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

2. REPUBLIC ACT 7875 ALL FILIPINOS
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)

13. SENIOR CITIZEN REGISTRATION PROCEDURE: NOT QUALIFIED?
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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
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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
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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)
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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:
Case is Emergency
Patient is Transferred to another Hospital
Patient Expired

20. Levels 3 & 4 Hospitals (Tertiary)
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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
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)
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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
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
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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
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
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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:
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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:
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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) = 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:
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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

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.
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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.
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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.
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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!