Updates on Membership Benefits Technical Session VI

“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

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 Protect

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 Phil. Health contribution is deducted every month from their salary. Amount varies based on their respective salary bracket. Employer shares 50% of premium Er 1 + Er 2 + PMRF = Phil. Health Identification Card

Employed Sector: Premium Contribution 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 P 50. 00 2 P 5, 000. 00 – P 5, 999. 99 P 5, 000. 00 P 125. 00 P 62. 50 3 P 6, 000. 00 – P 6, 999. 99 P 6, 000. 00 P 150. 00 P 75. 00 4 P 7, 000. 00 – P 7, 999. 99 P 7, 000. 00 P 175. 00 P 87. 50 5 P 8, 000. 00 – P 8, 999. 99 P 8, 000. 00 P 200. 00 P 100. 00 23 P 26, 000. 00 - P 26, 999. 99 P 26, 000. 00 P 650. 00 P 325. 00 24 P 27, 000. 00 - P 27, 999. 99 P 27, 000. 00 P 675. 00 P 337. 50 25 P 28, 000. 00 - P 28, 999. 99 P 28, 000. 00 P 700. 00 P 350. 00 26 P 29, 000. 00 - P 29, 999. 99 P 29, 000. 00 P 725. 00 P 362. 50 27 P 30, 000. 00 - UP P 30, 000. 00 P 750. 00 P 375. 00 “ Those who earn more, must contribute more to the common fund! ”

Phil. Health Circular No. 11, s. 2012 New Premium Schedule for the Formal Sector Effective JANUARY 1, 2013 Mpnthly Salary Range P 7, 000 & Below P 7, 000 to P 50, 000 & Above Monthly Premium Rate Employer Share Employee Share P 210. 00 3% P 1, 500. 00 P 105 1. 5 % P 750 üAll 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 Phil. Health Offices or through Phii. Health Accredited Collecting Agents nationwide. ü It must be supported by a monthly Employer Remittance List (RF-1) which shall be submitted to nearest Phil. Health Local Health Insurance Offices not later than the 15 th 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 Phil. Health 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 Phil. Health 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 (P 600), Semi-annually (P 1, 200), or Annually (P 2, 400). Hence, only P 200 a month or P 6. 70 a day! * (below P 25 K) 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) Phil. Health Member Registration Form (PMRF) & attach documentary requirements for declared qualified dependents 3. Pay at least one (1) quarter (P 600. 00). Then present the validated receipt to secure the Phil. Health 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. Others -Organized Groups -Brgy. Health Workers -Contractors -House Helpers -Religious Sector -Disqualified as Indigent /Non-Paying Members -Etc. Be an advocate of Phil. Health!

The National Health Insurance Program (NHIP) Average of 3 -5 dependents per household O. W. P. A EMPLOYED E SPONSORED C D B I. P. P. LGU Legislative Private Gov’t Agencies LIFETIME MEMBERSHIP PROGRAM (Phil. Health’s Long Term Benefit) ü Must have reached the age of 60 years old and above AND ü Must have contributed at least 120 monthly contributions (10 years)

ncr-central 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 MEMBER (exclusive for the member) 45 DAYS / Calendar Year (to be shared by qualified dependents) • Legitimate spouse not yet a Phil. Health member • Children 20 years old below, single & unemployed (legitimate, illegitimate, stepchildren, adopted, etc). • Parents-60 years old and above and not a DEPENDENTS GSIS or SSS Retiree / Pensioner (biological parent, step parent & adoptive parent)

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

ü Register now in all SM Malls & Bayad Centers P 50. 00 per card ; must be an ACTIVE member!

Health Insurance Card Ø Has a space for member’s photograph and biometric capture Ø Will serve as a key card for hospitals and merchant-partners to access member records

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

ncr-central What are my Benefits? A. In-Patient Care ( FEE FOR SERVICE SCHME) ü 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

ncr-central New Inpatient Phil. Health 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 A Room & Board B C D P 500 P 800 P 1, 100 P 4, 200 P 14, 000 P 28, 000 P 40, 000 P 3, 200 P 10, 500 P 21, 000 P 30, 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)

ncr-central New Inpatient Phil. Health Benefits Schedule Admissions starting April 05, 2009 (Circular 09, s. 2009) Levels 3 & 4 Hospitals (Tertiary) Case Type Professional Fees A B C D P 300 P 400 P 500 P 600 P 1, 200 P 2, 400 P 4, 000 P 6, 000 P 500 P 600 P 700 P 800 P 2, 000 P 3, 600 P 5, 600 P 8, 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 Gen. Practitioner (1 st Tier – Group 1) RVU x PCF 40 = PF 1 40% of surgeon’s fee (PF 1) With Training (2 nd Tier – Group 5 & 6) RVU x PCF 48 = PF 2 48% of surgeon’s fee (PF 1) Diplomate / Fellow (3 rd Tier – Group 2, RVU x PCF 56 = PF 3 56% of surgeon’s fee (PF 1) RVU x PCF 80 = PF 4 40% of surgeon’s fee (PF 4) 3, 4)

ncr-central What are my Benefits? B. Out-Patient Care ü Allowance for: Drugs and Medicines X-ray and Laboratories Operating Room Fees Professional Fees SAMPLE CASES: ü Day surgeries ü 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 ü Cancer treatment procedures such as: ü chemotherapy ü radiotherapy

ncr-central What are my Benefits? C. Special Benefit Packages ü Maternity Care Package (Accredited Non-Hospital Facilities)** • Facility Fee = Php 6, 500. 00 • Member’s Pre-natal Care = Php 1, 500. 00 üNormal Spontaneous Delivery (NSD) ** up to *4 th 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) ü 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 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

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

ncr-central Common Reasons for Denial of Claims: q 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 q Case is not compensable q No Qualifying Contribution q Patient is not a legal dependent q Non-compliance to previous request

Improved Phil. Health 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 Phil. Health. • 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 Phil. Health’s Regional and Branch Offices • View accredited health facilities • View Corporate data using statistical maps

Please Remember. . . ÆHelp Lines: : 4417442 ÆWebsite: www. philhealth. gov. ph ÆFacebook: www. facebook/Phil. Health ÆEmail Address: info@philhealth. gov. ph ü We do conduct FREE Phil. Health Seminars!

Thank you! delioaseron@yahoo. com