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COMMISSION ON AUDIT MEMORANDUM NO.

2001-041
September 12, 2001

TO : All COA Officials and Employees

SUBJECT : Revised/Restated Guidelines in the Implementation of the COA


Medical Assistance Program

1.0 RATIONALE

This Memorandum is being issued to provide increased medical benefits to


Personnel Welfare and Assistance (PWA) members in line with the continuing
policy of the Commission to maintain a medical assistance program responsive
to the needs of its members.

2.0 DEFINITION OF TERMS

For purposes of this Memorandum, the following terms shall be construed to


mean, as follows:

2.1 Major Medical Case

Serious illness or injury, dreaded disease or catastrophic condition which


requires or needs special diagnostic procedures, highly specialized or
sophisticated apparatus/facility, or prolonged hospital care.

2.2 Minor Medical Case

Ordinary illness or disease other than those categorized under the Major
Medical Case.

2.3 Major Surgical Case

Surgery involving the brain, heart, lungs, abdominal organs (gastro-


intestinal, genito-urinary, liver, gallbladder, pancreas, spleen and
reproductive organs), vertebral column and severe traumatic injuries
needing amputations of the upper and lower extremities, as well as those
cases using general anaesthesia.

2.4 Minor Surgical Case


Surgery other than those categorized under the Major Surgical Case.

2.5 Emergency Case

A condition where the sudden onset of illness/physical injury occurs and


generally requires immediate medical or surgical attention which, if not
rendered, threatens his life or will result in the loss of function of limb,
eyesight or any vital part of his body due to accident, heart attack, cerebro-
vascular accident, animal bites, stab wound, and other serious wounds
which are life threatening.

2.6 Convalescent Care/Intermediate Care

Care in a hospital, nursing home or similar institutions for the purpose of


recuperating after a member has been discharged from a hospital.

2.7 Custodial Care

Care other than for the care or alleviations of a medical condition which is
provided for reasons of a member’s physical or mental inability to tend for
himself.

2.8 Domiciliary Care

Care in a hospital, nursing home or similar establishment for a treatment


which in normal circumstances would be carried out in the home.

2.9 Member-in-good-standing (MIGS)

A member in-good-standing is one who has complied with all his required
financial obligations with the PWA, such as payment of regular
contributions and loan amortizations.

3.0 AVAILMENT

3.1 The Medical Assistance Program (MAP) shall be available to all members
of the PWA who are "in good standing", as defined in 2.9.

3.2 A member who is suspended from the service shall not lose his benefit
under the MAP or shall it be diminished by reason of such suspension
provided that the member remains to be "in good standing".

3.3 Should a member be "not in good standing" for failure to comply with any
of his financial obligations with the PWA, his benefits under the MAP
shall be suspended until after he has complied with all his PWA financial
obligations.

4.0 GUIDELINES
4.1 FUNDING

4.1.1 The MAP Fund shall be sourced from the contributions of the
members and savings of the Commission.

4.1.2 Each member shall contribute monthly one-half of one percent (1/2
of 1%) of his basic monthly salary, through payroll deduction,
which shall be given priority after the mandatory statutory
deductions.

4.1.3 If the member’s contributions are not paid due to suspension from
the service, or leave of absence, the arrearages shall be deducted
from his first salary claim upon resumption to office, or the
member may pay directly to the PWA.

4.1.4 The Commission shall contribute additional funds to the MAP


Fund upon the recommendation of the PWA Board of Trustees and
approval by the Commission Proper.

4.2 MEDICAL BENEFITS

4.2.1 Medical benefits shall be granted to members when confined in a


hospital or clinic for at least twelve hours due to illness or injury
requiring hospitalization.

4.2.2 No minimum period of confinement in a hospital or clinic is


required if the member:

4.2.2.1 was treated due to an emergency case such as those


mentioned in 2.5;

4.2.2.2 undergoes surgical procedure on an outpatient basis;

4.2.2.3 receives chemotherapy, radiotherapy, dialysis, and the


like.

4.2.3 Expenses incurred by the member on account of illness or injury


requiring confinement or treatment as defined under 4.2.2 shall be
paid on a reimbursement basis.

4.2.4 The maximum amount a member may avail in one year shall not
exceed sixty thousand pesos (P60,000.00), regardless of the
number of times of confinement.

