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Republic Act No. 6111

Republic Act No. 6111

AN ACT ESTABLISHING THE PHILIPPINE MEDICAL CARE PLAN AND CREATING THE PHILIPPINE MEDICAL CARE COMMISSION, PRESCRIBING ITS DUTIES, POWERS AND FUNCTIONS, AND APPROPRIATING FUNDS THEREFOR

SECTION 1. Short Title. — This Act shall be known as the “Philippine Medical Care Act of 1969.”

SECTION 2. Declaration of Policy. — It is hereby declared to be the policy of the Republic of the Philippines to gradually provide total medical service for our people by adopting and implementing a comprehensive and coordinated medical care program based on accepted concepts of health care, namely:

(a) There shall be total coverage of medical services according to the needs of patients;

(b) There shall be coordination and cooperation in the use of all medical facilities of both the government and the private sector; and

(c) The freedom of choice of physicians and hospitals and the family doctor-patient relationship shall be preserved.

SECTION 3. Purposes and Objectives. — The main purposes and objectives of this Act are:

(a) Extension of medical care to all residents in an evolutionary way within our economic means and capability as a nation;

(b) Providing the people of the country a practical means of helping themselves pay for adequate medical care; and

(c) To establish a Medical Care Commission.

SECTION 4. Philippine Medical Care Commission. — To carry out the above purposes and objectives, the Philippine Medical Care Commission, hereinafter referred to as the “Commission”, is hereby created to be composed of nine (9) members, namely: (1) the Chairman; (2) the Administrator of the Commission as Vice-Chairman; (3) The Administrator of the Social Security System; (4) The General Manager of the Government Service Insurance System; (5) The President or the duly designated representative of the Philippine Medical Association; (6) The President or the duly designated representative of the Philippine Hospital Association; (7) The Secretary of Health or the Director of Medical Services if designated by the former; and (8) two members, one of whom shall preferably be a duly registered physician with at least ten years private practice, representing the private sector.

The Chairman, the Administrator and the two members from the private sector shall be appointed by the President of the Philippines with the consent of the Commission on Appointments to serve for a term of six (6) years.

SECTION 5. Functions, Powers and Duties of the Commission. — The Commission shall have the following functions and powers:

(a) To formulate policies, administer and implement the Medical Care Plan, hereinafter provided;

(b) To organize its offices, fix the compensation of, and appoint such personnel as may be deemed necessary in accordance with Civil Service rules and regulations: provided, that the plantilla of the Commission shall be included in the Appropriations Act for the next fiscal year, and yearly thereafter: provided, further, that the respective Community Health funds of the provinces, cities and municipalities shall not be used for payment of salaries of the employees of the Commission;

(c) To establish the provincial, city and municipal Medical Care Councils;

(d) To authorize actuarial studies for the purpose of determining and fixing, from time to time, the contributions necessary and the extent and scope of benefits of the beneficiaries of the Plan as its resources may permit in order to ensure adequate financing and disbursement of funds to all participants of the Plan;

(e) To set up the requisites and procedures for the registration of beneficiaries under this Act;

( f ) To devise control measures to prevent abuses of the Plan;

(g) To provide from its funds the necessary amount for the Provincial Medical Care Council, the City Medical Care Council, and the Municipal Medical Care Council to carry out their respective functions under the Plan;

(h) To be empowered to withhold, withdraw or suspend medical care benefits from any one who refuses to pay his contribution as provided herein except in emergency cases;

(i) To promulgate such supplementary rules and regulations as may be necessary to implement the provisions of this Act;

( j) To submit to the President, and to each House of Congress of the Republic of the Philippines annually within the first ten days of each regular session, a report covering its activities in the administration and enforcement of this Act during the preceding fiscal year; and

(k) Generally to exercise all powers necessary to attain the purposes and objectives for which the Commission is organized.

