The following are the maximum allowances or ceilings to be applied per single period of confinement** effective April 5, 2009 admissions onwards.
| Level 2 Hospitals (Secondary) | |||
|---|---|---|---|
| Benefit Item | Case Type | ||
| A | B | C | |
| Room and Board (maximum of 45 days per year) |
400 | 400 | 600 |
| Drugs and Medicine (per single period of confinement) |
3,360 | 11,200 | 22,400 |
| X-ray, Laboratory and Others (per single period of confinement) |
2,240 | 7,350 | 14,700 |
| Operating Room | For procedures with RVU 30 and below = 750 For procedures with RVU 31 to 80 = 1,200 For procedures with RVU 81 to 600: RVU x PCF 15 (minimum = 2,200 and maximum = 7,500) |
||
| Professional Fees | |||
| a. Daily Visits | |||
| General Practitioner (Groups 1, 5, & 6) | |||
| Per Day | 300 | 400 | 500 |
| Maximum per confinement | 1,200 | 2,400 | 4,000 |
| Specialist (Groups 2, 3, & 4) | |||
| Per Day | 500 | 600 | 700 |
| Maximum per confinement | 2,000 | 3,600 | 5,600 |
| b. Surgery (for Case Type A, B and C) | |||
| Surgeon | Anesthesiologist | ||
| General Practitioner 1st Tier (Group 1) |
RVU x PCF 40=PF1 maximum of 3,200 |
40% of surgeon's fee (PF1) maximum of 1,280 |
|
| With Training 2nd Tier (Group 5 and 6) |
RVU x PCF 48=PF2 | 48% of surgeon's fee (PF1) | |
| Diplomate/Fellow 3rd Tier (Group 2, 3 and 4) |
RVU x PCF 56=PF3 | 56% of surgeon's fee (PF1) | |
* Not to exceed 45 days for each calendar year.
** Refers to a confinement or series of confinements of the same illness
not separated from each other by 90 days within a calendar year. In this
case, a member or beneficiary is not entitled to another set of benefits
until after 90 days. They can only avail of the unused portion of the benefits
and the room and board fees until the 45 days allowance is exhausted.
However, a member can avail of new set of benefits if succeeding confinements are of different illness or condition.