rural areas where there are no existinggovernment or private hospitals, at a maximum rate of six percent(6%) per annum on a long-term basis. chanroblespublishingcompanyUntil such time as the Commission can otherwise provide therefore,the major aspect of out-patient and domiciliary care shall be carriedout initially by existing government hospitals, rural health units andother government clinics. chanroblespublishingcompanySECTION 28. Registration and Contribution. — To be entitled tothe benefits under this Act, and subject to the regulations andprocedures for registration to be promulgated by the Commission,every resident shall be registered and issued a medical care card uponpayment to the respective provincial, city, or municipal treasurerconcerned of the required yearly assessments to be fixed by theCommission. The yearly assessments shall be payable on or beforeJanuary 20 of each year to be collected by the City or MunicipalTreasurer concerned, and shall respectively be held by them in trustfor the City Medical Care Council or the Municipal Medical CareCouncil, as agents of the latter.SECTION 29. Provincial Medical Care Council. — TheCommission shall establish in each province a Provincial MedicalCare Council of seven (7) members, to be composed of: 1) the

Provincial Health Officer; 2) the Provincial Treasurer; 3) arepresentative of the Provincial Governor; 4) the duly designatedrepresentative of the component society of the Philippine MedicalAssociation; 5) a representative of the Philippine Hospital Associationfrom one of the private hospitals in the province if any, preferably achief of a hospital; and 6) and 7) two (2) private citizens from theprovince, one of whom shall be a duly registered physician, to beappointed by the Commission. The last four (4) mentioned membersshall be appointed for a term of four (4) years each, arranged on astaggered basis so that only one is appointed annually, except theinitial appointees who shall have terms of one, two, three, and fouryears, respectively. The Council shall elect its Chairman and shall:(a)Supervise the operation of the program on the municipal level;(b) Insure homogenous distribution and maximum utilization ofmedical facilities within the province;(c) Act as an adjudicatory body for the parties involve in claims forpayment;(d) Perform such other functions and duties as may be assigned toit by the Commission; and chanroblespublishingcompany(e) Hold in trust, through the Provincial Treasurer as Member ofthe Provincial Medical Care Council, Community Mutual HealthFunds of cities and municipalities as provided for under Section32(b).SECTION 30. City Medical Care Council. — The Commission shallestablish in each chartered city the City Medical Care Council of seven(7) members, to be composed of 1) the City Health Officer; 2) the CityTreasurer; 3) a representative of the Mayor; 4) the duly designatedrepresentative of the component society of the Philippine MedicalAssociation; 5) a representative to be appointed by the Commissionupon the recommendation of the Philippine Hospital Associationpreferably from one of the City private hospitals; and 6) and 7) two(2) private citizens from the City, one of whom shall be a dulyregistered physician to be appointed by the Commission. The last four(4) mentioned member shall have terms of four (4) years each,

arranged on a staggered basis so that only one is appointed annually,except the initial appointees who shall have terms of one, two, three,and four years, respectively. This Council shall elect its Chairman,shall administer the Community Mutual Health Fund, as provided forin Section 32, and implement the rules and regulations set forth bythe Commission. It shall disburse funds for the payment of medicaland hospital care for its members directly to the institutions ormedical practitioner concerned. Wherever it may be deemedexpedient or necessary, the City Medical Care Council may set up anumber of Community Medical Care Councils to be composed of five(5) members chosen from representatives of the community, civic,and government sectors. The latter shall assist the City Medical CareCouncil in the discharge of its functions. chanroblespublishingcompanySECTION 31. Municipal Medical Care Council. — TheCommission shall establish in each municipality a Municipal MedicalCare Council of seven (7) members, to be composed of: 1) theMunicipal Health Officer; 2) the Municipal Treasurer; 3) arepresentative of the Mayor; 4) a designee of the component societyof the Philippine Medical Association preferably a resident medicalpractitioner; 5) a representative of the Philippine HospitalAssociation in places with registered hospitals, or in their absence,the highest public school official in the town; and 6) and (7) two (2)private citizens from the municipality, one of whom shall preferablybe a duly registered physician, to be appointed by the Commission.The last four (4) mentioned members shall be appointed for a term offour (4) years each, arranged on a staggered basis so that only one isappointed annually, except the initial appointees who shall haveterms of one, two, three, and four years respectively.This Council shall elect its own Chairman, Vice-Chairman, andSecretary; administer the Community Mutual Health Fund;implement the rules and regulations promulgated by theCommission; and disburse funds for the payment of hospitalizationand hospital care for its members directly to the institution ormedical practitioner concerned, within ten (10) days after receipt ofthe bill. chanroblespublishingcompanySECTION 32. Community Mutual Health Fund. —

(a) There is hereby established in each city or municipality, aCommunity Mutual Health Fund. To this Fund shall accrue the yearlycontributions of residents in the city or municipality, and a nationalgovernment counterpart in aid amounting to one hundred percent(100%) of the amount collected by the city or municipality.(b) Community Mutual Health Funds of cities or municipalitieswhich, by virtue of their change of corporate personality, or loss ofany portion thereof through regrouping, shall be held in trust by theProvincial Treasurer as Member of the respective Provincial MedicalCare Council until such time as the Commission shall haveestablished the new Medical Care Council and defined its jurisdiction.SECTION 33. Revolving Funds. — The gross income of thegovernment hospitals shall be constituted into a revolving fund forthat particular hospital for the upgrading, expansion of its facilities,and for its maintenance and operation, subject to the approval of theDepartment of Health.SECTION 34. Reparations Allocations. — The reparationsCommission shall allocate and include in accordance with thereparations law, as amended, in its annual schedule beginning withthe fourteenth up to the twentieth reparations year, the procurementof machineries, equipments and instruments worth at least $1.5million annually as the Philippine Medical Care Commission mayrecommend. The latter shall, with the approval by the Department ofHealth, distribute such machineries, equipments and supplies to thedifferent government hospitals and rural health units. A similarallocation of at least $1.5 million shall likewise be made for theprivate hospitals involved in this plan pursuant to the provisions ofthis Act. chanroblespublishingcompanySECTION 35. Terms Defined. — For the purposes of this Act, thefollowing terms shall, unless the context indicate otherwise, have thefollowing meanings: chanroblespublishingcompany(a) SSS. — The Social Security System created under Republic ActNumbered One thousand one hundred sixty-one, as amended.

(b) GSIS. — The Government Service Insurance System createdunder Commonwealth Act Numbered One hundred eighty-six, asamended.(c) Employee. — Any person compulsorily covered by the SSSunder Republic Act Numbered One thousand one hundred sixty-one,as amended; or by the GSIS under Commonwealth Act NumberedOne hundred eighty-six, as amended, except members of the ArmedForces of the Philippines. chanroblespublishingcompany(d)Employer. — The employer of the employee.(e) Benefit. — The hospitalization, surgical and/or medical expensebenefit provided for under this Act.( f ) Hospital. — Any hospital, government or private, licensed withthe Bureau of Medical Services.(g) Medical Practitioner. — Any Doctor of Medicine duly licensed topractice in the Philippines and an active member of good standing ofthe Philippine Medical Association.(h) Confinement. — Confinement in a hospital defined in Section35 (f), due to sickness or bodily injury.(i) Single Period of Confinement. — A continuous period ofconfinement or periods of confinement for the same or any relatedillness, injury or condition not separated from each other by morethan ninety days.( j) Commission. — Philippine Medical Care Commission createdunder this Act.(k)II.Service Beds. — Beds reserved for beneficiaries under Program(l) Community Mutual Health Funds. — Funds accruing from thecontributions of residents in each chartered city or municipality, plusthe one hundred percent (100%) government counterpart funds.