SECTION 6. Board Meetings. — Regular meetings of the Commission shall be held once a week. Special meetings not to exceed four sessions a month may be held at the discretion of the Chairman or at the written request of the majority of the members of the Commission. The presence of five members of the Commission shall constitute a quorum. Members of the Commission who are government officials shall serve without additional compensation, but may be allowed traveling and other necessary expenses. Members who are not government officials shall receive a per diem of fifty pesos for each session actually attended by them. The Commission shall fix the compensation of, and appoint its secretary.

SECTION 7. The Chairman of the Commission. — The Chairman shall be a reputable member of the medical profession with at least twelve years of experience in medical practice and with proven executive ability in business or medical undertakings. He shall hold office on a full time basis and shall receive a compensation of at least thirty thousand pesos per annum. He shall be entitled to commutable traveling and representation expenses not to exceed six thousand pesos per annum. He shall preside at all meetings of the Commission and shall exercise such other duties as will achieve the purposes and objectives of this Act.

SECTION 8. Administrator of the Commission. — The Commission shall have under its general supervision an Administrator, who shall serve as its Chief Executive Officer. He shall hold office on a full-time basis for a term of six (6) years and may not be removed except for cause. The Administrator shall be a duly registered physician with at least ten years experience in practice, who has proven executive ability and experience in business or medical undertakings. He shall be appointed by the President of the Philippines with the consent of the Commission on Appointments and shall receive a minimum compensation of P24,000.00 per annum and such other privileges as may be fixed by the Commission. All travel and other representation expenses shall not be more than six thousand pesos per annum. No other allowances and/or representation expenses under any denomination shall be allowed.

SECTION 9. The Philippine Medical Care Plan. — The Philippine Medical Care plan shall consist of two basic programs, namely:

(a) Program I — For the members of the SSS and GSIS; and

(b) Program II — For those not covered in program I.

Beneficiaries under Program I shall be entitled to medical care benefits specifically provided for in subsequent sections of this Act.

The Commission shall, within three years after the effectivity of this Act, formulate an integrated program for the proper implementation of program II as envisioned in this Act. Likewise, it shall, within the same period, recommend to Congress who shall be entitled to Medical Care benefits under Program II and the amount of contributions they shall make.

PROGRAM I

SECTION 10. Medical Care for SSS and GSIS Members. — The SSS and the GSIS shall set up their respective medical care funds and shall administer the same in accordance with the following provisions of this Act, and the policies and implementing rules and regulations promulgated by the Commission.

Within five years from the approval of this Act, the SSS and the GSIS shall, with the approval of the Commission, respectively adopt a supplementary plan designed to take over the medical care needs of the legal dependents of their members from Program I for which the SSS and the GSIS may require additional premiums.

SECTION 11. Compulsory Coverage. — Coverage under this Act shall be compulsory and automatic upon all employees entitled under Section 35 of this Act: provided, that in the case of an employee who is both covered by the SSS and GSIS, only his employment with the latter shall be considered for purposes of his coverage.

SECTION 12. Effect of Separation from Employment. — Subject to such rules, regulations and/or conditions as the SSS or GSIS may prescribe, an employee who is no longer obliged to contribute under Section 22 hereof by separation from employment, may elect to continue paying contributions representing the contribution of the employer as well as that of the employee only within sixty days following the date of such separation: provided, that an employee shall be entitled to the benefits under this Act if he has satisfied the contribution requirements specified in Section 21 of this Act.

SECTION 13. Hospitalization Expense Benefit. — Under such rules, regulations and/or conditions as the SSS and GSIS may prescribe, subject to the approval of the Commission, an employee who is confined in a hospital on account of sickness or bodily injury requiring hospitalization, shall be entitled to confinement not exceeding forty-five days annually to:

(a) Room and board expense benefit for each day of confinement in a hospital not exceeding twelve pesos (P12.00) a day; and

(b) Special charge expense benefit for charges necessary for the care of the employee, such as laboratory examination fees, drugs, X-ray, operating room and the like, not to exceed one hundred fifty pesos (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 the hospital pharmacy wherein he is confined or from any retail drug store of his own choice, subject only to the rules and regulations or as provided 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 shall have undergone surgical procedure in a hospital shall be entitled to a surgical expense benefit as may be determined by the SSS or GSIS, as the case may be, taking into account the nature and complexity of the procedure: provided, that the amount of benefit shall not exceed fifty pesos for a minor operation, one hundred fifty pesos for a medium operation and three hundred fifty pesos for a major operation.

