Updates on Philhealth

“Updates on Membership & Benefits”Technical Session VI – 34th GACPA Convention

Mr. DELIO A. ASERON IIChief Social Insurance Officer

Deputy Spokesperson & Head of Corporate Call CenterCorporate Affairs Group

The National Health Insurance Act of 1995 was signed into Law on February 14, 1995

AN ACT INSTITUTING AAN ACT INSTITUTING A NATIONAL HEALTH NATIONAL HEALTH INSURANCE PROGRAMINSURANCE PROGRAM FOR ALL FILIPINOSFOR ALL FILIPINOSAND ESTABLISHING AND ESTABLISHING

PHILHEALTH FOR THIS PURPOSEFOR THIS PURPOSE

AN ACT INSTITUTING AAN ACT INSTITUTING A NATIONAL HEALTH NATIONAL HEALTH INSURANCE PROGRAMINSURANCE PROGRAM FOR ALL FILIPINOSFOR ALL FILIPINOSAND ESTABLISHING AND ESTABLISHING

PHILHEALTH FOR THIS PURPOSEFOR THIS PURPOSE

M A N D A T Eto provide health insurancecoverage and ensure affordable, acceptable, available & accessiblehealth care services for …

ALL FILIPINOS“Financial Risk Protection”

REPUBLIC ACT 7875As amended by R.A. 9241

The Aquino Health Agenda (AHA): Achieving Universal Health Care for all

Filipinos

…. Universal coverage can only become a reality if everyone pulls together in the same direction……

Universal Health Care Goal

Bawat Pilipino, Miyembro

Bawat Miyembro, Protektado

Kalusugan Natin, Segurado

EMPLOYEDEMPLOYEDEMPLOYEDEMPLOYED

Compulsory coverage of all those formally employed in the

government and private sector(All SSS & GSIS Members)

Er1 + Er2 + PMRF = PhilHealth Identification Card

PhilHealth contribution is deducted every month from their salary. Amount varies based on their

respective salary bracket.Employer shares 50% of premium

Employed Sector: Premium ContributionSalary

Monthly Bracket

Monthly Salary Range

Employed Sector: Premium ContributionSalary Base

(BS)Total MonthlyContribution

Personal Share (PS)

(PS=SB x 1.25%)

Employer Share (ES)(ES=PS)

1 P 4,999.99 and below P 4,000.00 P 100.00 P50.00 P50.00

P 8,000.00 – P 8,999.99

2 P 5,000.00 – P 5,999.99 P 5,000.00 P 125.00 P62.50 P62.50

3 P 6,000.00 – P 6,999.99 P 6,000.00 P 150.00 P75.00 P75.00

4 P 7,000.00 – P 7,999.99 P 7,000.00 P 175.00 P87.50 P87.50

5 P 8,000.00 P 200.00 P100.00 P100.00

23 P 26,000.00 - P 26,999.99 P 26,000.00 P 650.00 P 325.00 P 325.00

24 P 27,000.00 - P 27,999.99 P 27,000.00 P 675.00 P 337.50 P 337.50

25 P 28,000.00 - P 28,999.99 P 28,000.00 P 700.00 P 350.00 P 350.00

26 P 29,000.00 - P 29,999.99 P 29,000.00 P 725.00 P 362.50 P 362.50

27 P 30,000.00 - UP P 30,000.00 P 750.00 P 375.00 P 375.00

“ Those who earn more, must contribute more to the common fund! ”

PhilHealth Circular No. 11, s. 2012 New Premium Schedule for the Formal Sector

Effective JANUARY 1, 2013

Mpnthly Salary Range Monthly Premium Rate

EmployerShare

Employee Share

P7,000 & Below P 210. 00 P105 P105

P7,000 to P50,000 3 % 1.5 % 1.5 %

P50,000 & Above P1,500. 00 P750 P750

All ERs are hereby reminded that monthly premium contributions should be remitted on or before the 10th day of the month following the applicable month at any PhilHealth Offices or through PhiiHealth Accredited Collecting Agents nationwide. It must be supported by a monthly Employer Remittance List (RF-1) which shall be submitted to nearest PhilHealth Local Health Insurance Offices not later than the 15th day of the month following the applicable month.

Overseas Workers ProgramOverseas Workers Program

Apart from existing benefits being provided by OWWA, Overseas worker-members are assured of a more expanded benefit package which they can avail of in times of medical contingencies.

