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“Updates on Membership & Benefits”

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1 “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

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 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”

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) 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

6 Employed Sector: Premium Contribution
Salary Monthly Bracket Monthly Salary Range Salary Base (BS) Personal Share (PS) Employer Share (ES) Total Monthly Contribution (PS=SB x 1.25%) (ES=PS) 1 P 4, and below P 4,000.00 P P50.00 P 8, – P 8,999.99 2 P 5, – P 5,999.99 P 5,000.00 P P62.50 3 P 6, – P 6,999.99 P 6,000.00 P P75.00 4 P 7, – P 7,999.99 P 7,000.00 P P87.50 5 P 8,000.00 P P100.00 23 P 26, P 26,999.99 P 26,000.00 P P 24 P 27, P 27,999.99 P 27,000.00 P P 25 P 28, P 28,999.99 P 28,000.00 P P 26 P 29, P 29,999.99 P 29,000.00 P P 27 P 30, UP P 30,000.00 P P “ 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, 2013 Mpnthly Salary Range Monthly Premium Rate Employer Share Employee Share P7,000 & Below P P105 P7,000 to P50,000 3 % 1.5 % P50,000 & Above P1, 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.

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 Sponsored Program LGU Legislative Private Gov’t Agencies
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 Sponsored Program 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.)

10 Individually Paying Program
*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

11 Market Segmentation of Potential Members
Self-Practicing Professionals Transport Sector Self-Employed Barangay 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 -Sari-sari Store Owners -Market vendors -Single proprietors -Entertainment Industry -Sidewalk vendors -Brgy. Tanods -Brgy. Health Workers and other Volunteer workers -Etc -Organized Groups -Contractors -House Helpers -Religious Sector -Disqualified as Indigent /Non-Paying Members Be 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 dependents per household SPONSORED LGU Legislative Private Gov’t Agencies D EMPLOYED A E I.P.P. B C 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)

ncr-central REGISTRATION PROCEDURE: NOT QUALIFIED? SENIOR CITIZEN Declare as Dependent of one of the Member-Child Requirements: Properly accomplished PMRF (to be accomplished by the Member-Child) Supporting documents: Member’s Birth Certificate & Parent’s Proof of age B. Enroll under IPP Requirements: Properly accomplished PMRF Quarterly Payment of Php C. Enroll under Sponsored Program - Depending on the existing program implementation 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 family MEMBER 45 DAYS / Calendar Year (exclusive for the member) 45 DAYS / Calendar Year (to be shared by qualified dependents) 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 (biological parent, step parent & adoptive parent)

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

16 P50.00 per card ; must be an ACTIVE member!
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 Has a space for member’s photograph and biometric capture The ‘Health Insurance’ Card It 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-central 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 Certificate

19 What are my Benefits? A. In-Patient Care ( FEE FOR SERVICE SCHME)
ncr-central 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: Case is Emergency Patient is Transferred to another Hospital Patient Expired

20 Levels 3 & 4 Hospitals (Tertiary)
ncr-central 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 Case Type A B C D Room & Board (maximum of 45 days/year) P500 P800 P1,100 Drugs and Medicines (per single period of confinement) P4,200 P14,000 P28,000 P40,000 X-ray, Lab & Others P3,200 P10,500 P21,000 P30,000 Operating Room For procedures with RVU 30 and below = 1,200 For procedures with RVU 31 to 80 = 1,500 For procedures with RVU 80 to 600: RVU x PCF 20 (minimum = 3,500)

21 Levels 3 & 4 Hospitals (Tertiary)
ncr-central New Inpatient PhilHealth Benefits Schedule Admissions starting April 05, 2009 (Circular 09, s. 2009) 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) P700 P800 P2,000 P3,600 P5,600 P8,000 B. Surgery For RVU 500 and below For RVU 501 and above Surgeon Anesthesiologist Gen. Practitioner (1st Tier – Group 1) RVU x PCF 40 = PF1 40% of surgeon’s fee (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) 48% of surgeon’s fee (PF1) Diplomate / Fellow (3rd Tier – Group 2, 3, 4) RVU x PCF 56 = PF3 56% of surgeon’s fee (PF1) RVU x PCF 80 = PF4 40% of surgeon’s fee (PF4)

22 What are my Benefits? B. Out-Patient Care Dialysis
ncr-central 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 impossible

23 What are my Benefits? C. Special Benefit Packages
ncr-central 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, 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-central 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

25 New Case Rates for Selected Medical Cases:
ncr-central 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

26 Common Reasons for Denial of Claims:
ncr-central 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

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 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-friendly Packed with necessary information Inclusion 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 member The 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 Offices View accredited health facilities View Corporate data using statistical maps

34 Help Lines: : 4417442 Please Remember . . .
Website: Facebook: Address: We do conduct FREE PhilHealth Seminars!

35 Thank you!

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