“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
REPUBLIC ACT 7875
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
MANDATE
to provide health insurance
coverage and ensure affordable,
acceptable, available & accessible
health care services for …
ALL FILIPINOS
“Financial Risk Protection”
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……
Universal Health Care Goal
Bawat Pilipino, Miyembro
Bawat Miyembro, Protektado
Kalusugan Natin, Segurado
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
Employed Sector:
Sector: Premium
Premium Contribution
Contribution
Employed
Salary
Monthly
Bracket
Monthly Salary
Range
Salary Base Total Monthly
(BS)
Contribution
Personal
Employer
Share (PS)
Share (ES)
(PS=SB x 1.25%) (ES=PS)
1
P 4,999.99 and below P 4,000.00
P 100.00
P50.00
P50.00
2
P 5,000.00 – P 5,999.99
P 5,000.00
P 125.00
P62.50
P62.50
3
P 6,000.00 – P 6,999.99
P 6,000.00
P 150.00
P75.00
P75.00
4
P 7,000.00 – P 7,999.99
P 7,000.00
P 175.00
P87.50
P87.50
5
P 8,000.00 – P 8,999.99
P 8,000.00
P 200.00
P100.00
P100.00
23
P 26,000.00 - P 26,999.99
P 26,000.00
P 650.00
P 325.00
P 325.00
24
P 27,000.00 - P 27,999.99
P 27,000.00
P 675.00
P 337.50
P 337.50
25
P 28,000.00 - P 28,999.99
P 28,000.00
P 700.00
P 350.00
P 350.00
26
P 29,000.00 - P 29,999.99
P 29,000.00
P 725.00
P 362.50
P 362.50
27
P 30,000.00 - UP
P 30,000.00
P 750.00
P 375.00
P 375.00
“ Those who earn more, must contribute more to the common fund! ”
PhilHealth Circular No. 11, s. 2012
New Premium Schedule for the Formal Sector
Effective JANUARY 1, 2013
Mpnthly Salary Range
P7,000 & Below
P7,000 to P50,000
P50,000 & Above
Monthly Premium
Rate
Employer
Share
Employee
Share
P 210. 00
3%
P1,500. 00
P105
1.5 %
P750
P105
1.5 %
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.
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 1,200.00 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.
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
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.)
Sponsored
Program
•LGU
•Legislative
•Private
•Gov’t Agencies
*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
Market Segmentation of Potential Members
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
Self-Practicing
Professionals
Transport
Sector
Self-Employed
Barangay
Sector
-Lawyers
-Jeepney Drivers
-Sari-sari Store Owners -Brgy. Tanods
-Doctors
-Consultants
-Freelance Journalist
-Etc.
-Tricycle Drivers
-Transport Operators
-FX/Taxi Drivers
-Etc.
-Market vendors
-Single proprietors
and other Volunteer
-Entertainment Industry workers
-Sidewalk vendors
-Etc
-Etc.
Others
-Organized Groups
-Brgy. Health Workers -Contractors
-House Helpers
-Religious Sector
-Disqualified as Indigent
/Non-Paying Members
-Etc.
Be an advocate of PhilHealth!
The National Health Insurance Program (NHIP)
Average of 3-5 dependents
per household
O.W.P.
A
EMPLOYED
E
SPONSORED
C
B
D
I.P.P.
LGU
Legislative
Private
Gov’t Agencies
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)
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REGISTRATION PROCEDURE:
NOT QUALIFIED?
A. Declare as Dependent of one of the
Member-Child
Requirements:
1. Properly accomplished PMRF (to be
accomplished by the Member-Child)
2 Supporting documents: Member’s Birth
Certificate & Parent’s Proof of age
B. Enroll under IPP
SENIOR
CITIZEN
Requirements:
1. Properly accomplished PMRF
2. Quarterly Payment of Php 600.00
C. Enroll under Sponsored Program
- Depending on the existing program
implementation in the city/municipality.