•Premium Contribution is pegged at Php 1,200.00 a year.

•Overseas workers may likewise pay their premiums in their place of employment using the currency where their payments will be made.

* A PhilHealth Certification Eligibility shall be issued for this purpose.

SponsoredSponsoredProgramProgram•LGU

•Legislative•Private

•Gov’t Agencies

SponsoredSponsoredProgramProgram•LGU

•Legislative•Private

•Gov’t AgenciesAside from the regular Philhealth Medicare

Benefits, the indigent members can also avail the

PRIMARY CARE BENEFIT PACKAGE from the

accredited RHUs/Health Centers (Ex. Sputum

Microscopy, Fecalysis, CBC, Chest X-ray etc.)

A joint partnership between Philhealth and the LGU/ Fund Sponsors in subsidizing the one (1) year

FREE PhilHealth coverage of the “poorest of the poor” constituents

Basis: DSWD’s NHTS-PR Masterlist

Individually Paying ProgramIndividually Paying ProgramIndividually Paying ProgramIndividually Paying Program

Premium contribution can be paid Quarterly (P600), Semi-annually

(P1,200), or Annually (P 2,400) . Hence, only P200 a month or P 6.70 a day! * (below P25K)

*All existing (active/inactive) SSS Self-employed/Voluntary Members *No Employer-Employee Relationship*Categorized under the Informal Sector *Disqualified as a legal dependent or from other program component of NHIP

3 STEPS ENROLMENT PROCEDURE1. Go to the nearest Service Office or directly to the Central Office2. Fill-up one (1) PhilHealth Member Registration Form (PMRF) & attach documentary requirements for declared qualified dependents3. Pay at least one (1) quarter (P600.00). Then present the validated receipt to secure the PhilHealth Identification Card (PIC) & MDR.*You can pay your succeeding contribution to any Accredited Banks/ Bayad-Centers

Self-PracticingProfessionals

Transport Sector

Self-EmployedBarangay

Sector

Individually Paying Members•All existing (active / inactive) members of the SSS Self-employed / Voluntary Program

•Individuals who don’t have an established/existing Employer-Employee Relationship

•Those who are categorized under the Informal Sector (based on the definition of ILO)

•Those individuals who failed to qualify from the other program components of the NHIP but wishes to join the program by paying for their own premium contributions

Others

-Lawyers-Doctors-Consultants-Freelance Journalist-Etc.

-Jeepney Drivers-Tricycle Drivers-Transport Operators-FX/Taxi Drivers-Etc.

-Sari-sari Store Owners-Market vendors-Single proprietors-Entertainment Industry-Sidewalk vendors -Etc.

-Brgy. Tanods-Brgy. Health Workersand other Volunteer workers-Etc

-Organized Groups

-Contractors-House Helpers-Religious Sector-Disqualified as Indigent /Non-Paying Members-Etc.

Market Segmentation of Potential Members

Be an advocate of PhilHealth!

O.W.P.O.W.P.

LIFETIME MEMBERSHIP PROGRAM (PhilHealth’s Long Term Benefit)

Must have reached the age of 60 years old and above AND Must have contributed at least 120 monthly contributions (10 years)

The National Health Insurance Program (NHIP)

Average of 3-5 dependents per household

I.P.P.I.P.P.I.P.P.I.P.P.

BEMPLOYEDEMPLOYEDEMPLOYEDEMPLOYED

A SPONSORED

LGULGULegislativeLegislative

PrivatePrivate Gov’t AgenciesGov’t Agencies

SPONSORED

LGULGULegislativeLegislative

PrivatePrivate Gov’t AgenciesGov’t Agencies

D

C

E

ncr-centralncr-central

REGISTRATION PROCEDURE:REGISTRATION PROCEDURE:

A.A. Declare as Dependent of one of the Declare as Dependent of one of the Member-ChildMember-Child

Requirements:

1. Properly accomplished PMRF (to be accomplished by the Member-Child)2 Supporting documents: Member’s Birth Certificate & Parent’s Proof of age

NOTNOT QUALIFIED?QUALIFIED?

