Phil Health Revised

8/2/2019 Phil Health Revised

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PhilHealth- Philippine Health Insurance Corporation

1. Vision

a. Adequate and Affordable Social Health Insurance Coverage for ALL

Filipinos.

2. Mission

a. To ensure adequate financial access of every Filipino to quality health

care services through the effective and efficient administration of the

National Health Insurance Program.

3. Core Values

a. People and Partnership- The alliance we have made are the wheels of

our program. Our members are at the core of our operations and it is

our duty to serve the public.

b. Harmony- Team PhilHealth moves as one, otherwise, we could not

have reached nor surpassed our goals.

c. Innovation- We support new and bright ideas to improve our

operations, and apply the Balanced Scorecards into how we carry out

our tasks.

d. Leadership- The entire PhilHealth organization leads and drives the

health system reforms in the country.

e. Honor, Accountability and Transparency- We are the custodians of

public coffers and we owe it to the people to keep the program afloat

for future generations.

f. Excellence and Lifetime Learning- We do not just meet targets; we

surpass them because we are movers and shapers. We are the few

who make things happen but we continue to learn new things.

g. Health for All- We aim for universal coverage. Right now, we cover

eight out of every ten Filipinos, and we aspire to sustain this coverage

in the long-term.

4. Business Profile

a. Nature Of Organization- Government Owned and Controlled

Corporation (GOCC)

b. Type Of Industry- Health Care Financing


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c. Affiliations

i. International Social Security Association

ii. ASEAN Social Security Association

iii. Philippine Social Security Association

d. Funding Sources

i. National and Local Government Units (for the annual premium of

enrolled sponsored members)

ii. Contribution of members into the Program

e. Key Program Partners

i. Institutional and Professional Health Care Providers

ii. National Government Agencies

iii. Local Government Units

iv. Collecting Banks and Agents

v. Private Organizations

5. Historya. THE call to serve the rural indigents echoed since the early '60s when

the Philippine Medical Association introduced the MARIA Project which

prioritized aid to communities in need of medical assistance. TheProject would then be considered a valuable precursor to the Medicareprogram, from which a medical care plan for the entire Philippines wascreated.

b. On August 4, 1969, Republic Act 6111 or the Philippine Medical CareAct of 1969 was signed by President Ferdinand E. Marcos which waseventually implemented in August 1971.

c. The Philippine Medical Care Commission (PMCC) was tasked to overseethe implementation of the program which went for almost a quarter ofa century.

d. In the 1990s, a vision for a better, more responsive government healthcare program was prompted by the passage of several bills that had

significant implications on health financing.e. The public's clamor for a health insurance that is more comprehensivein terms of covered population and benefits led to the development ofHouse Bill 14225 and Senate Bill 01738 which became "The NationalHealth Insurance Act of 1995" or Republic Act 7875, signed byPresident Fidel V. Ramos on February 14, 1995.

i. The law paved the way for the creation of the Philippine HealthInsurance Corporation (PhilHealth), mandated to provide socialhealth insurance coverage to all Filipinos in 15 years' time.


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f. PhilHealth assumed the responsibility of administering the formerMedicare program for government and private sector employees fromthe Government Service Insurance System in October 1997, from theSocial Security System in April 1998, and from the Overseas WorkersWelfare Administration in March 2005.

6. Main Office: Citystate Centre, 709 Shaw Boulevard, Pasig City 1603,

Philippines7. Benefits

a. Inpatient coverage- PhilHealth provides subsidy for room and

board, drugs and medicines, laboratories, operating room and

professional fees for confinements of not less than 24 hours.

b. Outpatient coverage- Day surgeries, dialysis and cancer treatment

procedures such as chemotherapy and radiotherapy in accredited

hospitals and free-standing clinics.

c. Special Benefit Packages

i. Case Rates

ii. TB Treatment through DOTS

iii. SARS and Avian Influenza

iv. Novel Influenza A(H1N1)

d. Exclusions / Non-Compensables

i. The following shall not be covered except when, after actuarial

studies, PhilHealth recommends their inclusion subject to

approval of its Board of Directors:

1. Fifth and subsequent normal obstetrical deliveries

2. Non-prescription drugs and devices

3. Alcohol abuse or dependency treatment

4. Cosmetic surgery

5. Optometric services

6. Other cost-ineffective procedures as defined by PhilHealth

8. Benefit Availment Conditions

a. Eligibility Requirements

i. The following must first be met to avail of your PhilHealth

benefits:


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1. Payment of at least three monthly premiums within the

immediate six months prior to confinement. For

pregnancy-related cases and availment of the new born

care package, dialysis (except those undergoing

emergency dialysis service during confinement),

chemotherapy, radiotherapy and selected surgicalprocedures, payment of nine (9) monthly premium

contributions within the last 12 months shall be required

except for those enrolled under the KASAPI program.

2. Confinement in an accredited hospital for at least 24

hours (except when availing of outpatient care and

special packages) due to an illness or disease requiring

hospitalization. Attending physicians must also be

PhilHealth-accredited.

3. Availment is within the 45 days allowance for room andboard.

b. After the automatic deduction or reimbursement of your benefits,

PhilHealth will send you (to the address you have indicated in your

claim form) a benefit payment notice or BPN. The BPN is a report of

actual payments made by PhilHealth relative to your

confinement/availment.

9. Benefit Availment Procedures

a. Outright/Automatic Deduction Of Benefits

i. Submit to the billing section the following prior to discharge

from the hospital:

1. Duly accomplished PhilHealth Claim Form 1

2. Proof of applicable premium payments

3. Clear copy of Member Data Record (MDR)

4. If patient is a qualified dependent but not is listed in the

MDR, submit applicable proof of dependency.

ii. Agree with your attending physicians on how much is left to be

paid for their services over the professional fee (PF) benefit.

iii. Upon submission of all applicable documents, the billing section

will compute and deduct your benefits from your total hospital

bill.


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b. Direct Filing/Reimbursement

i. Submit the following to PhilHealth or through the hospital in

addition to the documents mentioned earlier within 60 calendar

days after discharge:

1. PhilHealth Claim Form 2 (to be filled up by the hospital

and attending physicians)

2. Official receipts or hospital and doctor's waiver

3. Operative record for surgical procedures performed

c. Confinements Abroad

i. Submit the following within 180 days after discharge. Overseas

confinements shall be paid based on Level 3 hospital benefit

rates.

ii. PhilHealth Claim Form 1

iii. Member Data Record (MDR) or supporting documents

iv. Proof of applicable premium payments

v. Original official receipt or detailed statement of account (written

in English)

vi. Medical certificate (written in English) indicating the final

diagnosis, confinement period and services rendered

10.Members

a. Overseas Worker Program (OWP)

i. Active landbase Overseas Filipino Workers (OFW) who

underwent the normal process of registration as an OFW at

Philippine Overseas Employment Agency (POEA) Offices.

ii. OFWs who are currently abroad but are not yet registered with

PhilHealth.

iii. Sea-based OFWs such as seafarers are considered locally

Employed Members and not Overseas Worker members.

iv. Member Registration Procedures


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1. Submit duly accomplished PhilHealth Membership

Registration Form together with applicable documents for

each qualified dependent declared.

2. Also submit any of the following documents as proof of

being an active OFW:

a. Valid Overseas Employment Certificate (OEC) or E-

receipt

b. Valid overseas employment contract or certificate

of employment

c. Valid re-entry visa

d. Valid job contract

v. Pay the one-year premium of Php 900. For your convenience,premium payments covering the entire contract (equivalent to

the number of years provided for in your contract) is highly

encouraged.

b. Employed Sector

i. Government Sector- Employees of the government, whether

regular, casual or contractual, who renders services in any

government branches, military or police force, political

subdivisions, agencies, or instrumentalities, including

government-owned and controlled corporations, financialinstitutions with original charter, constitutional commissions,

and is occupying either an elective or appointive position,

regardless of status of appointment.

