Presentation on theme: "“Updates on Membership & Benefits”"— Presentation transcript:
1 “Updates on Membership & Benefits” Technical Session VI – 34th GACPA ConventionMr. DELIO A. ASERON IIChief Social Insurance OfficerDeputy Spokesperson & Head of Corporate Call CenterCorporate Affairs Group
2 REPUBLIC ACT 7875 ALL FILIPINOS As amended by R.A. 9241The National Health Insurance Act of 1995 wassigned into Law on February 14, 1995AN ACT INSTITUTING ANATIONAL HEALTHINSURANCE PROGRAMFOR ALL FILIPINOSAND ESTABLISHINGPHILHEALTHFOR THIS PURPOSEM A N D A T Eto provide health insurancecoverage and ensure affordable,acceptable, available & accessiblehealth care services for …ALL FILIPINOS“Financial Risk Protection”
3 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……Kalusugan Pangkalahatan is the country’s health reform agenda. Its main aim is to provide financial risk protection for all Filipinos, especially the poor, by ensuring universal PhilHealth coverage and improving the benefits of PhilHealth.
4 Universal Health Care Goal Bawat Pilipino, Miyembro Bawat Miyembro, Protektado Kalusugan Natin, Segurado
5 (All SSS & GSIS Members) Compulsory coverage of all those formally employed in the government and private sector(All SSS & GSIS Members)EMPLOYEDPhilHealth contribution is deducted every month from their salary.Amount varies based on their respective salary bracket.Employer shares 50% of premiumEr1 + Er2 + PMRF =PhilHealth Identification Card
6 Employed Sector: Premium Contribution SalaryMonthlyBracketMonthly SalaryRangeSalary Base(BS)PersonalShare (PS)EmployerShare (ES)Total MonthlyContribution(PS=SB x 1.25%)(ES=PS)1P 4, and belowP 4,000.00PP50.00P 8, – P 8,999.992P 5, – P 5,999.99P 5,000.00PP62.503P 6, – P 6,999.99P 6,000.00PP75.004P 7, – P 7,999.99P 7,000.00PP87.505P 8,000.00PP100.0023P 26, P 26,999.99P 26,000.00PP24P 27, P 27,999.99P 27,000.00PP25P 28, P 28,999.99P 28,000.00PP26P 29, P 29,999.99P 29,000.00PP27P 30, UPP 30,000.00PP“ Those who earn more, must contribute more to the common fund! ”
7 PhilHealth Circular No. 11, s. 2012 New Premium Schedule for the Formal Sector Effective JANUARY 1, 2013Mpnthly Salary RangeMonthly Premium RateEmployerShareEmployee ShareP7,000 & BelowPP105P7,000 to P50,0003 %1.5 %P50,000 & AboveP1,P750All 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.
8 Overseas Workers Program Apart from existing benefits being provided by OWWA,Overseas worker-members are assured of a more expanded benefitpackage which they can avail of in times of medical contingencies.Premium Contribution is pegged at Php 1, a year.Overseas workers may likewise pay their premiums in their place ofemployment using the currency where their payments will be made.* A PhilHealth Certification Eligibility shall be issued for this purpose.
9 Sponsored Program LGU Legislative Private Gov’t Agencies A joint partnership between Philhealth and the LGU/ Fund Sponsors in subsidizing the one (1) yearFREE PhilHealth coverage of the “poorest of the poor” constituentsBasis: DSWD’s NHTS-PR MasterlistSponsoredProgramLGULegislativePrivateGov’t AgenciesAside from the regular Philhealth MedicareBenefits, the indigent members can also avail thePRIMARY CARE BENEFIT PACKAGE from theaccredited RHUs/Health Centers (Ex. SputumMicroscopy, Fecalysis, CBC, Chest X-ray etc.)