SECTION 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 shall have received necessary professional medical treatment by a medical practitioner while confined shall be entitled to a medical expense benefit of P5.00 for each daily visit: provided, that the maximum benefit shall not exceed one hundred pesos for a single period of confinement or for any one sickness or injury: provided, further, that in determining the compensable daily visit occasioned by any one sickness or injury not more than one visit for any one day shall be counted: provided,finally, that specialists who are properly certified by the Philippine Medical Association shall be entitled to collect ten pesos 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 choose the hospital in which he will be confined and the medical practitioner by whom he will be treated.

SECTION 17. Notification of Illness, Confinement and Supervision. — When an employee becomes sick or is injured and confined in a hospital, his confinement as well as the nature of his sickness or injury shall be communicated by said hospital to the SSS or GSIS, as the case may be. The SSS or GSIS may exercise supervision over the confined employee and, at its expense, require him to be examined by a medical practitioner of his choice.

SECTION 18. Payment of Claims. — Benefits provided under this Act shall be payable directly to the hospital, the medical practitioner and the retail drug store, if any, under such rules, regulations and/or conditions as the SSS or GSIS may prescribe, subject to the approval of the Commission: provided, that when the charges and fees agreed upon between the employee and the hospital and/or medical practitioner are in excess of the amount of the benefits provided for under this Act, such employee shall be liable only for the payment of that portion of such fees and charges as are in excess of the benefits payable under this Act.

SECTION 19. Limitation on the Right to Benefits. —

(a) No employee shall be entitled to the benefits herein granted unless he shall have paid at least three monthly contribution during the last twelve months prior to the first day of the single period of confinement: provided, that in case of sickness on which surgery may be deferred at the election of the employee in such cases as hermictomy, hemorrhoidectomy, tonsillectomy, adenoidectomy and the like, the required monthly contributions paid immediately prior to the operation shall be at least for twelve consecutive monthly installments: And, provided, further, that until such time that such an employee is entitled to the benefits under Program I, he shall be covered by Program II;

(b) When the SSS or GSIS, as the case may be, has not been duly notified by the hospital in the manner prescribed under Section 17 of this Act, no claim for any of the benefits of the Act shall be paid to the hospital concerned and said hospital shall further pay to the medical practitioner damages equivalent to the benefits which said medical practitioner would have received had there been due notification: provided, that in no case may a claim for benefit filed after the lapse of sixty days from the last day of confinement be paid;

(c) The SSS or GSIS may deny or reduce any benefits provided under Program I of this Act when an employee, hospital or medial practitioner, as the case may be:

(1) Fails without good cause or legal ground to comply with the advice of the medical practitioner with respect to hospitalization;

(2) Furnishes false or incorrect information concerning any matter required by this Act or the rules and regulations of the SSS or the GSIS;

(3) Is guilty during his confinement or illness of gross negligence with regard to his health;

(4) Refuses to be examined by or fails to comply with the advice of the medical practitioner appointed for supervision purposes by the SSS or GSIS; and

(5) Fails to comply with any provision of Program I of this Act or rules and regulations of the SSS or GSIS required for entitlement to the benefits provided in this Act.

SECTION 20. Exclusion. — The benefits granted under this Act shall not cover any expense for:

(a) Cosmetic surgery or treatment;

(b) Dental Service, except major dental surgery or operation which needs hospitalization;

(c) Optometric service or surgery;

(d) Services related to the case of psychiatric illness or of diseases traceable to such illness; and

(e) Services which are purely diagnostic.

