[ OCA CIRCULAR NO. 160-2014, December 16, 2014 ]

[ OCA CIRCULAR NO. 160-2014, December 16, 2014 ]

[ OCA CIRCULAR NO. 160-2014, December 16, 2014 ]

TO : ALL JUDGES AND PERSONNEL OF THE FIRST AND SECOND LEVEL COURTS

SUBJECT : COMPREHENSIVE HEALTH CARE PLAN FOR THE LOWER COURTS

In a Resolution dated October 21, 2014 in A.M. No. 12-9-3-SC, the Court en banc awarded the contract for the Comprehensive Health Care Plan for the Lower Courts to Medocare Health Systems, Inc. The one-year contract shall take effect on January 1, 2015 and all concerned judges and court personnel are hereby informed of the following guidelines relative to the implementation of the health care plan:

I. Coverage

A. All judges, officials and personnel of the first and second level courts (Regional Trial Courts, Metropolitan Trial Courts, Municipal Trial Courts, Municipal Circuit Trial Courts, Municipal Trial Courts in Cities, Shari'a Circuit Courts, Shari'a District Courts) and maintenance staff of the Halls of Justice who are in the service as of the date of effectivity of the contract shall be covered from January 1 to December 31,2015.

B. The amount of Two Hundred Seventy Pesos (Php270.00) per month, representing the employee's share of the premium, shall be deducted from the salaries of judges and court personnel starting January 1, 2015.

C. Judges, officials and other employees who enter the service after January 1, 2015 shall be covered effective on the date of their appointment or hiring as certified by the Administrative Services, Office of the Court Administrator. The corresponding premium shall be pro-rated.

D.The Maximum Benefit Limit (MBL) shall be SEVENTY THOUSAND PESOS (Php70,000.00) per illness per year. Judges, officials and other employees whose employee's share has not been remitted due to their exclusion from the payroll at the time of availment of the health care services will only be given an MBL that is proportionate to the Court's subsidy of the total premium which is in the amount of THIRTY THOUSAND PESOS (Php30,000.00). Medical costs exceeding the MBL of THIRTY THOUSAND PESOS (Php30,000.00) shall not be reimbursable.

The employee shall be reinstated to his/her MBL of SEVENTY THOUSAND PESOS (Php70,000.00) upon MEDOCARE's receipt of the corresponding employee's share for the covered months, subject to the following conditions:

1. If any health services has not yet been availed of, the employee shall be reinstated in full to his/her MBL of SEVENTY THOUSAND PESOS (Php70,000.00);

2. If an employee has availed of the health services when his/her MBL was at THIRTY THOUSAND PESOS (Php30,000.00), his/her MBL shall be the remaining balance on the amount of Php70,000.00 less the costs of health services availed of which shall not exceed Php30,000.00.

II. Services and Benefits

The benefits under the Comprehensive Health Care Plan for the Lower Courts shall include the following:

A. Out-Patient Services which shall include:

1. Professional fees and charges for consultation and management by accredited doctors, specialist/s and sub-specialist/s;

2. Referrals and the corresponding fees/charges for prescribed special diagnostic procedures and other modern modalities of treatment up to the Maximum Coverage Limit (MCL) (please refer to Annex A hereof) such as, but not limited to the following:

a. All prescribed diagnostic procedures such as, but not limited to x-ray, ECG, Hematology, Blood Chemistry, including Pap Smear for women and PSA for men; b. Diagnostic and therapeutic ultrasound and the like; c. Radiographic studies; d. Rhinoscopic, bronchoscopic and/or endoscopic exams; e. 3D Imaging, CT scan and/or MRI of body organs or regions; f. All forms of Echocardiography, Treadmill Stress Test and other cardiac diagnostic studies, such as angiography/ scintigraphy and the like; g. Electromyography with Nerve Conduction Tests; h. Mammography; i. Peritoneal or Hemodialysis up to the MCL; j. Cancer treatment to include radiotherapy and chemotherapy, in any form, whether oral or intravenous, up to the MCL; k. Eye, ear, nose and throat treatment; l. Coverage for cataract extraction or glaucoma laser treatment up to MCL. Entitlement to the lens shall be up to Php5,000.00 per eye.