10 Individually Paying Program *All existing (active/inactive) SSSSelf-employed/Voluntary Members*No Employer-Employee Relationship*Categorized under the Informal Sector*Disqualified as a legal dependent orfrom other program component ofNHIPPremium 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 Program3 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 documentaryrequirements for declared qualified dependents3. Pay at least one (1) quarter (P600.00). Then present the validated receipt tosecure the PhilHealth Identification Card (PIC) & MDR.*You can pay your succeeding contribution to any Accredited Banks/ Bayad-Centers
11 Market Segmentation of Potential Members Self-PracticingProfessionalsTransportSectorSelf-EmployedBarangayIndividually Paying MembersAll existing (active / inactive) members of the SSS Self-employed / Voluntary ProgramIndividuals who don’t have an established/existing Employer-Employee RelationshipThose 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 contributionsOthers-Lawyers-Doctors-Consultants-Freelance Journalist-Etc.-Jeepney Drivers-Tricycle Drivers-Transport Operators-FX/Taxi Drivers-Sari-sari Store Owners-Market vendors-Single proprietors-Entertainment Industry-Sidewalk vendors-Brgy. Tanods-Brgy. Health Workersand other Volunteerworkers-Etc-Organized Groups-Contractors-House Helpers-Religious Sector-Disqualified as Indigent/Non-Paying MembersBe an advocate of PhilHealth!
12 LIFETIME MEMBERSHIP PROGRAM (PhilHealth’s Long Term Benefit) The National Health Insurance Program (NHIP)O.W.P.Average of 3-5 dependentsper householdSPONSOREDLGULegislativePrivateGov’t AgenciesDEMPLOYEDAEI.P.P.BCLIFETIME MEMBERSHIP PROGRAM (PhilHealth’s Long Term Benefit)Must have reached the age of 60 years old and above ANDMust have contributed at least 120 monthly contributions (10 years)
13 SENIOR CITIZEN REGISTRATION PROCEDURE: NOT QUALIFIED? ncr-centralREGISTRATION PROCEDURE:NOT QUALIFIED?SENIORCITIZENDeclare as Dependent of one of theMember-ChildRequirements:Properly accomplished PMRF (to beaccomplished by the Member-Child)Supporting documents: Member’s BirthCertificate & Parent’s Proof of ageB. Enroll under IPPRequirements:Properly accomplished PMRFQuarterly Payment of PhpC. Enroll under Sponsored Program- Depending on the existing programimplementation in the city/municipality.- Inquire at LGU-Local Social Welfare Ofc
14 (exclusive for the member) (to be shared by qualified dependents) Coverage that extends to your immediate familyMEMBER45 DAYS / Calendar Year(exclusive for the member)45 DAYS / Calendar Year(to be shared by qualified dependents)DEPENDENTSLegitimate spouse not yet a PhilHealth memberChildren 20 years old below, single & unemployed (legitimate, illegitimate, stepchildren, adopted, etc).Parents-60 years old and above and not aGSIS or SSS Retiree / Pensioner(biological parent, step parent & adoptive parent)
15 PhilHealth Identification Cards ncr-centralPhilHealth Identification CardsEMPLOYEDINDIVIDUALLY PAYING MEMBERSOFWsJan.1, 2011 – Dec. 31, 2011SPONSOREDLIFE TIME MEMBER
16 P50.00 per card ; must be an ACTIVE member! Register now in all SM Malls & Bayad CentersP50.00 per card ; must be an ACTIVE member!