(m) Administrator. — Refers to the Administrator of theCommission, unless specified otherwise.SECTION 36. Study and Research. — Immediately upon itsorganization, the Commission shall undertake actuarial studies forthe purpose of determining the contributions necessary in order toinsure adequate financing and disbursement of funds to allparticipants of the plan and the extent and scope of benefits of thebeneficiaries of the plan. chanroblespublishingcompanyImmediately upon completion of such study, the Commission shallsubmit to Congress a report with its recommendations as to theamount to be assessed from each resident or inhabitant covered bythe plan for purposes of legislation by Congress. chanroblespublishingcompanySECTION 37. Penal Provisions. —(a) Any person, who for the purpose of securing entitlement to anybenefit or payment under this Act or the issuance of any certificate ordocument for any purpose connected with this Act, whether for himor for some other person, commits fraud, collusion, falsification,misrepresentation of facts or any other kind of anomaly shall bepunished with a fine of not exceeding one thousand pesos orimprisonment not exceeding one year or by both such fine andimprisonment, at the discretion of the court; and(b) Any contribution or other amount collected by the treasurer, asprovided for under Section 28 of this Act, shall not be used,appropriated or diverted for a purpose other than that authorized bythis Act. Any person violating this provision shall be punished withimprisonment for not less than one year nor more than five years orwith a fine of not less than one thousand pesos, nor more than fivethousand pesos or by both such imprisonment and fine, at thediscretion of the court.SECTION 38. Separability Clause. — In the event any provision ofthis Act or the application of such provision to any person orcircumstance is declared invalid, the remainder of the Act or theapplication of said provision to other persons or circumstances shallnot be affected by such declaration.

SECTION 39. Repealing Clause. — All laws, executive orders, andadministrative rules and regulations or parts thereof which areinconsistent with the provisions of this Act are hereby repealed ormodified accordingly: Provided, however, That nothing in this Actshall be construed to remove or eliminate the present powers andfunctions of existing agencies involved.SECTION 40. Appropriation. — The sum of one million pesos ishereby appropriated out of any funds in the National Treasury nototherwise appropriated for the initial organizational expenses of theCommission and the Medical Care Councils, as provided for inSections 29, 30 and 31. Thereafter, the necessary funds for the yearlyoperation of the above-mentioned agencies shall be incorporated inthe General Appropriations Act. chanroblespublishingcompanySECTION 41. Effectivity. — Program I shall be implementedimmediately and upon the effectivity of this Act.Program II shall be implemented in the manner and time to bedetermined by Congress upon recommendation of the Commission.Approved: August 4, 1969chanroblespublishingcompany

IMPLEMENTING RULES AND REGULATIONSOF PROGRAM I OF THE REVISEDPHILIPPINE MEDICAL CARE ACTPursuant to Section 6 of Presidential Decree No. 1519, as amended,otherwise known as the Revised Philippine Medical Care Act definingthe functions, powers and duties of the Philippine Medical CareCommission, to wit:(a) To formulate policies for, administer and implement theMedical Care Plan.(b) To promulgate or prescribe rules and regulations necessary tocarry out the provisions and purposes of the Revised Medical CareAct.the implementing rules and regulations are hereby amended asfollows:RULE IDefinition of TermsSECTION 1. For purposes of these rules, the following termsshall be understood as:(a) ACCREDITED BED CAPACITY — Number of hospital bedsauthorized by the Commission to be used for Medicare purposes.(b) ADMINISTRATIVE ORDERS — Written promulgation in theform of PMCC Resolutions, Medicare Circulars, MemorandumCirculars, Special Orders, and Office Orders issued and dulycircularized by the Commission, pertaining but not limited toconducting, directing or superintending the execution, application orconduct and affairs of the Program as embodied in the Medicare Law,

R.A. 6111 as amended by P.D. 1519 and its Implementing Rules andRegulations including Medicare accreditation warranties.(c) BENEFICIARIES — The Medicare members and their legaldependents.(d) CIRCUMSTANCE — Any attendant situation present in a givencase which tends to exempt or aggravate the violation and liability ofthe respondent.(e) COMMISSION — The Philippine Medical Care Commissioncreated under R.A. 6111, as revised.(f) CONFINEMENT — Admission and stay in a hospital due toillness or bodily injury, medical and/or surgical, requiringhospitalization.(g) DIAGNOSTIC/TREATMENT TERMINOLOGY — Terminologywhich conforms with the American Standard of Nomenclature ofDiseases and Operations or the International Classification ofDiseases.(h) EMERGENCY — Means medical and surgical conditions thatthreaten immediate loss of life when not attended to.(i) GSIS — The Government Service Insurance System createdunder Commonwealth Act 186, as amended.(j) HOSPITAL — A health care facility with an organization ofprofessional health workers and supportive personnel housed in aphysical plant having adequate facilities and equipment to rendermedical care and ancillary health services on an out-patient and inpatientbasis, duly licensed by the Department of Health, member ingood standing of a national association of government and privatelyownedhospitals whose membership comprises the majority oflicensed hospitals in the Philippines, and with a continuing programfor hospital administration and discipline of its members, accreditedand categorized by the Commission under such terms and conditionsas it may set.

(k) LEGAL DEPENDENT — The legal dependents of a member are:1) the legitimate spouse who is not a Medicare member; 2) theunmarried and unemployed legitimate, legitimated, acknowledgedchildren as appearing in the birth certificate; legally adopted orstepchildren below 21 years of age; 3) children who are suffering fromcongenital disability either physical or mental, or any disabilityacquired below the age of 21 that renders them totally dependentupon the member for support; 4) the parents who are 60 years oldand above whose income is P1,000.00 or less a month.(l) MEDICARE SERVICE BEDS — Hospital beds set aside forbeneficiaries as may be prescribed by the Commission, and whenoccupied by a Medicare beneficiary, no fees beyond Medicare ratesshall be charged to the account of the beneficiary.(m) MEDICINE — A drug, mixture of drugs, active principle,chemical product, preparation mixtures or combination of drugsintended for cure and/or prevention of complications orrehabilitation.(n) MEMBER — Any person covered by SSS or GSIS eithercompulsorily or by special coverage.(o) OPERATING ROOM COMPLEX — Means emergency room,delivery room, operating room, and recovery room.(p) OTHERS — All items used in the management of the patientexcluding medicine, consisting of but not limited to syringe, gloves,vaco sets, butterfly, including contrast media and other agents used inestablishing the correct diagnosis and treatment of the patient.(q) PRACTITIONER — Any doctor of medicine or dental medicineduly licensed/authorized to practice in the Philippines, a member ingood standing of a national association of government and privatelyemployedphysicians or dentists whose membership comprises themajority of registered practicing physicians or dentists in thePhilippines and with a program of continuing medical education anddiscipline for its members, and accredited by the Commission undersuch terms and conditions as it may set.