3. Treatment of minor injuries and illnesses;

4. Minor surgeries not requiring confinement (e.g.excision of cysts and other superficial mass/es);

5. Speech and physical therapy up to seven (7) sessions per employee per year;

6. Cauterization of warts up to a maximum of Php3,000.00 from the neck down, but excluding genital warts;

7. Excision of moles (malignant or suspected to be malignant) up to maximum of Php5,000.00 per employee per year;

8. All expenses for out-patient services rendered in any accredited hospital or clinic and done by an accredited physician, specialist or sub-specialist shall be on a "no cash-out basis" and shall be covered up to the MCL based on the contractor's existing Relative Unit Value (RUV) rates.

9. In case it becomes inevitable or necessary for an accredited physician or specialist to refer the member to a non-accredited physician, specialist, or sub-specialist, 100% of the actual professional fees based on existing RUV rates shall be settled by the contractor directly with the non-accredited physician on a best effort basis. Otherwise, the same shall be settled by the contractor on reimbursement basis.

10. Payment in excess of what is allowed shall be shouldered by the patient.

11. Information on the contractor's prevailing surgical and hospital rates shall be provided in advance by the contractor for the information of the members.

B. Emergency Care Services shall be provided for a member who is in severe pain or suffering from a serious illness or injury due to sudden and unexpected occurrence which requires immediate medical or surgical intervention to alleviate the pain or to prevent the loss of life or limb or any vital part of the body. Emergency care services shall not be limited to the emergency room and shall include:

1. Emergency Doctor or Specialist's services; 2. Emergency room fees, as well as fees of other hospital facility/ies used in the emergency treatment; 3. Surgery or treatment of lacerations and other injuries; 4. Medicines and/or drugs for emergency treatment; 5. X-ray, laboratory examinations and all diagnostic procedures necessary for the emergency management of the patient; 6. Oxygen, intravenous fluids, blood transfusions and human blood products; 7. Dressings, sutures and plaster casts; 8. Active and passive immunization/vaccines against tetanus, snake venoms, human bites, and rabies. (Initial dose shall be covered up to Php 25,000.00 per member); 9. Expenses for hiring ground ambulance service from the patient's residence or his/her location to the nearest hospital up to Php3,000.00; 10. All other services, items and supplies necessary for the emergency management of the patient; 11. All expenses for emergency care services enumerated in this Section B which were used in the emergency treatment of the patient in an accredited hospital or clinic and by an accredited physician, specialist and/or sub-specialist shall be covered up to the MCL (please refer to Annex A) and provided on a "no-cash-out basis."

If at the time of the emergency, the accredited hospital has no room available corresponding to the member's room and board category, the room and board may be upgraded to the next higher room (except suite room). The contractor shall cover the difference in the room rates and the other room based on charges or incremental costs for the first 24 hours;

12. All expenses for the emergency care services enumerated in Section B which were used in the emergency treatment of the patient in a non-accredited hospital or clinic and by a non-accredited physician, specialist and/or sub-specialist shall be covered and will be reimbursed as follows:

a. In areas where the contractor has no accredited hospital or clinic, the contractor shall reimburse all actual covered expenses including doctor's fees advanced by the patient subject to MCL computed based on RUV for the professional fees and approved HMO rates; b. In areas where the contractor has an accredited hospital or clinic, the contractor shall reimburse all actual covered expenses subject to MCL including doctor's fees incurred by the patient based on the contractor's existing RUV rates as if the patient has been confined in the accredited hospital or clinic and/or seen by accredited physicians, specialists and/or sub-specialists.

13. The transfer of a patient from a non-accredited hospital to an accredited hospital shall be covered by the contractor up to the MCL based on RUV rates and HMO standard rates only in the following situations:

a. In serious or life-threatening cases where the immediate transfer of the patient is medically contraindicated, 100% of the actual covered expenses subject to MCL based on what it would have cost the contractor had it been done in an accredited hospital shall be defrayed by the contractor including ground ambulance until transfer is eventually effected. b. In serious or life-threatening cases where the immediate transfer by any means is an absolute necessity for the patient's survival, the contractor shall defray 100% of all actual covered expenses subject to MCL based on existing RUV rates and HMO standards rates until transfer is eventually effected (air ambulance is not included).

C. Hospitalization/In-Patient Services shall include:

1. Room Accommodation:

a. Regular private room; b. If the appropriate room and board accommodation are not available at the time of confinement in a non-emergency case, the patient has the option to avail of a higher room and board accommodation, but he/she shall pay the difference in the room rates and other room-based charges or incremental costs; c. Operating room and recovery room services except suite room and its charges up to the MCLand d. ICU/CCU up to the MCL.