17 Has a space for member’s photograph and biometric capture Health Insurance CardHas a space for member’s photograph and biometric captureThe ‘Health Insurance’ CardIt is envisioned to be a valid, government-issued and transactional ID card of members and their dependents to serve as the instrument for proper identification, eligibility verification and utilization recording.The new card comes with a space for the member’s photograph and biometric capture, and will serve as a key card for hospitals to access member records through point-of-sale terminals when a member is availing himself of PhilHealth benefits.It will be available to members for a fee. Soon.Will serve as a key card for hospitals and merchant-partners to access member records
18 Updating of Member’s Data Record ncr-centralUpdating of Member’s Data RecordSubmit a properly accomplished PMRF Form and attach the necessary supporting requirements…Legal Spouse – Xerox of Marriage ContractAll Children 20 yrs.old below – Xerox of Birth CertificateParents above 60 yrs. old – Senior Citizen’s ID & Member’s Birth Certificate
19 What are my Benefits? A. In-Patient Care ( FEE FOR SERVICE SCHME) ncr-centralWhat are my Benefits?A. In-Patient Care ( FEE FOR SERVICE SCHME)Allowance for:Room and BoardDrugs and MedicinesX-Ray and LaboratoriesOperating Room FeesProfessional FeesConfinement of less than 24 hours will not be paid except the ff:Case is EmergencyPatient is Transferred to another HospitalPatient Expired
20 Levels 3 & 4 Hospitals (Tertiary) ncr-centralNew Inpatient PhilHealth Benefits ScheduleFor all PHIC Members and their DependentsAdmissions starting April 05, 2009 (Circular 09, s. 2009)Levels 3 & 4 Hospitals (Tertiary)Benefit ItemCase TypeABCDRoom & Board(maximum of 45 days/year)P500P800P1,100Drugs and Medicines(per single period of confinement)P4,200P14,000P28,000P40,000X-ray, Lab & OthersP3,200P10,500P21,000P30,000Operating RoomFor procedures with RVU 30 and below = 1,200For procedures with RVU 31 to 80 = 1,500For procedures with RVU 80 to 600: RVU x PCF 20 (minimum = 3,500)
21 Levels 3 & 4 Hospitals (Tertiary) ncr-centralNew Inpatient PhilHealth Benefits ScheduleAdmissions starting April 05, 2009 (Circular 09, s. 2009)Levels 3 & 4 Hospitals (Tertiary)Professional FeesCase TypeABCDA. Daily VisitsGen. Practitioner (Groups 1, 5 and 6)Per dayP300P400P500P600Maximum per confinementP1,200P2,400P4,000P6,000Specialist (Groups 2, 3 & 4)P700P800P2,000P3,600P5,600P8,000B. SurgeryFor RVU 500 and belowFor RVU 501 and aboveSurgeonAnesthesiologistGen. Practitioner (1st Tier – Group 1)RVU x PCF 40 = PF140% of surgeon’s fee (PF1)40% of surgeon’s fee (PF1)With Training (2nd Tier – Group 5 & 6)RVU x PCF 48 = PF248% of surgeon’s fee (PF1)48% of surgeon’s fee (PF1)Diplomate / Fellow (3rd Tier – Group 2, 3, 4)RVU x PCF 56 = PF356% of surgeon’s fee (PF1)RVU x PCF 80 = PF440% of surgeon’s fee (PF4)
22 What are my Benefits? B. Out-Patient Care Dialysis ncr-centralWhat are my Benefits?B. Out-Patient CareAllowance for:Drugs and MedicinesX-ray and LaboratoriesOperating Room FeesProfessional FeesSAMPLE CASES:Day surgeriesDialysisCancer treatment procedures such as:chemotherapyradiotherapyProcedures must be performed in Philhealth Accredited Hospital and Free-Standing Clinicsconfinement / 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
23 What are my Benefits? C. Special Benefit Packages ncr-centralWhat are my Benefits?C. Special Benefit PackagesMaternity Care Package (Accredited Non-Hospital Facilities)**Facility Fee = Php 6,Member’s Pre-natal Care = Php 1,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 )
24 New Case Rates for Selected Surgical Cases: ncr-centralNew Case Rates for Selected Surgical Cases:Effective September 1, 2011 (9/12 Rule)Cesarian Section (CS) = Php 19,000Dilation & Curettage = Php 11,000Hysterectomy = Php 30,000Mastectomy = Php 22,000Appendectomy = Php 24,000Cholecystectomy = Php 31,000Herniorrhaphy = Php 21,000Thyroidectomy = Php 31,000Radiotherapy = Php 3,000Hemodialysis = Php 4,000Cataract = Php 16,000
