Updates on Membership & Benefits

Technical Session VI 34th GACPA Convention

Mr. DELIO A. ASERON II

Chief Social Insurance Officer Deputy Spokesperson & Head of Corporate Call Center Corporate Affairs Group

REPUBLIC ACT 7875

As amended by R.A. 9241

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

AN ACT INSTITUTING A NATIONAL HEALTH INSURANCE PROGRAM FOR ALL FILIPINOS AND ESTABLISHING

MANDATE
to provide health insurance coverage and ensure affordable, acceptable, available & accessible health care services for

ALL FILIPINOS
Financial Risk Protection

PHILHEALTH

FOR THIS PURPOSE

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

Compulsory coverage of all those formally employed in the government and private sector (All SSS & GSIS Members)

EMPLOYED

PhilHealth contribution is deducted every month from their salary. Amount varies based on their respective salary bracket. Employer shares 50% of premium

Er1 + Er2 + PMRF =

PhilHealth Identification Card

Employed Sector: Premium Contribution

Salary Monthly Bracket Monthly Salary Range Salary Base Total Monthly (BS) Contribution Personal Employer Share (PS) Share (ES) (PS=SB x 1.25%) (ES=PS)

1
2 3 4 5 23 24 25 26

P 4,999.99 and below P 4,000.00

P 5,000.00 P 5,999.99 P 6,000.00 P 6,999.99 P 7,000.00 P 7,999.99 P 8,000.00 P 8,999.99 P 26,000.00 - P 26,999.99 P 27,000.00 - P 27,999.99 P 28,000.00 - P 28,999.99 P 29,000.00 - P 29,999.99 P 5,000.00 P 6,000.00 P 7,000.00 P 8,000.00 P 26,000.00 P 27,000.00 P 28,000.00 P 29,000.00

P 100.00
P 125.00 P 150.00 P 175.00 P 200.00 P 650.00 P 675.00 P 700.00 P 725.00

P50.00
P62.50 P75.00 P87.50 P100.00 P 325.00 P 337.50 P 350.00 P 362.50

P50.00
P62.50 P75.00 P87.50 P100.00 P 325.00 P 337.50 P 350.00 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 Employer Share Employee Share

P7,000 & Below P7,000 to P50,000 P50,000 & Above

P 210. 00 3% P1,500. 00

P105 1.5 % P750

P105 1.5 % 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 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.

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:

DSWDs NHTS-PR Masterlist

Sponsored Program
LGU Legislative Private Govt Agencies

Aside 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.)

*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

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)

Individually Paying Program

3 STEPS ENROLMENT PROCEDURE 1. Go to the nearest Service Office or directly to the Central Office 2. Fill-up one (1) PhilHealth Member Registration Form (PMRF) & attach documentary requirements for declared qualified dependents 3. 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

Market Segmentation of Potential Members

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

Self-Practicing Professionals
-Lawyers
-Doctors -Consultants -Freelance Journalist -Etc.

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

Self-Employed

Barangay Sector

Others

-Sari-sari Store Owners -Brgy. Tanods

-Market vendors -Single proprietors and other Volunteer -Entertainment Industry workers -Sidewalk vendors -Etc -Etc.

-Organized Groups -Brgy. Health Workers -Contractors

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

Be an advocate of PhilHealth!

The National Health Insurance Program (NHIP)

Average of 3-5 dependents per household

A
EMPLOYED

O.W.P.
E

SPONSORED
LGU Legislative Private Govt Agencies

C B I.P.P. D

LIFETIME MEMBERSHIP PROGRAM (PhilHealths 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)

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REGISTRATION PROCEDURE:
NOT QUALIFIED? A. Declare as Dependent of one of the Member-Child
Requirements:

1. Properly accomplished PMRF (to be accomplished by the Member-Child) 2 Supporting documents: Members Birth Certificate & Parents Proof of age B. Enroll under IPP

SENIOR CITIZEN

Requirements:

1. Properly accomplished PMRF 2. Quarterly Payment of Php 600.00

C. Enroll under Sponsored Program - Depending on the existing program implementation in the city/municipality. - Inquire at LGU-Local Social Welfare Ofc

Coverage that extends to your immediate family

45 DAYS / Calendar Year

(exclusive for the member)

MEMBER

45 DAYS / Calendar Year

(to be shared by qualified dependents)
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

DEPENDENTS

(biological parent, step parent & adoptive parent)

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PhilHealth Identification Cards

EMPLOYED

INDIVIDUALLY PAYING MEMBERS OFWs

Jan.1, 2011 Dec. 31, 2011

SPONSORED

LIFE TIME MEMBER

 Register now in all SM Malls & Bayad Centers

P50.00 per card ; must be an ACTIVE member!