SENIOR SENIOR CITIZENCITIZEN

B.B. Enroll under IPPEnroll under IPP

Requirements:

1. Properly accomplished PMRF2. Quarterly Payment of Php 600.00

C.C. Enroll under Sponsored ProgramEnroll under Sponsored Program

- Depending on the existing programimplementation in the city/municipality.- Inquire at LGU-Local Social Welfare Ofc

45 DAYS / Calendar Year

(exclusive for the member)MEMBER

45 DAYS / Calendar Year (to be shared by qualified

dependents)

Coverage that extends to your immediate family

•Legitimate spouse not yet a PhilHealth member

• Children 20 years old below, single & unemployed (legitimate, illegitimate, stepchildren, adopted, etc).

• Parents-60 years old and above and not a

GSIS or SSS Retiree / Pensioner

(biological parent, step parent & adoptive parent)

DEPENDENTS

PhilHealth Identification CardsPhilHealth Identification Cards

EMPLOYED

INDIVIDUALLY PAYING MEMBERS

OFWs

SPONSORED

LIFE TIME MEMBER


Jan.1, 2011 – Dec. 31, 2011

Register now in all SM Malls & Bayad Centers P50.00 per card ; must be an ACTIVE member!

Has a space for member’s photograph and biometric capture

Health Insurance Card

Will serve as a key card for hospitals and merchant-partners to access member records

Updating of Member’s Data RecordUpdating of Member’s Data Record

Submit a properly accomplished PMRF Form and attach the necessary supporting requirements…

•Legal Spouse – Xerox of Marriage Contract

•All Children 20 yrs.old below – Xerox of Birth Certificate

•Parents above 60 yrs. old – Senior Citizen’s ID & Member’s Birth Certificate


What are my Benefits?What are my Benefits?

A. In-Patient Care ( FEE FOR SERVICE SCHME)

Allowance for:

Room and Board

Drugs and Medicines

X-Ray and Laboratories

Operating Room Fees

Professional Fees

Confinement of less than 24 hours will not be paid except the ff:

1. Case is Emergency

2. Patient is Transferred to another Hospital

3. Patient Expired


NewNew Inpatient PhilHealth Benefits Schedule For all PHIC Members and their Dependents

Levels 3 & 4 Hospitals (Tertiary)

Benefit Item Case Type

A B C D

Room & Board(maximum of 45 days/year)

P500 P500 P800 P1,100

Drugs and Medicines(per single period of confinement)

P4,200 P14,000 P28,000 P40,000

X-ray, Lab & Others(per single period of confinement)

P3,200 P10,500 P21,000 P30,000

Operating RoomFor procedures with RVU 30 and below = 1,2001,200

For procedures with RVU 31 to 80 = 1,5001,500

For procedures with RVU 80 to 600: RVU x PCF 20RVU x PCF 20 (minimum = 3,500)


Admissions starting April 05, 2009 (Circular 09, s. 2009)

NewNew Inpatient PhilHealth Benefits Schedule

Levels 3 & 4 Hospitals (Tertiary)

Professional Fees Case Type

A B C D

A. Daily Visits

Gen. Practitioner (Groups 1, 5 and 6)

Per day P300 P400 P500 P600

Maximum per confinement P1,200 P2,400 P4,000 P6,000

Specialist (Groups 2, 3 & 4)

Per day P500 P600 P700 P800

Maximum per confinement P2,000 P3,600 P5,600 P8,000

B. Surgery

For RVU 500 and below For RVU 501 and above

Surgeon Anesthesiologist Surgeon Anesthesiologist

Gen. Practitioner (1st Tier – Group 1) RVU x PCF 40 = PF1 40% of surgeon’s fee (PF1)

RVU x PCF 40 = PF1

40% of surgeon’s fee (PF1)

With Training (2nd Tier – Group 5 & 6) RVU x PCF 48 = PF2 48% of surgeon’s fee (PF1)

RVU x PCF 48 = PF2


Diplomate / Fellow (3rd Tier – Group 2, 3, 4)

RVU x PCF 56 = PF3 56% of surgeon’s fee (PF1)

RVU x PCF 80 = PF4



Admissions starting April 05, 2009 (Circular 09, s. 2009)


B. Out-Patient Care

Allowance for:

Drugs and Medicines

X-ray and Laboratories

Operating Room Fees

Professional Fees

SAMPLE CASES:

Day surgeries

Dialysis

Cancer treatment procedures such as:

chemotherapy

radiotherapy

Procedures must be performed in Philhealth Accredited Hospital and Free-Standing Clinics

confinement / admission in a non-accredited hospital/ facility can be paid if the case is emergency, the facility has current DOH License and when physical transfer / referral to accredited health care institution is impossible