(r) PROVIDER — A practitioner, hospital, or other persons orfacilities engaged in health care services and accredited by theCommission under such terms and conditions as it may set.(s) RELATIVE UNIT VALUE — Points assigned to surgicalprocedures according to their comparative complexity as adopted bythe Commission.(t) SINGLE PERIOD OF CONFINEMENT — A single confinementor series of confinements for the same illness, with intervals of notmore than ninety (90) days.When a patient is admitted in the same or another hospital withinfive (5) days immediately following a previous discharge, such patientshall be deemed to be suffering from the same illness unless the chiefcomplaints, clinical manifestations, and the course of managementare entirely different from its first confinement.(u) SSS — The Social Security System created under R.A. 1161, asamended.(v)(w)SYSTEM — The GSIS or SSS as the case may be.VIOLATION — Any act or omission constituting infraction of:1) the provisions of P.D. 1519, as amended; and/or2) the Medicare implementing rules and regulations; and/or3) the warranties of accreditation; and/or4) administrative orders of the Commission; and/or5) other Medicare related laws, decrees, and regulations.RULE IICoverageSECTION 1. The nature and scope of coverage under thePhilippine Medical Care Act shall be compulsory on all persons

covered by the SSS or GSIS including existing laws covering retireesfrom the government service and other special coverage.SECTION 2. Registration of Membership. — Registration andrecording of members shall be according to the respective charters ofthe System.SECTION 3. Dual Membership. — A person covered by bothSystems may choose under which System he shall be covered forpurposes of Medicare under such procedures as may be circularizedby the Commission.RULE IIIBenefitsThe benefits under the Medicare Act consist of the following: hospitalroom and board; medical expense consisting of medicines, x-ray,laboratory examinations, and others; professional fees which includesurgical, medical/dental, and anesthesiologist fees; operating roomfees; and surgical family planning procedures (sterilization benefits).SECTION 1. Entitlement to Benefits. — A beneficiary shall beentitled to benefits if he meets the following conditions:(a) He is confined in a hospital due to illness or injury requiringhospitalization; or undergoes a surgical procedure in the operatingroom complex on an out-patient basis or receives chemotherapy,radiotherapy, or hemodialysis similarly on an outpatient basis.(b) The member has paid at least three (3) monthly contributionsthrough salary deduction within the immediate twelve (12)-monthperiod prior to the first day of confinement; provided that in the caseof a self-employed member, he shall have qualified under theregistration rules of SSS and has paid the aforementioned monthlycontributions prior to the first day of confinement.(c) The 45-day room and board allowance for the calendar year hasnot been consumed.

SECTION 2. Types of Benefits. — A beneficiary of Program I whois confined in a hospital on account of sickness or injury requiringhospitalization is entitled to confinement days per calendar year asfollows: a) Maximum of forty-five (45) days for members; and b)maximum of forty-five (45) days for all dependents. Any unusedbenefits for any prior year shall not be carried over to the succeedingyear. The benefits for such confinement shall not exceed thefollowing:(a)ALLOWANCE FOR HOSPITAL ROOM AND BOARD PER DAY:BENEFICIARIESMEMBERSHIPHOSPITAL CATEGORYPRIMARY SECONDARY TERTIARYSSS P30 P35 P45GSIS 20 24 33(b) ALLOWANCE FOR MEDICAL EXPENSE PER SINGLEPERIOD OF CONFINEMENTFOR SSS BENEFICIARIESMEDICAL EXPENSEBENEFITSHOSPITAL CATEGORYPRIMARY SECONDARY TERTIARY1. ORDINARY CASES:Drugs & Medicines P175 P200 P300X-ray/Lab./Others 75 150 3502. INTENSIVE CARE CASES:Drugs & Medicines 375 400 500X-ray/Lab./Others 125 200 5003. CATASTROPHIC CASES:Drugs & Medicines 800 1,000X-ray/Lab./Others 400 1,000

FOR GSIS BENEFICIARIESMEDICAL EXPENSEBENEFITSHOSPITAL CATEGORYPRIMARY SECONDARY TERTIARY1. ORDINARY CASES:Drugs & Medicines P150 P175 P250X-ray/Lab./Others 50 75 1002. INTENSIVE CARE CASES:Drugs & Medicines 250 300 350X-ray/Lab./Others 100 125 2503. CATASTROPHIC CASES:Drugs & Medicines 400 450X-ray/Lab./Others 150 300CATASTROPHIC CASES shall include the following:1. Illnesses or injuries such as cancer cases requiringchemotherapy and/or radiotherapy, meningitis, encephalitis,cirrhosis of the liver, myocardial infraction, cerebrovascular attack,rheumatic heart disease — Grade III, renal conditions requiringdialysis or transplant, massive hemorrhage;2. Surgical procedures or multiple surgical procedures done in onesitting with a total Relative Unit Value of 20 and above such ascoronary bypass, open heart surgery, neurosurgery shall beconsidered catastrophic.INTENSIVE CARE CASES shall include the following:1. All confinements in an intensive care unit other than thoseclassified as catastrophic;2. Other similar serious illnesses or injuries such as cancer,pneumonia, moderately and far advanced pulmonary tuberculosis

including its complications, cardiovascular attack, diseases of theheart, chronic obstructive pulmonary disease, liver disease, typhoidfever, H-fever, kidney disease, septicemia, diarrhea with severedehydration, severe injuries, black water fever;3. Surgical procedure or multiple surgical procedures done in onesitting with a total Relative Unit Value of 8 and above but notexceeding 10.99 shall be considered as intensive care cases.ORDINARY CASES are illnesses or injuries other than those includedin the above enumeration.For purposes of reimbursement of medicines, a mark-up of not morethan 50% of the price based on the latest and updated issue ofPhilippine Index of Medical Specialties (PIMS) shall be adopted.(c)ALLOWANCE FOR PROFESSIONAL FEES1. Medical/Dental Practitioners fee of P15.00 per day but not toexceed P200.00 for ordinary cases and P300.00 for intensive care orcatastrophic cases per single period of confinement.2. Surgeons fee not exceeding P650.00 shall be paid in accordancewith the Relative Unit Value promulgated by the Commission.The surgeons fees shall include two (2) days of pre- and five 5 dayspost-operative care.Surgical procedures without any assigned Relative Unit Value shall beevaluated taking into consideration its similarity to existingprocedures.Two or more surgical procedure done through the same incision shallbe considered as a single procedure and shall be paid based on thehighest Relative Unit Value.A qualified beneficiary who undergoes surgical procedure in thehospital operating room complex on an out-patient basis is entitled tobenefits provided that one day is deducted from his forty-five (45)-day room and board benefits.

All claims for surgical expense shall be made by listing the operationas appearing in the Standard Nomenclature of InternationalClassification of Surgical Procedures.3. Anesthesiologists fee not exceeding thirty percent (30%) of theallowable Surgeons fee.To be entitled to the above fee, the following must be observed:a. Only one anesthesiologist shall be compensated for eachoperation.b. Local anesthesia is not compensable except when it is a regionalnerve block anesthesia.c. When the operating surgeon administers anesthesia himself, noseparate anesthesiologists fee shall be allowed.(d) ALLOWANCE FOR OPERATING ROOM FEE:SURGICAL PROCEDURE WITH HOSPITAL CATEGORYRELATIVE UNIT VALUE OF: PRIMARY SECONDARY TERTIARY0 — 5 P30 P35 P655.1 — 10 — 120 16510.1 — above — 170 225(e) SURGICAL FAMILY PLANNING PROCEDURES(STERILIZATION BENEFITS):The following procedures are compensable under Medicare:1. Vasectomy P200.00Hospital services & medicines P120.00Professional fees 80.002. Tubal Ligation P300.00Hospital services & medicines P180.00Professional fees 120.00