ii. Private Sector

1. Corporations, partnerships, or single proprietorships, non-

government organizations, cooperatives, non-profit

organizations, social, civic, or professional or charitable

institutions, organized and based in the Philippines

2. Foreign corporations, business organizations, non-

government organizations based in the Philippines

3. Foreign governments or international organizations with

quasi-state status based in the Philippines which entered

into an agreement with PhilHealth to cover their Filipino

employees


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4. Foreign business organizations based abroad with

agreement with PhilHealth to cover their Filipino

employees

5. Sea-based OFWs

6. Household employees

iii. Member Registration Procedures

1. For Newly Hired And Existing Employees Without PIN Yet

a. Fill out PhilHealth Member Registration Form

b. Attach clear copy of supporting documents for

qualified dependents declared

c. Submit to the HR Department for them to forward

the above documents to PhilHealth together with

ER2 Form (Report of Employee-Members).

d. PhilHealth will send the PhilHealth Identification

Card or PIC and a copy of the Member Data Record

to the member, through the employer

2. For Newly Hired Employees With PIN

a. Report your PIN to your employer for them to

indicate the same in their ER2

iv. Premium contributions are shared by the employee and the

employer, the amount of which is determined using the table of

contributions. After deducting half of the premium requirement

from your monthly salary, total premiums are remitted by your

employer to PhilHealth.

c. Individually Paying

i. Self-employed individuals - those who work for him/herself and

is therefore both the employer and employee, including but not

limited to the following:

ii. Self-earning professionals like doctors and lawyers

iii. Business partners and single proprietors / proprietresses

iv. Actors, actresses, directors, scriptwriters and news reporters

who are not under an employer-employee relationship


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v. Professional athletes, coaches, trainers and jockeys

vi. Farmers and fisherfolks

vii. Workers in the informal sector such as ambulant vendors,

watch-your-car boys, hospitality girls, tricycle drivers, etc.

viii. Separated from employment - those who were previously

formally employed (with employer-employee relationship) and

are separated from employment.

ix. Employees of international organizations and foreign

governments based in the Philippines without agreement with

PhilHealth for the coverage of their Filipino employees in the

program.

x. All other individuals not covered under the previous categories

mentioned, including but are not limited to the following:

xi. Parents who are not qualified as legal dependents, indigents or

retireess/pensioners

xii. Retirees who did not meet the minimum of 120 monthly

premium contributions to qualify as non-paying members

xiii. Children who are not qualified as legal dependents

xiv. Unemployed individuals who are not qualified as indigents

xv. Member Registration Procedures

1. Fill out PhilHealth Membership Registration Form

2. Attach clear copy of supporting documents for qualified

dependents to be declared

3. Registrant will be issued his/her PhilHealth Identification

Number or PIN and the PhilHealth Member Registration Form

or PMRF and shall be asked to pay the required premiums to

the PhilHealth Cashier or at any of PhilHealth's accredited

collecting banks

xvi. Individually Paying Members (IPMs) earning an average monthly

income of P25,000 and below pay P300 quarterly or P1,200 per

year, while those earning above P25,000 pay P600 quarterly or

P2,400 per year. Premium contributions may be paid quarterly,

semi-annually and annually.
http://www.philhealth.gov.ph/downloads/membership/pmrf.pdfhttp://www.philhealth.gov.ph/downloads/membership/pmrf.pdf


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Schedule of payment:

Quarterly Semi-annual Annual

Pay until the lastworking day of thequarter being paid

for.

Example:Period: January to

MarchDeadline: March 31

Pay until the last workingday of the first quarter ofthe semester being paid

for.

Example:Period: January to June

Deadline: March 31

Pay until the lastworking day of the first

quarter of the yearbeing paid for.