SECTION 21. Rates of Contributions. — For employees covered by the GSIS and the SSS, the initial monthly contributions shall be in accordance with the following schedule:

Monthly Salary Covered Employer’s Employee’s

Wage or Earnings Wage Contribution Contribution

Below P49.99 P25.00 P0.30 P0.30

P50.00 — 99.00 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 — over 300.00 3.75 3.75

SECTION 22. Collection of Employee’s and Employer’s Contribution. —

(a) Within such time and manner as the SSS or GSIS may prescribe, the employer shall deduct and withhold from his employee’s monthly compensation the employee’s contribution; and

(b) Within such time and manner as the SSS or GSIS may prescribe, but not beyond twenty days from the date due, the employer shall remit directly to the GSIS or the SSS, as the case may be, his corresponding contributions together with the employee’s contribution. No employer shall deduct, directly or indirectly, from the compensation of the covered employees or otherwise recover from them his own contributions in behalf of such employees: provided, that 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 Act.

SECTION 23. Health Insurance Fund. — The Health Insurance Funds of the SSS and the GSIS are hereby created which shall consist of all contributions and all accruals thereto and shall be kept separate and distinct from all other funds paid to and collected by said agencies to be utilized for the purpose of meeting claims for benefits under this Act.

SECTION 24. Administration and Disbursement of Funds. — Subject to Section 25 hereof, the Health Insurance Funds of the SSS or GSIS shall be administered and disbursed in the same manner and under the same conditions, requirements and safeguards as provided by Republic Act Numbered One thousand one hundred sixty-one, as amended, and Commonwealth Act Numbered One hundred eighty-six, as amended, with regard to such other funds as are thereunder being paid to or collected by the SSS and the GSIS, respectively: provided, that they conform with the policies, rules and regulations established by the Commission.

SECTION 25. Deposit of Contributions. — All the contributions collected by and remitted to the GSIS and the SSS under this Act shall, within thirty days of receipt be deposited in interest bearing government deposit banks doing business in the Philippines, having an unimpaired paid-up capital and surplus equivalent to one million five hundred thousand pesos or over.

SECTION 26. Records and Reports. — The Philippine Medical Care Commission, the provincial, city and municipal Medical Care Councils, the SSS and the GSIS shall keep and cause to be kept records of the operation of their respective funds and of disbursement thereof, and all accounts or payments made out of said funds. They shall also cause to be kept such records as may be required for the purpose of making actuarial valuations including such data necessary in the computation of the rate of morbidity in the Philippines and any other information that may be useful for the adjustment of benefits.

PROGRAM II

SECTION 27. Hospitalization, Out-Patient and Domiciliary Care. — Subject to the provisions of Section 13 hereof, for purposes of hospitalization under this Act, private hospitals and clinics duly licensed by the Bureau of Medical Services shall set aside at least twenty percent (20%) of their total bed capacity as service beds to be subsidized at the rate of P10.00 per bed per day to be paid by the month not later than the tenth day of the following month, from any special fund appropriated for this purpose: provided, that said service beds shall remain such only when payments of these monthly subsidies do not become delinquent for more than three consecutive months.

Hospital loans shall be given priority by government financing institutions, especially in the rural areas where there are no existing government or private hospitals, at a maximum rate of six percent (6%) per annum on a long-term basis.

Until such time as the Commission can otherwise provide therefore, the major aspect of out-patient and domiciliary care shall be carried out initially by existing government hospitals, rural health units and other government clinics.

SECTION 28. Registration and Contribution. — To be entitled to the benefits under this Act, and subject to the regulations and procedures for registration to be promulgated by the Commission, every resident shall be registered and issued a medical care card upon payment to the respective provincial, city, or municipal treasurer concerned of the required yearly assessments to be fixed by the Commission. The yearly assessments shall be payable on or before January 20 of each year to be collected by the City or Municipal Treasurer concerned, and shall respectively be held by them in trust for the City Medical Care Council or the Municipal Medical Care Council, as agents of the latter.