- Inquire at LGU-Local Social Welfare Ofc
Coverage that extends to your immediate family
45 DAYS / Calendar Year
(exclusive for the member)
MEMBER
45 DAYS / Calendar Year
(to be shared by qualified 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
DEPENDENTS
(biological parent, step parent & adoptive parent)
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PhilHealth Identification Cards
 EMPLOYED
 INDIVIDUALLY
PAYING MEMBERS
 OFWs
Jan.1, 2011 – Dec. 31, 2011
 SPONSORED
 LIFE TIME MEMBER
Register now in all SM Malls & Bayad Centers
P50.00 per card ; must be an ACTIVE member!
Health Insurance Card
 Has a space for member’s photograph and
biometric capture
 Will serve as a key card for hospitals and
merchant-partners to access member records
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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
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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:
1. Case is Emergency
2. Patient is Transferred to another Hospital
3. Patient Expired
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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)
Case Type
Benefit Item
Room & Board
A
B
C
D
P500
P500
P800
P1,100
P4,200
P14,000
P28,000
P40,000
P3,200
P10,500
P21,000
P30,000
(maximum of 45 days/year)
Drugs and Medicines
(per single period of confinement)
X-ray, Lab & Others
(per single period of confinement)
For procedures with RVU 30 and below = 1,200
Operating Room
For procedures with RVU 31 to 80 = 1,500
For procedures with RVU 80 to 600: RVU x PCF 20
(minimum = 3,500)
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New Inpatient PhilHealth Benefits Schedule
Admissions starting April 05, 2009 (Circular 09, s. 2009)
Levels 3 & 4 Hospitals (Tertiary)
Case Type
Professional Fees
A
B
C
D
P300
P400
P500
P600
P1,200
P2,400
P4,000
P6,000
P500
P600
P700
P800
P2,000
P3,600
P5,600
P8,000
A. Daily Visits
Gen. Practitioner (Groups 1, 5 and 6)
Per day
Maximum per confinement
Specialist (Groups 2, 3 & 4)
Per day
Maximum per confinement
B. Surgery
For RVU 500 and below
For RVU 501 and above
Surgeon
Anesthesiologist
Surgeon
Anesthesiologist
Gen. Practitioner (1st Tier – Group 1)
RVU x PCF 40 = PF1
40% of surgeon’s fee
(PF1)
RVU x PCF 40 =
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)
RVU x PCF 48 =
PF2
48% of surgeon’s
fee (PF1)
Diplomate / Fellow (3rd Tier – Group
RVU x PCF 56 = PF3
56% of surgeon’s fee
(PF1)
RVU x PCF 80 =
PF4
40% of surgeon’s
fee (PF4)
2, 3, 4)
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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
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
 Cancer treatment procedures such as:
 chemotherapy
 radiotherapy
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What are my Benefits?
C. Special Benefit Packages
 Maternity Care Package (Accredited Non-Hospital Facilities)**
•Facility Fee
= Php 6,500. 00
•Member’s Pre-natal Care = Php 1,500. 00
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 )
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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
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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
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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
Improved
PhilHealth
Benefits
and other
Updates
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
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
The New Corporate Website
• More user-friendly
• Packed with necessary information
• Inclusion of several online services
Electronic Registration
• A web-based application for
individuals who want to sign up with
PhilHealth.
• Visitors can register as IPM, OFW,
Lifetime Member or Employed
Member
e-Claims Project Phase I
• Called Claims Eligibility Web Service
(CEWS)
• Enables accredited institutional health
care providers to check the eligibility of
the member
• Minimize RTH
Online Mapping Services
• View locations of PhilHealth’s Regional
and Branch Offices
• View accredited health facilities
• View Corporate data using statistical maps
Please Remember . . .
Help Lines: : 4417442
Website: www.philhealth.gov.ph
Facebook: www.facebook/PhilHealth
Email Address: info@philhealth.gov.ph

We do conduct FREE PhilHealth Seminars!
Thank you!
delioaseron@yahoo.com