SECTION 3. Exclusions. — The above benefits shall not includeexpenses for the following:(a) Cosmetic surgery or treatment — surgery or treatment topreserve, enhance or restore comeliness, the primary purpose ofwhich is to beautify or bring about aesthetic effects;(b)(c)Optometric services;Psychiatric illness;(d) Services which are purely diagnostic in nature such as routingphysical and medical examinations, executive check-ups, and similarmedical diagnostic services;(e) Normal obstetrical delivery — any vaginal delivery which is notcomplicated by eclampsia, retained placenta, profuse bleedingrequiring surgical intervention, breech extraction or similarcomplications.SECTION 4. Requirements for Availment of MEDICAREBenefits:(a)Members:1. A member must present to the hospital a duly accomplishedPMCC Form I.2. A self-employed member must present a true copy of hisregistration and receipt of payment (SSS Form, RS-5).3. A retiree from the public sector must present a certificate orother evidence to prove that he is a qualified retiree from the publicservice such as annuity voucher or xerox copy of approved retirementapplication.(b)Dependents:1. Dependent parents/spouses/children — submission of a dulyaccomplished PMCC Form I shall be prima facie evidence of

dependency status. Verification of the status of the dependent by theSystem shall not suspend the usual processing of the claim andpayment to the hospital and medical or dental practitioner withoutprejudice to whatever recourse the System may take against themember. Whenever there is a need, it shall be the obligation of themember to furnish the corresponding System through his employerwith an updated list of his legal dependents as defined herein. In thecase of a newly born dependent, a certified xerox copy of the birthcertificate shall be submitted.SECTION 5. Benefits of Members while Abroad. —(a) A member, including his legal dependents, who is abroad shallbe eligible to Medicare benefits while outside the country providedthe conditions for entitlement in Section 1(b) and (c) of this Rule aremet.(b) The medical care benefits to be granted shall be in accordancewith the provisions of Section 12 of P.D. 1519, as amended.SECTION 6. Benefits of Patients Confined in Service Beds. —The cost of medical care services of patients confined in Medicareservice beds shall be limited to the prescribed medical care benefitallowances.RULE IVPayment of ClaimsSECTION 1. General Provisions. —(a) A member shall be free to choose from among the accreditedhospitals and physicians. However, when he has no choice ofphysicians, he shall be considered under the care of the medical staffof the hospital.(b) The hospital and the attending physician shall file their claimsthrough the prescribed PMCC forms.(c) All claims for payment of services rendered shall be filed withinsixty (60) calendar days from the day of discharge of the patient or

from the time that he has been declared well, otherwise the claimshall be barred except in case of force majeure. If the claim is sentthrough the mail, the date of mailing as stamped by the Post Office oforigin shall be considered as the date of filling.A claim returned by the System for completion of supportingdocuments must be refiled within 120 days from its receipt by thehospital.(d) When the beneficiary has complied with the requisites foravailment as Medicare patient under Section 4 of Rule III, thehospital and the practitioner shall deduct from the hospitalizationcosts all expenses reimbursable by Medicare; Provided, that in highlyexceptional circumstances as may be determined by the System, thebeneficiary may be directly reimbursed of his or her expensesallowable under Rule III of these Rules.(a) The System may deny or reduce any benefit provided by thePhilippine Medical Care Plan when the beneficiary:1. Fails without good cause or legal ground to comply with theadvice of the medical practitioner with respect to the hospitalization;or2. Furnishes false or incorrect information concerning any matterrequired by law or the Rules and Regulations on Medicare.In such cases, the member may be required to pay for the amountdenied or reduced except when false information was supplied by theemployer, in which case the System shall intervene in behalf of themember or the hospital against the employer.The System may deny or reduce any benefit provided by thePhilippine Medical Care Plan when the health provider:1. Furnishes false or incorrect information concerning any matterrequired by law or the Rules and Regulations of Medicare; or2. Fails to comply with any provision of the Rules and Regulationsgoverning the Medicare Program.

When the claim is reduced or denied, the amount thus reduced ordenied shall not be charged directly or indirectly to the beneficiaryinvolved unless the latter is directly responsible for the cause of suchreduction or denial. Any and all actions taken by the System on theclaims may be appealed to the Commission whose decision shall befinal.(f) Primary hospitals are required to submit clinical records ofpatients in connection with their Medicare claims.(g) Family-owned secondary and tertiary hospitals which haveviolated rules and regulations may be required, uponrecommendation of the Hearing Committee, to submit the same untilsuch time that the Commission lifts such requirements.(h) All employee hospitalization claims not compensable under theEmployees’ Compensation Program shall be automatically consideredas a claim under the Medicare Program provided that the claim hasbeen filed within the reglementary period of sixty (60) days.(i) When the bed census as reflected by claims filed with theSystem exceeds its accredited bed capacity, such claims shall beaccompanied by justification in writing, otherwise these shall not begiven due course.(j) Any operation performed beyond the authorized capability ofthe hospital shall be considered a violation, except when done inemergency to save life or referral to a higher category hospital isphysically impossible. Primary care hospitals shall be compensatedonly for simple operations as listed by the Commission.RULE VCollection/Remittance of ContributionsSECTION 1. Rates of Contributions. — Contributions shall beshared equally by the employer and the member in conformity withthe following schedules:

SALARY MONTHLY SALARY CONTRIBUTION EMPLOYERS EMPLOYEES TOTALBRACKET WAGE OR EARNING BASE CONTRIBUTION CONTRIBUTIONNUMBER1 Below - P49.99 P25.00 P0.30 P0.30 P0.602 50.00 - 99.99 75.00 0.95 0.95 1.903 100.00- 149.99 125.00 1.55 1.55 3.104 150. - 199.99 175.00 2.20 2.20 4.405 200.00- 249.99 235.00 2.80 2.80 5.606 250.00-349.99 300.00 3.75 3.75 7.507 350.00-499.99 425.00 5.35 5.35 10.508 500.00-699.99 600.00 7.50 7.50 15.009 700.00-899.99 800.00 10.00 10.00 20.0010 900.00-Over 1,000.00 12.50 12.50 25.00SECTION 2. Collection of Contributions. —(a) The members contribution shall be deducted and withheld bythe employer from the formers salary, wage or earnings. Failure of theemployer to deduct the same shall not be a basis for invalidation of aproperty filed claim.(b) The employers counterpart contribution shall not in anymanner be recovered from the employee.SECTION 3. Remittance of Contribution. — The monthlycontribution of members shall be remitted by the employer directly tothe System, as the case may be, in accordance with the respectiverules and regulations. Remittance shall be accompanied by theappropriate forms.Failure of the employer to remit to the System the correspondingemployees and employers contribution shall not be a reason fordepriving the beneficiary of his benefits under the law.RULE VIEffect of Separation, Re-Employment or TransferSECTION 1. Separation from Employment. —(a) When a covered employee is separated from employment, hisemployers obligation to remit the applicable Medicare contributions

on his behalf ceases from the date of separation. The separatedemployee may elect to continue his Medicare membership by giving awritten notice to the System and paying the same monthly Medicarecontribution representing the employers and his own.(b) The option to continue membership shall be approved whenexercised within six (6) months following date of separation. If hefails to pay the corresponding contributions after the option tocontinue has been exercised, the membership is terminated.SECTION 2. Effect of Re-Employment. — Should the separatedemployee be re-employed, his new employer shall assume theobligation of reporting and remitting the monthly contribution basedon the employees covered wage under his new employment.SECTION 3. Transfer of Membership. — When an employeetransfers from private to government employment, his medical carecoverage under the SSS shall cease when he becomes covered underthe GSIS. When the transfer is from government to privateemployment, medical care coverage under GSIS shall cease when theemployee is covered under SSS. Provided, the rights of the beneficiaryunder Section 15 of the Medical Care Law shall not be prejudiced. Theobligation to remit contributions shall be on the basis of hisemployment. The employee and the employer shall jointly notify theSystem of such transfer of employment.RULE VIIAccreditationSECTION 1. Prerequisites. — A hospital may be accredited if itsatisfies the following prerequisites:(a)It must be licensed by the Department of Health;(b) It must be a member in good standing of a national associationof government and privately-owned hospitals whose membershipcomprises the majority of licensed hospitals in the Philippines andwith a continuing program for hospital administration and disciplineof its members;

(c) It has been in operation for at least twelve (12) months prior toaccreditation.SECTION 2. Prerequisites. — A practitioner may be accredited ifhe satisfies the following prerequisites:(a)He must be licensed to practice in the Philippines; and(b) He must be a member in good standing of a national associationof government and privately-employed physicians or dentists whosemembership comprises the majority of licensed physicians/dentistsin the Philippines and with a program of continuing medicaleducation and discipline of its members.SECTION 3.Terms and Conditions:(a) The hospital must comply at all times during the period ofaccreditation with all the requisites of R.A. 4226 otherwise known asthe Hospital Licensure Act and its Implementing Rules andRegulations, and other DOH Administrative Orders;(b) The practitioner must comply at all times with the Code ofEthics as prescribed under Section 24, Paragraph 12 of the MedicalAct of 1959, as amended;(c) The hospital and practitioner must comply at all times duringthe period of accreditation with all the requirements of the MedicareLaw, including its Implementing Rules and Regulations, warranties ofaccreditation, and other administrative orders of the Commission;(d) Hospitals and Medicare providers agree to have their pendingclaims with the System be applied in satisfaction of the fine imposed,if any, as provided under Rule X, Section 15(d).SECTION 4. Period of Accreditation. — The period ofaccreditation shall be for two (2) calendar years for hospitals andthree (3) calendar years for practitioners to take effect upon theapproval by the Commission.