SECTION 29. 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; 2) the Provincial Treasurer; 3) a representative of the Provincial Governor; 4) the duly designated representative of the component society of the Philippine Medical Association; 5) a representative of the Philippine Hospital Association from one of the private hospitals in the province if any, preferably a chief of a hospital; and 6) and 7) two (2) private citizens from the province, one of whom shall be a duly registered physician, to be appointed by the Commission. The last four (4) mentioned members shall be appointed for a term 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. 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 of medical facilities within the province;

(c) Act as an adjudicatory body for the parties involve in claims for payment;

(d) Perform such other functions and duties as may be assigned to it by the Commission; andsia

(e) Hold in trust, through the Provincial Treasurer as Member of the Provincial Medical Care Council, Community Mutual Health Funds of cities and municipalities as provided for under Section 32(b).

SECTION 30. City Medical Care Council. — The Commission shall establish in each chartered city the City Medical Care Council of seven (7) members, to be composed of 1) the City Health Officer; 2) the City Treasurer; 3) a representative of the Mayor; 4) the duly designated representative of the component society of the Philippine Medical Association; 5) a representative to be appointed by the Commission upon the recommendation of the Philippine Hospital Association preferably from one of the City private hospitals; and 6) and 7) two (2) private citizens from the City, one of whom shall be a duly registered 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 for in Section 32, and implement the rules and regulations set forth by the Commission.t shall disburse funds for the payment of medical and hospital care for its members directly to the institutions or medical practitioner concerned. Wherever it may be deemed expedient or necessary, the City Medical Care Council may set up a number 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 Care Council in the discharge of its functions.

SECTION 31. Municipal Medical Care Council. — The Commission shall establish in each municipality a Municipal Medical Care Council of seven (7) members, to be composed of: 1) the Municipal Health Officer; 2) the Municipal Treasurer; 3) a representative of the Mayor; 4) a designee of the component society of the Philippine Medical Association preferably a resident medical practitioner; 5) a representative of the Philippine Hospital Association 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 preferably be a duly registered physician, to be appointed by the Commission. The last four (4) mentioned members shall be appointed for a term 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 own Chairman, Vice-Chairman, and Secretary; administer the Community Mutual Health Fund; implement the rules and regulations promulgated by the Commission; and disburse funds for the payment of hospitalization and hospital care for its members directly to the institution or medical practitioner concerned, within ten (10) days after receipt of the bill.

SECTION 32. Community Mutual Health Fund. —

(a) There is hereby established in each city or municipality, a Community Mutual Health Fund. To this Fund shall accrue the yearly contributions of residents in the city or municipality, and a national government 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 municipalities which, by virtue of their change of corporate personality, or loss of any portion thereof through regrouping, shall be held in trust by the Provincial Treasurer as Member of the respective Provincial Medical Care Council until such time as the Commission shall have established the new Medical Care Council and defined its jurisdiction.

SECTION 33. Revolving Funds. — The gross income of the government hospitals shall be constituted into a revolving fund for that particular hospital for the upgrading, expansion of its facilities, and for its maintenance and operation, subject to the approval of the Department of Health.

SECTION 34. Reparations Allocations. — The reparations Commission shall allocate and include in accordance with the reparations law, as amended, in its annual schedule beginning with the fourteenth up to the twentieth reparations year, the procurement of machineries, equipments and instruments worth at least $1.5 million annually as the Philippine Medical Care Commission may recommend. The latter shall, with the approval by the Department of Health, distribute such machineries, equipments and supplies to the different government hospitals and rural health units. A similar allocation of at least $1.5 million shall likewise be made for the private hospitals involved in this plan pursuant to the provisions of this Act.

