COA MEMORANDUM NO.

2001-041

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 (MILS)

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 he 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, acupunture 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.