SECTION 5. Accreditation Fees. — For purposes ofdocumentation and processing of applications for accreditation ofMedicare providers, the Commission shall impose accreditation feesas may be circularized from time to time.SECTION 6. Commission Option. The Commission has theoption to accredit a number of beds less than the authorized bedcapacity per DOH license.SECTION 7. Denial of Accreditation. — The Commission maydeny accreditation where there is saturation of accredited hospitalsbased on the national hospital bed to population ratio or otherstandard as determined by the DOH or the renewal of suchaccreditation where there is a prima facie evidence of violation of thelaw and these rules and regulations.RULE VIIIPayment of MEDICARE Benefits of Members AbroadSECTION 1. Requirements. — The requirements shall includethe following documents (in addition to the pertinent requirementsfor settlement of claims):(a) Statement of account or the official receipt of payment from theforeign hospital where the patient was confined;(b) Certification of the attending physician as to the final diagnosis,period of confinement, and services rendered.SECTION 2. Manner of Payment. — Payment shall be made tothe beneficiary in Philippine Currency.RULE IXSupervision and/or InspectionSECTION 1. The Commission and/or the System may exercisesupervision through authorized representatives to perform suchfunction.

SECTION 2. For purposes of inspection, all providers arerequired to give access to the medical records of Medicare patients toduly authorized representatives of the Commission and/or theSystem. Such representatives are likewise authorized to inspect thephysical plant and equipment thereof.SECTION 3. Whenever necessary and with the consent of thepatient or the attending physician or director of the hospital, theCommission and the System representatives may conductexaminations on Medicare patients during confinement to determinewhether laboratory procedures were actually performed ormedications and/or treatment were actually administered.RULE XHearing ProceduresIn accordance with Section 29 of Presidential Decree No. 1519, asamended, the rules for hearing and/or investigation of cases orviolation of Medicare Law and its Implementing Rules andRegulations shall be as follows:SECTION 1. Grounds for Investigations. — Investigation shall beconducted by the Hearing Committee upon proper complaint for anyviolation of the following:(a)(b)(c)(d)(f)the provision of P.D. 1519 as amended;its Implementing Rules and Regulations;the warranties of accreditation;administrative orders of the Commission;other subsequent Medicare related laws and regulations.SECTION 2. Complaint. — The System, the Commission, anyperson, firm or corporation may file a complaint against any person,Medicare provider, and other juridical entities provided thatcomplaints other than those filed by the System and the Commissionshall be under oath.

The complaint shall state the name, residence, and such otherpersonal circumstances of the complainant and those of therespondent, the substance of the facts and acts constituting theviolation charged, the grounds of action and the relief sought. Thecomplaint shall contain evidence in support of the complaint.A complaint may be withdrawn by the complainant in writing whichshould also be verified. The Commission shall forthwith dismiss thecomplaint unless the Commission, for reasons of public interest, shalldeem it necessary to prosecute, notwithstanding its withdrawal by thecomplainant.SECTION 3. Summons. — The Hearing Committee, upon receiptof the complaint filed by the proper office or person, shall issuesummons either by personal service or by registered mail to therespondent at his last known address or to his/her/its dulyauthorized representative or to any persons having charge thereofattaching thereto copies of the complaints and other documentsnecessary to inform the respondent of the charges against her/him/it.SECTION 4. Answer. — Within fifteen (15) days from receipt ofthe summons, the respondent shall file his/her/its answer in writingand under oath, submitting six (6) copies thereof. The answer shallcontain either an admission or specific denial of the materialallegations in the complaint, or explanation why no action shall betaken against him/her/it. Failure to specifically deny the allegationshall be deemed an admission.Failure of the respondent to answer as prescribed shall be a waiver ofrespondents right to present evidence on his/her/its behalf and theHearing Committee shall proceed to deliberate on the case.SECTION 5. Deliberation of the Hearing Committee. — After theanswer has been received by the Hearing Committee or after the 15-day period within which the respondent should file his/her/its answerhas lapsed, the case shall be scheduled for deliberation. The HearingCommittee, for the purpose of this Rule, may sit en banc or indivision. It shall sit en banc in cases of motions for reconsiderationand petitions for reconsideration of Preventive Suspension.

The Hearing Committee, in its deliberation or hearing, may render itsfindings in accordance with the facts presented or may, when deemedproper, issue either an order setting the case for formal hearing or anorder of referral to the duly authorized investigating body or officerwhich shall conduct fact-finding investigation in accordance with theprovisions of Section 6 hereof.SECTION 6. Order of Referral and Fact-Finding Investigation. —(a) The order of referral shall contain the specifications ofguidelines as to what problem areas or issues the Committee wants tobe clarified, informed, or enlightened.(b) Within twenty-one (21) working days from receipt of the orderof referral from the Hearing Committee, the investigating body orofficer shall conduct investigation in accordance with the following:1. In case the Hearing Officer or a member of the investigatingbody shall be involved directly/indirectly in the complaint underinvestigation, he/she shall abstain or inhibit himself/herself from theinvestigation. The respondent shall be afforded ample opportunity tobe heard in person and/or thru counsel during the investigation.2. The minutes of the investigation shall be duly recorded,transcribed, and attested to by the Hearing Officer or members of theinvestigating body, as the case may be.(c) Within thirty (30) days after the termination of theinvestigation, the investigating body or Hearing Officer shall forwardits/his findings and recommendations to the Hearing Committee,attaching thereto all the transcribed stenographic notes, if any, andsuch documents and other papers presented at the investigationpertinent to the case. In case the investigation is not terminatedwithin the 21-day period, the investigating body or Hearing Officershall submit to the Hearing Committee an explanation or informationin writing about the delay.Upon receipt of the findings and recommendations of the body, theHearing Committee shall convene within thirty (30) days to resolve

the case with the report as its basis or to conduct further hearingswhen deemed necessary.SECTION 7. Hearing. — In case the Hearing Committee in itsdeliberation deems it necessary to conduct furtherhearing/investigation, the parties shall be notified in writing of thescheduled date thereof.A subpoena or subpoena duces tecum or both may be issued by theChairman of the Committee or his duly authorized representative tocompel attendance of witnesses or the production of books, papers,and other records deemed necessary in connection with any questionpending before the Hearing Committee.The filing of a criminal case involving the same facts in theadministrative case shall not suspend proceedings in the latter case.SECTION 8. Contempt. —(a) Direct Contempt. A person guilty of misbehavior in thepresence of or so near the Chairman or any member of theCommission, or of the Chairman or any member of the HearingCommittee as to obstruct or interrupt the proceedings before thesame, including disrespect toward said officials, offensivepersonalities towards others, or refusal to be sworn or to answer as awitness or to subscribe an affidavit or deposition when lawfullyrequired to do so may be summarily adjudged in Direct Contempt bysaid officials and punished by a fine not exceeding One HundredPesos (P100.00) or imprisonment not exceeding two (2) days or bothif it be in the presence of the Chairman of the Commission or amember thereof, or by a fine not exceeding Fifty Pesos (P50.00) orimprisonment not exceeding one (1) day or both if it be in thepresence of the Chairman of the Hearing Committee or a memberthereof. Judgment of Direct Contempt is immediately executory andunappealable in court.(b) Indirect Contempt shall be dealt with by the Commission orHearing Committee in the manner prescribed under Rule 71 of theRevised Rules of Court.

