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“Updates on Membership & Benefits” Technical Session VI – 34 th GACPA Convention Mr. DELIO A. ASERON II Chief Social Insurance Officer Deputy Spokesperson.

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Presentation on theme: "“Updates on Membership & Benefits” Technical Session VI – 34 th GACPA Convention Mr. DELIO A. ASERON II Chief Social Insurance Officer Deputy Spokesperson."— Presentation transcript:

1 “Updates on Membership & Benefits” Technical Session VI – 34 th GACPA Convention Mr. DELIO A. ASERON II Chief Social Insurance Officer Deputy Spokesperson & Head of Corporate Call Center Corporate Affairs Group

2 The National Health Insurance Act of 1995 was signed into Law on February 14, 1995 AN ACT INSTITUTING A NATIONAL HEALTH NATIONAL HEALTH INSURANCE PROGRAM FOR ALL FILIPINOS AND ESTABLISHING PHILHEALTH FOR THIS PURPOSE AN ACT INSTITUTING A NATIONAL HEALTH NATIONAL HEALTH INSURANCE PROGRAM FOR ALL FILIPINOS AND ESTABLISHING PHILHEALTH FOR THIS PURPOSE M A N D A T E to provide health insurance coverage and ensure affordable, acceptable, available & accessible health care services for … ALL FILIPINOS “Financial Risk Protection” REPUBLIC ACT 7875 As amended by R.A. 9241

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……

4 Universal Health Care Goal Bawat Pilipino, Miyembro Bawat Miyembro, Protektado Kalusugan Natin, Segurado

5 EMPLOYEDEMPLOYED 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

6 Employed Sector: Premium Contribution Salary Monthly Bracket Monthly Salary Range Employed Sector: Premium Contribution Salary Base (BS) Total Monthly Contribution Personal Share (PS) (PS=SB x 1.25%) Employer Share (ES) (ES=PS) 23P 26, P 26,999.99P 26,000.00P P P 27, P 27,999.99P 27,000.00P P P 28, P 28,999.99P 28,000.00P P P 29, P 29,999.99P 29,000.00P P P 30, UPP 30,000.00P P “ Those who earn more, must contribute more to the common fund! ”

7 PhilHealth Circular No. 11, s New Premium Schedule for the Formal Sector Effective JANUARY 1, 2013 Mpnthly Salary RangeMonthly Premium Rate Employer Share Employee Share P7,000 & BelowP P105 P7,000 to P50,0003 %1.5 % P50,000 & AboveP1, P750 All ERs are hereby reminded that monthly premium contributions should be remitted on or before the 10 th 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 benefit package 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 of employment using the currency where their payments will be made. * A PhilHealth Certification Eligibility shall be issued for this purpose.

9 SponsoredProgram LGU Legislative Private Gov’t AgenciesSponsoredProgram LGU Legislative Private Gov’t 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.) 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

10 Individually 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 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

11 Self-Practicing Professionals Transport Sector Self-Employed Barangay 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 Workers and 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!

12 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. B EMPLOYEDEMPLOYED A SPONSOREDLGULegislativePrivate Gov’t Agencies Gov’t Agencies SPONSOREDLGULegislativePrivate Gov’t Agencies Gov’t Agencies D C E

13 ncr-centralREGISTRATION PROCEDURE: A.Declare as Dependent of one of the Member-Child Member-Child Requirements: 1.Properly accomplished PMRF (to be accomplished by the Member-Child) 2Supporting documents: Member’s Birth Certificate & Parent’s Proof of age NOT QUALIFIED? SENIORCITIZEN B.Enroll under IPP B. Enroll under IPP Requirements: 1.Properly accomplished PMRF 2.Quarterly Payment of Php C.Enroll under Sponsored Program C. Enroll under Sponsored Program - Depending on the existing program implementation in the city/municipality. - Inquire at LGU-Local Social Welfare Ofc

14 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

15 PhilHealth Identification Cards  EMPLOYED  INDIVIDUALLY PAYING MEMBERS  OFWs  SPONSORED  LIFE TIME MEMBERncr-central Jan.1, 2011 – Dec. 31, 2011

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

17  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

18 Updating 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 Certificatencr-central

19 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 Expiredncr-central

20 New New Inpatient PhilHealth Benefits Schedule For all PHIC Members and their Dependents Levels 3 & 4 Hospitals (Tertiary) Benefit Item Case Type ABCD Room & Board (maximum of 45 days/year) P500 P800P1,100 Drugs and Medicines (per single period of confinement) P4,200P14,000P28,000P40,000 X-ray, Lab & Others (per single period of confinement) P3,200P10,500P21,000P30,000 Operating Room 1,200 For procedures with RVU 30 and below = 1,200 1,500 For procedures with RVU 31 to 80 = 1,500 RVU x PCF 20 For procedures with RVU 80 to 600: RVU x PCF 20 (minimum = 3,500)ncr-central Admissions starting April 05, 2009 (Circular 09, s. 2009)

21 New New Inpatient PhilHealth Benefits Schedule Levels 3 & 4 Hospitals (Tertiary) Professional Fees Case Type ABCD A. Daily Visits Gen. Practitioner (Groups 1, 5 and 6) Per day P300P400P500P600 Maximum per confinement P1,200P2,400P4,000P6,000 Specialist (Groups 2, 3 & 4) Per day P500P600P700P800 Maximum per confinement P2,000P3,600P5,600P8,000 B. Surgery For RVU 500 and belowFor RVU 501 and above SurgeonAnesthesiologistSurgeonAnesthesiologist Gen. Practitioner (1 st Tier – Group 1) RVU x PCF 40 = PF140% of surgeon’s fee (PF1) RVU x PCF 40 = PF1 40% of surgeon’s fee (PF1) With Training (2 nd Tier – Group 5 & 6) RVU x PCF 48 = PF248% of surgeon’s fee (PF1) RVU x PCF 48 = PF2 48% of surgeon’s fee (PF1) Diplomate / Fellow (3 rd Tier – Group 2, 3, 4) RVU x PCF 56 = PF356% of surgeon’s fee (PF1) RVU x PCF 80 = PF4 40% of surgeon’s fee (PF4) ncr-central Admissions starting April 05, 2009 (Circular 09, s. 2009)

22 What are my Benefits? 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 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 impossiblencr-central

23 What are my Benefits? C. Special Benefit Packages Maternity 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 Package includes care services: Eye prophylaxis, umbilical cord care, vitamin K, thermal care & BCG & resuscitation, 1 st dose of Hepatitis B immunization, New Born Screening tests – ( a total of Php 1,750 )ncr-central

24 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 16,000ncr-central

25 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. Hospitalsncr-central

26 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 60 th day falls on a Saturday, Sunday, or Holiday (legal/declared), the 60 th day to be considered is the following working day  C Case is not compensable  No Qualifying Contribution  Patient is not a legal dependent  Non-compliance to previous requestncr-central

27 Improved PhilHealth Benefits and other Updates

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 NBB Can even be just a number of NBB beds from the total hospital beds of a hospital

30 More user-friendly Inclusion of several online services Packed with necessary information The New Corporate Website

31 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

32 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

33 View locations of PhilHealth’s Regional and Branch Offices Online Mapping Services View accredited health facilities View Corporate data using statistical maps

34 Please Remember...  Website:  Facebook:  Address:  Help Lines: : We do conduct FREE PhilHealth Seminars!

35 Thank you!


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