Government Procurement of Health Coverage from HMOs

Introduction: In light of Executive Order 150 and COA Resolution No. 2024-004, government agencies, GOCCs, and GFIs are now permitted to procure health coverage from private Health Maintenance Organizations (HMOs). This guide provides a detailed overview of the procurement process, the scope of PhilHealth coverage, and the exclusions that necessitate supplemental HMO coverage.

Understanding the COA Resolution: The Commission on Audit (COA) has allowed government entities to purchase healthcare coverage from private HMOs for services not covered by PhilHealth. This move aims to fill the gaps in healthcare services provided to government employees.

PhilHealth Coverage Inclusions: PhilHealth covers essential health services, including:

1. Basic and essential health services for select inpatient and outpatient services.

2. Primary care services and select diagnostic and commodities.

3. Select catastrophic cases.

PhilHealth Coverage Exclusions: Certain services are excluded from PhilHealth coverage, necessitating supplemental HMO coverage:

1. Hospital amenities.

2. Expanded choice of specialists and health facilities.

3. Specialist outpatient care.

4. Most outpatient drugs.

5. Non-PNF drugs.

6. Commodities, devices, and procedures without HTA.

7. Outpatient emergency services.

8. Select rehabilitative and palliative care.

9. Annual Physical Examination.

Cost Sharing with PhilHealth: PhilHealth allows cost-sharing for:

1. Fixed co-pay in public hospitals and Z Benefits contracted hospitals.

2. Additional costs in private hospitals and clinics.

Compliance and Certification: Government entities must comply with COA rules when procuring private health coverage. PhilHealth will cease issuing individual certifications and will announce the availability of PhilHealth Plus, a supplemental coverage plan. Agencies must ensure that HMO coverage does not overlap with PhilHealth benefits and that premiums are discounted based on assumed PhilHealth payments.

Conclusion: This guide ensures that government agencies, GOCCs, and GFIs can effectively navigate the procurement of health coverage from private HMOs, ensuring comprehensive healthcare for their employees while adhering to COA guidelines.

Reference: Guidance on Procurement of Health Coverage from Private Health Maintenance Organizations (HMOs) by Government Agencies