Example:Period: January to

DecemberDeadline: March 31

d. Sponsored Program

i. The Sponsored Program is open to qualified indigents belonging

to the lowest 25% of the Philippine population. Families that will

be given health insurance coverage are identified through the

family data survey using the framework of Community-based

Information System - Minimum Basic Needs or CBIS-MBN. The

CBIS-MBN is being conducted by the Department of Social

Welfare and Development through its local social welfare

development offices.

ii. Also qualified under this program are families who are listed inthe National Household Targeting System for Poverty Reduction

(NHTS-PR) of the Department of Social Welfare and

Development are qualified under this category.

iii. The Sponsored Program is being made possible through the

partnership of PhilHealth and sponsors such as local

governments (LGUs), private individuals and corporations and

members of Congress, among others.

iv. The National Government (through PhilHealth) and the

abovementioned sponsors jointly pay the annual premium ofPhp 1,200 for each enrolled family.

e. Lifetime

i. The following shall be entitled to PhilHealth's lifetime coverage

as Lifetime Members:


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13.Retired underground mine workers who have reached the

age of retirement as provided for by law and have met

the required premium contributions.

ii. Member Registration Procedures

1. Submit the following to any PhilHealth Office nearest you:

a. 1. Duly accomplished PhilHealth Membership

Registration Form

b. 2. Two (2) latest 1" x 1" ID picture

c. 3. Certified True Copy (CTC) of the SSS or GSIS

Retirement Certification or the following as

applicable:

2. For SSS Retirees/Pensioners:

a. Printout of Death, Disability and Retirement (DDR)

from any SSS office indicating that the type of

claim is retirement in nature and the effectivity

date of pension; and

b. Printout of contributions issued by any SSS office

indicating the latest contributions (if he/she retires

after March 4, 1995.

3. For GSIS Retirees - any of the following:

a. Certification/Letter of Approval of Retirement from

the GSIS indicating the effectivity date of

retirement;

b. Service Record issued by the employer/s indicating

not less than 120 months of service excluding leave

of absences without pay;

c. Certification/retirement Gratuity from the employer

indicating not less than 120 months of service.

d. For AFP, PNP, BFP and BJMP Retirees/Pensioners -

those who are in active military service until they

retire at age 56 and those separated by retirement

or other reasons prior to the said age but have

reached the age of 60, shall submit any of the

following:


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e. Statement of Services issued by previous employer

indicating not less than 120 months of service

excluding leave of absences without pay;

f. Certification/Letter of Approval of Retirement from

the GSIS indicating not less than 120 months ofservice;

g. General, Bureau or Special Order indicating the

effectivity date of retirement.

4. Certified true copy (CTC) of Birth Certificate or any two of

the following:

a. CTC of Baptismal Certificate

b. CTC of Marriage Contract/Certificate

c. Passport

d. Driver's License

e. SSS Members ID

f. Alien Certificate of Registration (ACR)

g. Service Record/s

h. Employee ID

i. School records

j. Voter's ID

k. Senior Citizens ID

l. Duly notarized joint affidavit of two disinterested

persons attesting to the fact of birth of the

registrant

5. Any other valid documents acceptable by PhilHealth

iii. Member will be issued his/her PhilHealth Lifetime Member Card

which is a valid ID to be used in all PhilHealth transactions.

11.Qualified Dependents


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a. the following also enjoy PhilHealth coverage without additional

premiums for each dependent:

i. Legal spouse (non-member or membership is inactive)

ii. Child/ren - legitimate, legitimated, acknowledged and illegitimate

(as appearing in birth certificate) adopted or step below 21 years ofage, unmarried and unemployed. Also covered are child/ren 21

years old or above but suffering from congenital disability, either

physical or mental, or any disability acquired that renders them

totally dependent on the member for support.

iii. Parents (non-members or membership is inactive) who are 60 years

old, including stepparents (biological parents already deceased)

and adoptive parents (with adoption papers).

b. All of your qualified dependents shall be entitled to a separate

coverage for up to 45 days per calendar year. However, their 45 daysallowance will be shared among them.

c. Your dependents need to be declared and/or updated with PhilHealth

to include them in your PhilHealth Member Registration Form or PMRF,

your official membership profile with PhilHealth. Your updated MDR will

make your benefit availments easier and convenient.