SECTION 9. Ex-parte Proceedings. — In case of failure of eitherparty to appear at the time of hearing despite due notice, the HearingCommittee shall proceed to receive evidence ex-parte and decide onthe basis of evidence adduced.SECTION 10. Order of Hearing. —(a) The lawyer of the Commission in charge of the case shall informthe members of the Hearing Committee of the nature of thecomplaint and/or status of the case every hearing thereafter.(b) The complainant shall then proceed with the presentation of itsevidence, oral or documentary. The complainant, his/her/its witnessshall be subject to clarificatory questions by the respondent or by themembers of the Hearing Committee.(c) After the complainant has presented all his/her/its evidences,the respondent shall then proceed to present his/her/its evidences,oral or documentary, to support his/her/its answer. The respondent,his/her/its witnesses shall be subject to clarificatory questions by themembers of the Hearing Committee. Presentation of rebuttal and/orsurrebuttal evidence may be allowed upon motion by the properparty.SECTION 11. Hearing Committee Resolution. — After thedeliberation or hearing, the Hearing Committee shall immediatelysubmit its findings and recommendation in the form of resolution tothe Commission signed by all members who participated therein and,shall contain clearly and distinctly the findings of facts and of the lawwhich were the basis of the recommendation.SECTION 12. Motion for Reconsideration. — A party not satisfiedwith the decision of the Commission may file a motion forreconsideration with the Commission in at least six (6) copies withinthe period for perfecting an appeal provided for in Section 13 thereof.The motion for reconsideration shall clearly point out the followinggrounds:(a)Error of law and/or fact relied upon by the party;

(b) Newly discovered evidence or fact which could not withreasonable diligence be discovered and produced at the hearing andwhen presented would probably alter the result of the investigation;and(c) Fraud, accident, mistake, or excusable negligence whichordinary prudence could not have guarded against and by reason ofwhich the right of the aggrieved party may have been impaired, whichif true and correct shall validly justify a consideration of the decision,otherwise, the same shall be deemed a pro-forma motion, hence, willnot be given due course and therefore will not stay the running of theperiod after which the decision becomes final and executory inaccordance with Section 13 hereof. Only one motion forreconsideration shall be entertained by the Commission.SECTION 13. Finality of Decision. — The decision of theCommission on the case shall become final and executory after thelapse of thirty (30) days from receipt of the decision by the parties.Within and before the lapse of the said period of appeal, the partyconcerned may file a Motion for Reconsideration or Appeal whichshall stay the running of the thirty (30)-day prescriptive period.SECTION 14. Appeal. — The party who is not satisfied with thedecision of the Commission may appeal the same to the Commissionwithin thirty (30) days from his receipt of the decision in accordancewith the procedure established under Administrative Order No. 18dated February 12, 1987.SECTION 15. Execution/Enforcement Decision. —(a) A writ of execution shall be issued only upon a decision or orderthat finally disposes of the case or proceedings. Such execution shallbe issued upon the expiration of the period to appeal therefrom if noappeal has been duly perfected, or if the appeal is denied.(b) The penalty of suspension or revocation shall be enforced by thetemporary or permanent cessation, as the case may be, of theprivilege and benefits under the Medicare Program. In which case,both Systems shall be duly advised in writing of the same.

Where the respondent is meted the sanction of fine, the Commissionshall issue a writ of execution enforceable in accordance with theRules of Court.(c) Except when the respondent voluntarily pays the fine withinfifteen (15) days before the finality of decision, the Committee maymotu propio issue a writ of execution for the purpose.(d) Where a respondent has a pending claim for payment from theHealth Insurance Fund (HIF), the fine imposed on such respondentmay be enforced against the proceeds of such claim.The System, upon receipt of the decision of suspension or revocationof accreditation and fine, shall immediately given notice as to theexistence of such claim of the respondent. Upon order from theCommission, the System shall remit to the Commission so muchamount charged against the claim in satisfaction of the fine.SECTION 16. Applicability of the Provisions of the Rules of Court.— Provisions of the Rules of Court which are consistent herewith mayserve to supplement the provisions herein provided.RULE XIPreventive SuspensionSECTION 1. At any time after proper complaint has been filed inaccordance with Rule X and pending the hearing and/or investigationof the case, the Hearing Committee hearing the case may preventivelysuspend any respondent beneficiary or provider from participation inthe Medicare Program if any of the following circumstances ispresent:(a) When the respondent has been found guilty of a violation ofPresidential Decree No. 1519, as amended, or of its rules andregulations at least twice and there is reasonable ground to believebased on evidence that the respondent is guilty of the present charge.(b) When the respondent, at the time of an authorized inspectionthereof, has committed or is committing a violation.

SECTION 2. The preventive suspension order should contain orincorporate, by reference documents containing a recital of theantecedent facts and circumstances mentioned in the precedingsection, serving as basis for its issuance. The order shall, likewise:(a) specify the violation charged, citing also the particular evidencegathered or available in support of the violation;(b) require the respondent to answer the charge within a period often (10) days from the date the respondent receives the order;(c) require the respondent to appear on the date set for the hearingof the case; and(d) state the period of the suspension, which period shall notexceed three (3) months from the date of its issuance.SECTION 3. The order, being interlocutory in nature, shall beunappealable but a petition for reconsideration thereof may be filedwith the Commission through the Hearing Committee. The merefiling of such petition shall not stay the preventive suspension orderissued but the resolution of any petition for reconsideration shall notbe delayed unnecessarily.SECTION 4. When the hearing/deliberation and/or investigationof the case is not terminated within the period of suspension stated inthe order, the preventive suspension order issued shall beautomatically lifted after the expiration of such period stated in theorder, except when the cause of non-termination is attributable to therespondent.SECTION 5. The actual period of preventive suspensionundergone or served by the respondent shall be credited in the serviceof the penalty of suspension that may be finally imposed upon therespondent in the decision of the case, in accordance with Section 15of Rule X.

RULE XIIPenaltiesIn the promulgation of decision, order or ruling of penalty forviolations of Medicare Law, Rules and Regulations, Warranties ofAccreditation, Administrative Order, the Hearing Committee shall beguided as follows:PART IGeneral ProvisionsSECTION 1. Classification of Violation according to Gravity. —(a) Serious violations are those that carry a penalty of fine of ThirtyThousand Pesos (P30,000.00) and revocation of accreditation withnon-accreditation for twenty-four (24) months or permanentrevocation of accreditation. In case of permanent revocation, arecommendation will be submitted to the Department of Health forcancellation of license to operate.(b) Less serious violations are those that carry a penalty of fine ofFive Thousand Pesos (P5,000.00) or Fifteen Thousand Pesos(P15,000.00) and suspension from participation in the MedicareProgram of six (6) months or one (1) year.(c) Special less serious violations are breach of warranties andviolations committed by beneficiaries which carry a penalty of three(3) or six (6) months suspension for the former and a fine of FiveThousand Pesos (P5,000.00) and a suspension from availing ofbenefits for three (3) or six (6) months for the latter.SECTION 2. Circumstances. — The following circumstances shallaffect the gravity of the violation and the liability of the respondenthospital or practitioner or beneficiary in the commission of theviolation(s).(a) Exempting Circumstances. The presence of force majeure shallexempt any hospital or practitioner or beneficiary from the liabilityfor the violations except civil liability.