C. Special Benefit Packages Maternity Care Package (Accredited Non-Hospital Facilities)**

•Facility Fee = Php 6,500. 00•Member’s Pre-natal Care = Php 1,500. 00

Normal Spontaneous Delivery (NSD) ** up to *4th Normal Delivery * Level 1 Hospitals = Php 8,000 (Php 1,500 Pre-Natal & Php 6,500 Facility)•Level 2 to 4 Hospitals = Php 6,500 (Php 1,500 Pre-Natal & Php 5,000 Facility)

**Admissions starting September 1, 2011 (Circular 11, s. 2011)

New Born Care Packageincludes care services: Eye prophylaxis, umbilical cord care,

vitamin K, thermal care & BCG & resuscitation, 1st dose of Hepatitis B immunization, New Born Screening tests – ( a total of Php 1,750 )


New Case Rates for Selected Surgical Cases:New Case Rates for Selected Surgical Cases:

Effective September 1, 2011 (9/12 Rule)

Cesarian Section (CS) = Php 19,000

Dilation & Curettage = Php 11,000

Hysterectomy = Php 30,000

Mastectomy = Php 22,000

Appendectomy = Php 24,000

Cholecystectomy = Php 31,000

Herniorrhaphy = Php 21,000

Thyroidectomy = Php 31,000

Radiotherapy = Php 3,000

Hemodialysis = Php 4,000

Cataract = Php 16,000


New Case Rates for Selected Medical Cases:New Case Rates for Selected Medical Cases:

Effective September 1, 2011 (3 / 6 Rule)

Dengue I (Dengue Fever & DHF Grades I & II) = Php 8,000

Dengue II (Dengue Hemorrhagic Fever Grades III & IV) = Php 16,000

Pneumonia I (Moderate Risk) = Php 15,000

Pneumonia II (High Risk) = Php 32,000

Essential Hypertension = Php 9,000

Cerebral Infarction (CVA I) = Php 28,000

Cerebro-Vascular (CVA II) = Php 38,000

Acute Gastroenteritis (AGE) = Php 6,000

Typhoid Fever = Php 14,000

Asthma = Php 9,000

** NO BALANCE BILLING POLICY – Sponsored Beneficiaries in Gov’t. Hospitals


Common Reasons for Denial of Claims:Common Reasons for Denial of Claims:

Late Filing / Re-filing (filing beyond 60 days)

Filing Period: 60 DAYS from the date of discharge

Note: if the 60th day falls on a Saturday, Sunday, or Holiday (legal/declared), the 60th day to be considered is the following working day

Case is not compensable

No Qualifying Contribution

Patient is not a legal dependent

Non-compliance to previous request


Improved PhilHealth Benefits

and other Updates

Catastrophic

• Case type Z

– Coordinated benefits with Office of the President, PCSO, PAGCOR– Childhood Leukemia, Breast & Prostate Cancer and Renal Transplant, etc.– Circular & Implementing rules to be finalized soon

Improved Case Rates

• Improved and expanded payments by case rates

• Expansion of No Balance Billing (NBB)– Offer incentives to hospitals (both public and

private) who sign up for NBB• Can even be just a number of NBB beds

from the total hospital beds of a hospital

• More user-friendly

• Inclusion of several online services• Packed with necessary information

The New Corporate Website

• A web-based application for individuals who want to sign up with PhilHealth.

Electronic Registration

• Visitors can register as IPM, OFW, Lifetime Member or Employed Member

• Called Claims Eligibility Web Service (CEWS)

e-Claims Project Phase I

• Minimize RTH

• Enables accredited institutional health care providers to check the eligibility of the member

• View locations of PhilHealth’s Regional and Branch Offices

Online Mapping Services

• View accredited health facilities• View Corporate data using statistical maps

Please Remember . . .

Website: www.philhealth.gov.phFacebook: www.facebook/PhilHealth

Email Address: [email protected]

Help Lines: : 4417442

We do conduct We do conduct FREEFREE PhilHealth PhilHealth Seminars!Seminars!

http://www.philhealth.gov.ph/

http://www.facebook/PhilHealth

Thank you!

[email protected]@yahoo.com

Updates on Philhealth

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