Case Rates

Since September 1, 2011, the following medical cases and surgicalprocedures are being paid through case rate:

Medical Cases 1. Dengue I (Dengue fever, DHFgrades I&II)

8,000

2. Dengue II (DHF grades III & IV) 16,0003. Pneumonia I ( moderate risk) 15,0004. Pneumonia II (high risk) 32,0005. Essential Hypertension 9,000

6. Cerebral Infarction (CVA-I) 28,0007. Cerebral Hemorrhage (CVA-II) 38,0008. Acute Gastroenteritis (AGE) 6,0009. Asthma 9,00010. Typhoid Fever 14,000

11. Newborn Care Package inHospitals and Lying in Clinics

1,750


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Surgical Cases

1. Radiotherapy 3,000

2. Hemodialysis 4,0003. Maternity Care Package (MCP) 8,0004. NSD Package in Level I Hospitals 8,0005. NSD Package in Levels 2 to 4Hospitals

6,500

6. Caesarean Section 19,0007. Appendectomy 24,000

8. Cholecystectomy 31,0009. Dilatation and Curettage 11,00010. Thyroidectomy 31,00011. Herniorrhaphy 21, 00012. Mastectomy 22,000

13. Hysterectomy 30,00014. Cataract Surgery 16,000

Premium Contribution Table

Salary

Bracket

Salary Range Salary

Base

Total Monthly

Premium

Employee

Share

Employer

Share

*Employee share represents half of the total monthly premiumwhile the other half is shouldered by the employer.

1 4,999.99 andbelow

4,000.00 100.00 50.00 50.00

2 5,000.00 -5,999.99

5,000.00 125.00 62.50 62.50

3 6,000.00 -6,999.99

6,000.00 150.00 75.00 75.00

4 7,000.00 -7,999.99

7,000.00 175.00 87.50 87.50

5 8,000.00 -8,999.99

8,000.00 200.00 100.00 100.00

6 9,000.00 -9,999.99

9,000.00 225.00 112.50 112.50


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7 10,000.00 -10,999.99

10,000.00 250.00 125.00 125.00

8 11,000.00 -11,999.99

11,000.00 275.00 137.50 137.50

9 12,000.00 -12,999.99

12,000.00 300.00 150.00 150.00

10 13,000.00 -13,999.99

13,000.00 325.00 162.50 162.50

11 14,000.00 -14,999.99

14,000.00 350.00 175.00 175.00

12 15,000.00 -15,999.99

15,000.00 375.00 187.50 187.50

13 16,000.00 -16,999.99

16,000.00 400.00 200.00 200.00

14 17,000.00 -17,999.99

17,000.00 425.00 212.50 212.50

15 18,000.00 -18,999.99

18,000.00 450.00 225.00 225.00

16 19,000.00 -19,999.99

19,000.00 475.00 237.50 237.50

17 20,000.00 -20,999.99

20,000.00 500.00 250.00 250.00

18 21,000.00 -21,999.99

21,000.00 525.00 262.50 262.50

19 22,000.00 -22,999.99

22,000.00 550.00 275.00 275.00

20 23,000.00 -23,999.99

23,000.00 575.00 287.50 287.50

21 24,000.00 -

24,999.99

24,000.00 600.00 300.00 300.00

22 25,000.00 -25,999.99

25,000.00 625.00 312.50 312.50

23 26,000.00 -26,999.99

26,000.00 650.00 325.00 325.00

24 27,000.00 - 27,000.00 675.00 337.50 337.50


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27,999.99

25 28,000.00 -28,999.99

28,000.00 700.00 350.00 350.00

26 29,000.00 -29,999.99

29,000.00 725.00 362.50 362.50

27 30,000.00 and up 30,000.00 750.00 375.00 375.00

Documents

Phil Health Revised