(b) Aggravating Circumstances. The following circumstances shallincrease the liability for the violation from low to high:1. Previous commission of two or more violations where thehospital, practitioner, or beneficiary had been found guilty within aperiod of two (2) years;2. Connivance;3. Laxity or negligence in the preparation of Medicare claims,clinical records, and supporting documents;4. Willful operation without license and/or accreditation;5. Machinations; and6. Membership in the Commission or in any of its intermediaries.Provided, that when the aggravating circumstance is a violation initself, it shall be treated as such and shall not be considered asaggravating circumstance anymore.SECTION 3. Rules for the Application of Circumstances. —(a) The presence of the exempting circumstance regardless of anyaggravating circumstances makes the violation non-penalizable,except the denial of the claim or refund of claim already paid.(b) The presence of any aggravating circumstance shall increase thepenalty of the violation from low to high.SECTION 4. Scale Penalties. — The scale or graduation ofpenalty shall be as follows:(a)For Serious Violations:High Penalty — a fine of Thirty Thousand Pesos (P30,000.00) andpermanent revocation of accreditation. A recommendation shall besubmitted to the Department of Health for cancellation of license tooperate.

Low Penalty — a fine of Thirty Thousand Pesos (P30,000.00) andrevocation of accreditation with non-accreditation for twenty-four(24) months.(b)For Less Serious Violations:High Penalty — a fine of Fifteen Thousand Pesos (P15,000.00) andone year suspension.Low Penalty — a fine of Five Thousand Pesos (P5,000.00) and three(3) or six (6) months suspension.(c) Common Provisions. All penalties shall carry with them denialof payment of claim(s) in question and/or refund to the System ifalready paid.Suspension shall be carried out by the temporary cessation of thebenefits or privilege under the Medicare Program.Should the aggregate period of suspension to be imposed upon theprovider on account of two or more violations exceed twenty-four(24) months, the high penalty for serious violations shall be imposed.In no case shall the penalty of fine exceed Thirty Thousand Pesos(P30,000.00).A notice of suspension, for the benefit of beneficiaries, shall be postedindicating the period of suspension in such form and manner to beprescribed by the Commission.SECTION 5. Rules for Application of Penalty. —(a) Where there are no aggravating circumstances, the low penaltyshall be imposed as follows:1. For less serious violations — a fine of Five Thousand Pesos(P5,000.00) and six (6) months suspension.

2. For serious violations — a fine of Thirty Thousand Pesos(P30,000.00) and revocation of accreditation with non-accreditationfor twenty-four months.3. For breach of warranties — three (3) months suspension.4. For violation by beneficiaries — a fine of Five Thousand Pesos(P5,000.00) and three (3) months suspension of Medicare privilege.(b) When there is an aggravating circumstance, the high penaltyshall be imposed as follows:1. For less serious violations — a fine of Fifteen Thousand Pesos(P15,000.00) and one (1) year suspension.2. For serious violations — a fine of Thirty Thousand Pesos(P30,000.00) and permanent revocation of accreditation. Arecommendation shall be submitted to the Department of Health forrevocation of license to operate.3. For breach of warranties — six (6) months suspension.4. For violations by beneficiaries — a fine of Five Thousand Pesos(P5,000.00) and six (6) months suspension of Medicare privilege.PART IIViolations and PenaltiesSECTION 6. Fraudulent Practices. —(a)Misrepresentation.1. Misrepresentation by Padding of Claims — Any provider who,for purposes of claiming payment from the System, files a Medicareclaim for an amount more than the benefits actually used by addingdrugs, medicines, procedures, services, supplies not actually done orgiven, shall be punished by a fine of Thirty Thousand Pesos(P30,000.00) and revocation of accreditation with non-accreditationfor twenty-four (24) months or permanent revocation. In case ofpermanent revocation, a recommendation shall be submitted to the

Department of Health for cancellation of license to operate. Thepadded claims shall be barred from payment or denied and, if paid,refunded.2. Misrepresentation by Claiming for Non-admitted Patients —Any provider who, for the purpose of claiming payment for noncompensableout-patient illness from the System, files a Medicareclaim for non-admitted patients:a. By making it appear that the patient is actually confined in thehospital when he is not; orb. By making it appear that the non-compensable illness orprocedure is compensable; andc. By such other machinations,shall be penalized by a fine of Thirty Thousand Pesos (P30,000.00)and revocation of accreditation with non-accreditation for twentyfour(24) months or permanent revocation. In case of permanentrevocation, a recommendation shall be submitted to the Departmentof Health for cancellation of license to operate. The claim shall bedenied and, if paid, refunded.3. Misrepresentation by Extending Period of Confinement — Anyprovider who, for the purpose of claiming payment from the System,files a Medicare claim with extended period of confinement:a. By increasing the period of actual confinement of any patient;and/orb. By continuously charting entries in the Doctors Order, NursesNotes and Observations despite actual discharge or absence of thepatients.c. By such other machinations,shall be penalized by a fine of Thirty Thousand Pesos (P30,000.00)and revocation of accreditation with non-accreditation for twentyfour(24) months or permanent revocation. In case of permanent

evocation, a recommendation shall be submitted to the Departmentof Health for cancellation of license to operate. The claim shall bedenied and, if paid, refunded.4. Misrepresentation by Postdating of Claims — Any provider who,for purposes of claiming payment from the System, files a Medicareclaim for payment of services rendered not within sixty (60) daysfrom the date of discharge of the patient but makes it appear to be soby changing, erasing, adding to the period of confinement or in anymanner altering dates so as to defeat or conform to the sixty (60) daysprescriptive period shall be punished by a fine of Five ThousandPesos (P5,000.00) and six (6) months suspension from participationin the Medicare Program or a fine of Fifteen Thousand Pesos(P15,000.00) and one (1) year suspension. The claim shall be barredfrom payment and, if paid, refunded.5. Other Misrepresentations — Any hospital or practitioner shallbe liable for fraudulent practice by other misrepresentation when, forpurposes of participating in the Program or claiming payment fromthe System, he/it furnishes false or incorrect information concerningany matter required by the Medicare Law and its Implementing Rulesand Regulations not otherwise punishable under this, sub-sections (1)to (4) of this Rule, shall be penalized by a fine of Five Thousand Pesos(P5,000.00) and six (6) months suspension from participation in theMedicare Program or a fine of Fifteen Thousand Pesos (P15,000.00)and one (1) year suspension. All claims shall be barred from payment,and if paid, refunded.(b)Other Fraudulent Practices.6. Filing of Multiple Claims — Any provider who, for the purposeof claiming payment from the System, files two or more Medicareclaims for a patient who has been confined once but was made toappear as having been confined for two or more times and/or for twoor more different illnesses shall be punished by a fine of ThirtyThousand Pesos (P30,000.00) and revocation of accreditation withnon-accreditation for twenty-four (24) months or permanentrevocation. In case of permanent revocation, a recommendation shallbe submitted to the Department of Health for cancellation of licenseto operate. The claims shall be denied and, if paid, refunded.