Health Insurance Card

Has a space for members photograph and biometric capture Will serve as a key card for hospitals and merchant-partners to access member records

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Updating of Members 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 Citizens ID & Members Birth Certificate

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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

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New Inpatient PhilHealth Benefits Schedule

For all PHIC Members and their Dependents
Admissions starting April 05, 2009 (Circular 09, s. 2009)

Levels 3 & 4 Hospitals (Tertiary)

Benefit Item
A B

Case Type
C D

Room & Board

(maximum of 45 days/year)

P500 P4,200 P3,200

P500 P14,000 P10,500

P800 P28,000 P21,000

P1,100 P40,000 P30,000

Drugs and Medicines

(per single period of confinement)

X-ray, Lab & Others

(per single period of confinement)

For procedures with RVU 30 and below = 1,200

Operating Room

For procedures with RVU 31 to 80 = 1,500 For procedures with RVU 80 to 600: RVU x PCF 20 (minimum = 3,500)

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New Inpatient PhilHealth Benefits Schedule

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

Levels 3 & 4 Hospitals (Tertiary)

Professional Fees
A A. Daily Visits Gen. Practitioner (Groups 1, 5 and 6) B

Case Type
C D

Per day
Maximum per confinement Specialist (Groups 2, 3 & 4)

P300
P1,200

P400
P2,400

P500
P4,000

P600
P6,000

Per day
Maximum per confinement B. Surgery

P500
P2,000

P600
P3,600

P700
P5,600

P800
P8,000

For RVU 500 and below

Surgeon Anesthesiologist 40% of surgeons fee (PF1) 48% of surgeons fee (PF1) 56% of surgeons fee (PF1)

For RVU 501 and above

Surgeon RVU x PCF 40 = PF1 RVU x PCF 48 = PF2 RVU x PCF 80 = PF4 Anesthesiologist 40% of surgeons fee (PF1) 48% of surgeons fee (PF1) 40% of surgeons fee (PF4)

Gen. Practitioner (1st Tier Group 1) With Training (2nd Tier Group 5 & 6) Diplomate / Fellow (3rd Tier Group
2, 3, 4)

RVU x PCF 40 = PF1 RVU x PCF 48 = PF2 RVU x PCF 56 = PF3

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What are my Benefits?

B. Out-Patient Care
Allowance for:
Drugs and Medicines X-ray and Laboratories Operating Room Fees Professional Fees SAMPLE CASES: Day surgeries
Procedures must be performed in Philhealth Accredited Hospital and Free-Standing Clinics

Dialysis chemotherapy radiotherapy

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

Cancer treatment procedures such as:

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What are my Benefits?

C. Special Benefit Packages
Maternity Care Package (Accredited Non-Hospital Facilities)** Facility Fee = Php 6,500. 00 Members 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 Package includes 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 )

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New Case Rates for Selected Surgical Cases:

Effective September 1, 2011 (9/12 Rule)
Cesarian Section (CS) Dilation & Curettage Hysterectomy Mastectomy Appendectomy Cholecystectomy Herniorrhaphy Thyroidectomy Radiotherapy Hemodialysis Cataract = = = = = = = = = = = Php 19,000 Php 11,000 Php 30,000 Php 22,000 Php 24,000 Php 31,000 Php 21,000 Php 31,000 Php 3,000 Php 4,000 Php 16,000

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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) = Pneumonia II (High Risk) Essential Hypertension Cerebral Infarction (CVA I) Cerebro-Vascular (CVA II) Acute Gastroenteritis (AGE) Typhoid Fever Asthma = = = = = = = Php 15,000 Php 32,000 Php 9,000 Php 28,000 Php 38,000 Php 6,000 Php 14,000 Php 9,000

** NO BALANCE BILLING POLICY Sponsored Beneficiaries in Govt. Hospitals

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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

The New Corporate Website

More user-friendly Packed with necessary information Inclusion of several online services

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

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

e-Claims Project Phase I

Called Claims Eligibility Web Service (CEWS) Enables accredited institutional health care providers to check the eligibility of the member

Minimize RTH

Online Mapping Services

View locations of PhilHealths Regional and Branch Offices View accredited health facilities View Corporate data using statistical maps

Please Remember . . .

Help Lines: : 4417442

Website: www.philhealth.gov.ph Facebook: www.facebook/PhilHealth Email Address: info@philhealth.gov.ph

We do conduct FREE PhilHealth Seminars!

Thank you!

delioaseron@yahoo.com