2. Professional services of accredited physician/s, specialist/ s, sub-specialist/s and/or consultant/s. More consultants or specialists may be called in when necessary;

3. Drugs and medicines for use in the hospital;

4. Whole blood and human blood products, transfusions and intravenous fluids, including blood screening and cross matching (excluding screening for donors);

5. X-ray and laboratory examinations;

6. Complete coverage of all diagnostic procedures and examinations including but not limited to MRI, CT Scan, EEG, Ultrasound, Holter monitoring, cardiac catheterization and other state of the art diagnostic and therapeutic procedures deemed necessary;

7. Anesthesia and its administration;

8. Oxygen and its administration;

9. Dressings, sutures, plaster casts and other miscellaneous supplies necessary for treatment;

10. Standard nursing services;

11. Hospital admissions kit;

12. Complete coverage of modern modalities of treatment and diagnostic procedures up to MCL, to include:

a. 3D Imaging b. Acquired (Adult) Hernia c. Angiography d. Venography e. Angioplasty f. 24 hours ambulatory blood pressure monitoring g. Arthroscopic Knee Surgery h. Chemotherapy i. Cryosurgery j. Dialysis k. Echocardiography with Doppler and contrast study l. Electromyelography with nerve conduction m. Endoscopic Procedure eye, ear, nose and throat care including:

i. Cataract surgery. Cost of lens shall not exceed Php5,000 per eye ii. Laser eye treatment except to correct error of refraction iii. Endoscopic sinus surgery iv. Laser Tonsillectomy

n. Flourescein Angiogram o. Hyperalimentation p. Hysteroscopic Myoma Resection q. Laparoscopic Cholecystectomy r. Laser Treatment for Retinal Detachment and Glaucoma s. Lithotripsy t. Mammography u. M-Mode Echocardiogram v. MRA w. Neuroscan x. Nuclear/Radioactive Isotope Scans (thyroid, bone, cardiovascular and other organ systems) ultrasound and brachytherapy (except the cost of radioactive pellets called seeds) y. Orthopedic surgery excluding cost of surgically implanted internal devices z. Pelvic Laparoscopy

aa. Physical Therapy up to 7 sessions per member per year bb. Radiotherapy cc. Thallium Scintigraphy dd. Treadmill Stress Test ee. Transurethral Microwave Therapy ff. Special modalities / Sophisticated Laboratory and Diagnostic procedures that are new in the market and are not readily available, subject to evaluation should there be no other alternative, and upon the recommendation of the contractor's medical director, gg. Speech Therapy up to 7 sessions per member per year hh. Sclerotherapy (not for beautification purposes)

D. Dental Care Services shall include the following:

1. Consultations and dental/oral examinations; 2. Oral Prophylaxis (once-a-year); 3. Any number of simple tooth extractions; 4. Treatment of mouth lesions, wounds and burns; 5. Gum treatment (e.g. for inflammation or bleeding); 6. Temporary restorations (unlimited temporary fillings,temporary caps/crowns); 7. Simple adjustment of dentures; 8. Orthodontic consultations; 9. Temporo Mandibular Joint (TMJ) consultations; 10. Dental/oral health education through chair side instruction.

E. Annual Physical Examination

1. Annual Physical Examinations (APE) shall include a standard battery/array of physical examination and laboratory tests. 2. The various sets of examinations/tests are packaged as follows:

Age Category Examinations Laboratory Tests

For All Ages History and P.E. CBC, Urinalysis, Fecalysis, and Chest X-Ray

35 and above All of above tests plus EKG, Papsmear (for women)

3. The APE of judges and lower court personnel shall be on an out-patient basis at the contractors affiliated clinics; or hospitals assigned for the APE in areas with no affiliated clinics.

F. Reimbursement for prescribed medicines up to Two Thousand Pesos (Php2,000.00) per member per contract year subject to the maximum of Twenty Million Pesos (Php20,000,000.00) per contract year for the whole account excluding vitamins and supplements.

G. Death Benefit:

Financial Assistance up to a limit of Twenty Thousand Pesos (Php20,000.00) shall be given regardless of the cause of death of the employee.

Please be advised accordingly.

16 December 2014

(SGD.) JOSE MIDAS P. MARQUEZ Court Administrator