4.2.5 Actual hospitalization expenses not exceeding the following may


be reimbursed:

Medical Case Surgical Case


Benefit Item Minor Major Minor Major

Room/day 630 630 630 630


Medicines/drugs 4,140 9,900 2,340 9,900
Laboratory & other services 4,500 5,625 4,500 7,875
Surgeon/Anaesth.’s fees -- -- 9,000 22,500
Physician’s fee/day 300 300 300 300

The above schedule of rates shall be applicable in every confinement


subject to the limitations set under 4.3.4.

4.2.6 The benefit for medicines/drugs shall include prescription drugs


and biologicals bought outside the hospital or clinic but shall be
limited to those which were actually administered to the member
during the period of his confinement or treatment in the hospital or
clinic.

4.2.7 The following cases shall not be covered by the schedule of rates
under 4.2.5 but shall not exceed the annual limit provided in 4.2.4:

4.2.7.1 members who are receiving chemotherapy, radiotherapy,


dialysis and the like; or

4.2.7.2 members who incurred expenses for hospital bill and


professional fees in a single confinement amounting to
P200,000 or more.

4.2.8 The benefits granted under the MAP shall be net of 50% of the
member’s Medicare benefits. In no case, however, shall the net
benefit exceed the total hospitalization/medical expenses of the
member concerned.

4.2.9 The benefits under this program shall not include expenses and
charges for:

4.2.9.1 Treatment of any injury attributable to a member’s own


misconduct, gross or contributory negligence, use of
illegal drugs, intemperate use of alcoholic beverages,
vicious or immoral acts, direct or indirect participation in
the commission of a crime, violation of a law or
ordinance.

4.2.9.2 Treatment of injury or illness resulting from suicide or


self-destruction, whether sane or insane.

4.2.9.3 Custodial, domiciliary, convalescent, intermediate and


maternity care including all other conditions that may
arise as a result of pregnancy, caesarian operation and
normal delivery.

4.2.9.4 Cosmetic services, plastic and reconstructive surgery,


experimental procedures, sex transformation, acupuncture
and services related to fertility, infertility, artificial
insemination, circumcision and organ transplant.

4.2.9.5 Long-term rehabilitation, speech therapy and psychiatric


conditions.

4.2.9.6 Sexually transmitted diseases

4.2.9.7 Medical/physical check-up

4.2.9.8 Maintenance medicines

4.2.9.9 All other items not directly related to the medical


management of the member-employee such as extra bed,
extra food, television and other amenities.

4.2.10 Cases not specifically covered by the above shall be referred to the
Board of Trustees for evaluation.

4.2.11 Members who are enrolled in other health insurance plans shall be
allowed to claim medical reimbursement from the Program.

4.3 SETTLEMENT OF CLAIMS

4.3.1 Claims shall be submitted to the PWA, Office of the Chairman.

4.3.2 Each claim shall be supported by the following:

4.3.2.1 Hospital Medical Certificate issued by the Clinic/Hospital


Medical Records Officer indicating therein, among other
things, the period of confinement and
illness/diagnosis/treatment.

4.3.2.2 Hospital/Clinic Statement of Account

4.3.2.3 Official Receipts issued by the hospital/clinic, doctors and


drug stores

4.3.2.4 Certificate of Payment issued by the concerned entity


indicating therein the breakdown of payment for hospital
bill and professional fees (if the hospital bill and
professional fees were paid by an entity where the
member is also enrolled)

4.3.2.5 Clinical data or Operating Room Record if the


illness/diagnosis is not indicated in the Medical
Certificate, or if there is a need for further clarification of
illness/diagnosis, or if the member-claimant underwent
surgical operation as an out-patient, duly certified by an
authorized hospital/clinic staff.

4.3.3 Claims with supporting documents that are incomplete or do not


conform with the requirements as stated above shall be returned to
the concerned member-claimant for completion of the required
supporting documents.

4.4 TERMINATION OF BENEFITS

The benefits under the MAP of the PWA member shall be terminated upon
resignation, retirement, transfer, expulsion or voluntary termination in case
the member decides to terminate such membership while still in the
service.

5.0 EFFECTIVITY

This Memorandum shall take effect 01 September 2001 in so far as those which
are inconsistent with previous issuances on the matter.

(Sgd.) GUILLERMO N.
CARAGUE
Chairman