7. Violation of Accredited Bed Capacity — Any hospital which, forpurposes of claiming payment from the System, files Medicare claimsfor patients confined in excess of the accredited bed capacity at anygiven time without explanation in form and manner prescribed by theCommission shall be punished by a fine of Five Thousand Pesos(P5,000.00) and six (6) months suspension from participation in theMedicare Program or a fine of Fifteen Thousand Pesos (P15,000.00)and one (1) year suspension. Its excess claims shall not be paid.8. Unauthorized Operations Beyond Service Capability — Anyprimary hospital which performs a surgical operation beyond itsauthorized capability shall be liable for unauthorized operations andshall be punished by a fine of Five Thousand Pesos (P5,000.00) andsix (6) months suspension from participation in the MedicareProgram or a fine of Fifteen Thousand Pesos (P15,000.00) and one(1) year suspension except when the operation is done in emergencyto save life or referral to a higher category hospital is physicallyimpossible.9. Fabrication or Possession of Fabricated Medicare Forms andSupporting Documents — Any provider who is found preparingclaims with misrepresentations or false entries or to be in possessionof Medicare claim forms and other documents with false entries tosupport Medicare claims shall be punished by a fine of Five ThousandPesos (P5,000.00) and six (6) months suspension from participationin the Medicare Program or a fine of Fifteen Thousand Pesos(P15,000.00) and one (1) year suspension.10. Fraudulent Acts — Any provider or beneficiary shall be liablefor fraudulent acts by:a. failure or refusal to give the benefits due a qualified Medicarebeneficiary; orb. charging the qualified Medicare patients for services ormedicines which are legally chargeable to and covered by Medicare;or

c. failure or refusal to refund to the beneficiary the paymentreceived from the System within thirty (30) days when the bill is fullypaid in advance by the beneficiary; ord. failure or refusal to accomplish and submit the required PMCCforms in connection with letter c; ore. deliberate failure or refusal to comply with the requisites of P.D.1519 as amended and its Implementing Rules and Regulations,shall be penalized by a fine of Thirty Thousand Pesos (P30,000.00)and revocation of accreditation with non-accreditation for twentyfour(24) months or permanent revocation. In case of permanentrevocation, a recommendation shall be submitted to the Departmentof Health for cancellation of license to operate. The claims shall bebarred from payment and, if paid, refunded.In paragraph (a), a mere refusal or failure to give benefits completesthe violation.In paragraph (b), payment of the patient completes the violation.In paragraph (c), lapse of thirty (30) days completes the violation.In paragraph (d), a mere refusal or failure to accomplish and submitthe forms completes the violation.SECTION 7. Gross Negligence. —(a) Violation Through Gross Negligence. Any provider orbeneficiary who, by gross negligence, caused a serious violation shallbe penalized with the high penalty for serious violations; if a lessserious violation had been caused, it shall be penalized with the highpenalty for less serious violations.Gross negligence is the want of even slight care and diligence as toraise a presumption that the practitioner or hospital or beneficiary atfault is conscious of the probable consequences or carelessness and isindifferent, or worse, oblivious to the danger of the injury to theperson or property of others.

SECTION 8. Breach of Warranties of Accreditation. — Anyhospital or practitioner who shall be found to have made any breachof warranties of accreditation shall be penalized by three (3) monthsor six (6) months suspension from participation in the MedicareProgram; Provided, that when the breach is in itself another violationor results to another violation as provided in Section 6 and 7, it shallbe penalized accordingly.SECTION 9. Penalty for Beneficiary. — A beneficiary who, forpurposes of claiming Medicare benefits or entitlement thereto,commits any of the violations as provided for in Sections 6 and 7 ofthis Rule independently or in connivance with the hospital orpractitioner shall be penalized by a fine of Five Thousand Pesos(P5,000.00) and suspension from availing of Medicare benefits forthree (3) or six (6) months.SECTION 10. Final Provisions. —(a) When one single act constitutes or results to two or moreviolations, or when the violation is a necessary means of committingthe other violation, the high penalty for the more serious violationshall be imposed.(b) Pendency of a complaint before the Commission of a decisionthereon shall not bar a separate independent criminal action and/orappropriate action before any board, office, tribunal or court againstthe erring respondent and vice-versa.(c) When a hospital has ceased operations or the practitioner stopshis practice before serving its/his penalty, execution shall be deferred,to be implemented when the same owner or medical director opens oroperates a new hospital irrespective of the name or location or whenthe practitioner practices again. A spouse or a relative within thesecond degree of consanguinity of the hospital owner or medicaldirector shall be presumed the alter-ego of the owner or medicaldirector; Provided, that the dispositive part of the resolutionrequiring reimbursement of paid claim or denial of payment shall beimmediately executory, notwithstanding the motion forreconsideration.

(d)Violations and penalties shall prescribe as follows:1. Violations punishable by revocation of accreditation with nonaccreditationfor twenty-four (24) months or permanent revocationwith recommendation to the Department of Health for cancellation oflicense to operate shall prescribe in five (5) years.Violations punishable by three (3) or six (6) months suspension orone (1) year suspension and penalties therefore shall prescribe inthree (3) years.2. The period of prescription of violations shall commence fromthe day the violation is discovered by the complainant and shall beinterrupted by the filling of the complaint/memorandum and shallcommence again if there is failure to act within a reasonable timewhich should not be more than one (1) year.The term of prescription shall not run when the erring respondent isnot in the Philippines or when he/it cannot be served with summonsdue to his/its fault.3. The period of prescription of penalties shall commence to runon the thirty-first (31st) day from the date the decision becomes finaland executory.SECTION 11. Applicability of this Rule. — Complaints alreadyfiled with and under deliberation by the Hearing Committee shall bepenalized in accordance with previous rules.RULE XIIIImplementing ProvisionsSECTION 1. These amended rules and regulations shall takeeffect immediately as provided by law.Approved by the Commission on August 27, 1987, duringthe 755 th Regular Meeting under Medicare ResolutionNumber 87-1962 and confirmed on December 8, 1987

during the 758th Regular Meeting under MedicareResolution Number 87-1987.MEDICARE SCHEDULE OF CONTRIBUTIONSI. The following shall take effect on January 1, 1991:SALARY BRACKET CONTRIBUTION BASE EMPLOYEE’S SHARE EMPLOYER’SSHAREP less than P149.99 P125.00 P1.55 P1.55150 — 199.99 175.00 2.20 2.20200 — 249.99 225.00 2.80 2.80250 — 349.99 300.00 3.75 3.75350 — 499.99 425.00 5.35 5.35500 — 699.99 600.00 7.50 7.50700 — 899.99 800.00 10.00 10.00900 — 1,099.99 1,000.00 12.50 12.501,100 — 1,399.99 1,250.00 15.65 15.651,400 — 1,749.99 1,500.00 18.75 18.751,750 — OVER 2,000.00 25.00 25.00II. The following shall take effect on January 1, 1992:SALARY BRACKET CONTRIBUTION BASE EMPLOYEE’S SHARE EMPLOYER’SSHAREP less than P149.99 P125.00 P1.55 P1.55150 — 199.99 175.00 2.20 2.20200 — 249.99 225.00 2.80 2.80250 — 349.99 300.00 3.75 3.75350 — 499.99 425.00 5.35 5.35500 — 699.99 600.00 7.50 7.50700 — 899.99 800.00 10.00 10.00900 — 1,099.99 1,000.00 12.50 12.501,100 — 1,399.99 1,250.00 15.65 15.651,400 — 1,749.99 1,500.00 18.75 18.751,750 — 2,249.99 2,000.00 25.00 25.002,250 — OVER 2,500.00 31.25 31.25III. The following shall take effect on January 1, 1993:SALARY BRACKET CONTRIBUTION BASE EMPLOYEE’S SHARE EMPLOYER’S SHAREP less than P149.99 P125.00 P1.55 P1.55

150 — 199.99 175.00 2.20 2.20200 — 249.99 225.00 2.80 2.80250 — 349.99 300.00 3.75 3.75350 — 499.99 425.00 5.35 5.35500 — 699.99 600.00 7.50 7.50700 — 899.99 800.00 10.00 10.00900 — 1,099.99 1,000.00 12.50 12.501,100 — 1,399.99 1,250.00 15.65 15.651,400 — 1,749.99 1,500.00 18.75 18.751,750 — 2,249.99 2,000.00 25.00 25.002,250 — 2749.99 2,500.00 31.25 31.252,750 — OVER 3,000.00 37.50 37.50