25 New Case Rates for Selected Medical Cases: ncr-centralNew Case Rates for Selected Medical Cases:Effective September 1, 2011 (3 / 6 Rule)Dengue I (Dengue Fever & DHF Grades I & II) = Php 8,000Dengue II (Dengue Hemorrhagic Fever Grades III & IV) = Php 16,000Pneumonia I (Moderate Risk) = Php 15,000Pneumonia II (High Risk) = Php 32,000Essential Hypertension = Php 9,000Cerebral Infarction (CVA I) = Php 28,000Cerebro-Vascular (CVA II) = Php 38,000Acute Gastroenteritis (AGE) = Php 6,000Typhoid Fever = Php 14,000Asthma = Php 9,000** NO BALANCE BILLING POLICY – Sponsored Beneficiaries in Gov’t. Hospitals
26 Common Reasons for Denial of Claims: ncr-centralCommon Reasons for Denial of Claims:Late Filing / Re-filing (filing beyond 60 days)Filing Period: 60 DAYS from the date of dischargeNote: if the 60th day falls on a Saturday, Sunday, or Holiday (legal/declared), the 60th day to be considered is the following working dayCase is not compensableNo Qualifying ContributionPatient is not a legal dependentNon-compliance to previous request
28 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
29 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 NBBCan even be just a number of NBB beds from the total hospital beds of a hospital
30 The New Corporate Website First is the new corporate website, which promises to be more user-friendly but is still packed with the necessary information on the National Health Insurance Program that a PhilHealth stakeholder needs.The new website opens to three major sections, namely, MEMBERS, CORPORATE PARTNERS and ONLINE SERVICES.The MEMBERS section leads site visitors to the five (5) member-categories, while the CORPORATE PARTNERS section leads to our accredited facilities, health care professionals, collecting agents, as well as to private partners.Finally, the ONLINE SERVICES features several electronic facilities that include the eRegistration, eClaims, and PhilGIS.<click>More user-friendlyPacked with necessary informationInclusion of several online services
31 Electronic Registration A web-based application for individuals who want to sign up with PhilHealth.The Electronic Registration System is a web-based application for those who want to sign up for the National Health Insurance Program. This online facility is offered to the public at no cost, and will primarily cater to individual registration via the internet. They can register as Individually Paying Member (IPM), Overseas Filipino Worker (OFW), Lifetime Member or Employed Member.<click>…Visitors can register as IPM, OFW, Lifetime Member or Employed Member
32 e-Claims Project Phase I Called Claims Eligibility Web Service (CEWS)Enables accredited institutional health care providers to check the eligibility of the memberThe second e-Innovation launched was Phase 1 of the E-Claims Project.Called the Claims Eligibility Web Service (CEWS), this facility enables accredited institutional health care providers to check whether or not the patients are registered with PhilHealth and have the required contributions to avail of benefits. This project is expected to speed up the eligibility verification process at the hospital level and minimize the incidence of Return-to-Hospital claims due to member eligibility concerns.<click>…Minimize RTH
33 Online Mapping Services The PhilGIS or the PhilHealth GIS Application System provides site visitors with online Mapping Services.This is a facility for viewing the locations of PhilHealth’s Regional and Branch Offices, as well as those of accredited health facilities. It also provides a visualization of various corporate data such as accreditation and claims, using statistical maps.It can be accessed through three locations in the corporate website: About Us, Health Facilities Locations, and PhilGIS.<click>…View locations of PhilHealth’s Regional and Branch OfficesView accredited health facilitiesView Corporate data using statistical maps
34 Help Lines: : 4417442 Please Remember . . . Website:Facebook:Address:We do conduct FREE PhilHealth Seminars!