SECTION 35. Terms Defined. — For the purposes of this Act, the following terms shall, unless the context indicate otherwise, have the following meanings:

(a) SSS. — The Social Security System created under Republic Act Numbered One thousand one hundred sixty-one, as amended.

(b) GSIS. — The Government Service Insurance System created under Commonwealth Act Numbered One hundred eighty-six, as amended.

(c) Employee. — Any person compulsorily covered by the SSS under Republic Act Numbered One thousand one hundred sixty-one, as amended; or by the GSIS under Commonwealth Act Numbered One hundred eighty-six, as amended, except members of the Armed Forces of the Philippines.

(d) Employer. — The employer of the employee.

(e) Benefit. — The hospitalization, surgical and/or medical expense benefit provided for under this Act.

( f ) Hospital. — Any hospital, government or private, licensed with the Bureau of Medical Services.

(g) Medical Practitioner. — Any Doctor of Medicine duly licensed to practice in the Philippines and an active member of good standing of the Philippine Medical Association.

(h) Confinement. — Confinement in a hospital defined in Section 35 (f), due to sickness or bodily injury.

(i) Single Period of Confinement. — A continuous period of confinement or periods of confinement for the same or any related illness, injury or condition not separated from each other by more than ninety days.

( j) Commission. — Philippine Medical Care Commission created under this Act.

(k) Service Beds. — Beds reserved for beneficiaries under Program II.

(l) Community Mutual Health Funds. — Funds accruing from the contributions of residents in each chartered city or municipality, plus the one hundred percent (100%) government counterpart funds.

(m) Administrator. — Refers to the Administrator of the Commission, unless specified otherwise.

SECTION 36. Study and Research. — Immediately upon its organization, the Commission shall undertake actuarial studies for the purpose of determining the contributions necessary in order to insure adequate financing and disbursement of funds to all participants of the plan and the extent and scope of benefits of the beneficiaries of the plan.

Immediately upon completion of such study, the Commission shall submit to Congress a report with its recommendations as to the amount to be assessed from each resident or inhabitant covered by the plan for purposes of legislation by Congress.

SECTION 37. Penal Provisions. —

(a) Any person, who for the purpose of securing entitlement to any benefit or payment under this Act or the issuance of any certificate or document for any purpose connected with this Act, whether for him or for some other person, commits fraud, collusion, falsification, misrepresentation of facts or any other kind of anomaly shall be punished with a fine of not exceeding one thousand pesos or imprisonment not exceeding one year or by both such fine and imprisonment, at the discretion of the court; and

(b) Any contribution or other amount collected by the treasurer, as provided for under Section 28 of this Act, shall not be used, appropriated or diverted for a purpose other than that authorized by this Act. Any person violating this provision shall be punished with imprisonment for not less than one year nor more than five years or with a fine of not less than one thousand pesos, nor more than five thousand pesos or by both such imprisonment and fine, at the discretion of the court.

SECTION 38. Separability Clause. — In the event any provision of this Act or the application of such provision to any person or circumstance is declared invalid, the remainder of the Act or the application of said provision to other persons or circumstances shall not be affected by such declaration.

SECTION 39. Repealing Clause. — All laws, executive orders, and administrative rules and regulations or parts thereof which are inconsistent with the provisions of this Act are hereby repealed or modified accordingly: provided, however, thatnothing in this Act shall be construed to remove or eliminate the present powers and functions of existing agencies involved.

SECTION 40. Appropriation. — The sum of one million pesos is hereby appropriated out of any funds in the National Treasury not otherwise appropriated for the initial organizational expenses of the Commission and the Medical Care Councils, as provided for in Sections 29, 30 and 31. Thereafter, the necessary funds for the yearly operation of the above-mentioned agencies shall be incorporated in the General Appropriations Act.

SECTION 41. Effectivity. — Program I shall be implemented immediately and upon the effectivity of this Act.

Program II shall be implemented in the manner and time to be determined by Congress upon recommendation of the Commission.

Approved: August 4, 1969