TamangSagot (TS) PhilHealth’s Frequently Asked Questions
Philippine Health Insurance Corporation May 2012 Updated May 20, 2012
Table of Contents A. THE ORGANIZATION .............................................................................................................................................................. 9 What is PhilHealth?.......................... ........................................ ........................... .......................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... ................... ......9 What is the National Health Insurance Program (NHIP)? ................................. .............................................. .......................... ........................... ........................... ........................... ........................... .......................... ................. ....9 What are the underlying principles/concepts principles/concepts behind the NHIP? ............................... ............................................ ........................... ........................... ........................... ........................... .......................... ................. ....9 What is PhilHealth‟s purpose of being? .......................... ....................................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... ........................... ........................... ................... ......9 When was PhilHealth created? ......................... ....................................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... .......................... ........................ ...........9 What are its enabling laws or legal bases? .................. ............................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... .......................... ........................... ...................... ........9 What is its vision? ........................... ........................................ ........................... ........................... .......................... .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ...................... ........9 What is its mission? ......................... ....................................... ........................... .......................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... ................... ......9 What is the role of PhilHealth‟s Board of Directors? Who composes it?............. it? .......................... ........................... ........................... .......................... .......................... ........................... ................... ..... 10 What is PhilHealth‟s classification as a government agency?............. agency? .......................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 10 What are its fund sources? ........................... ........................................ .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 10 Why does PhilHealth have to keep a reserve fund? .................... ................................. .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 10 10 With what organizations is it affiliated?................. .............................. ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............10 How do I contact PhilHealth? PhilHealth? .......................... ....................................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... .......................... ....................... .......... 10
B. MEMBERSHIP .............................. ................................ ................................. ................................ ................................ .......... 11 Who can be members of PhilHealth? PhilHealth? .......................... ....................................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ..................... ........ 11 What are the different membership types at PhilHealth?.......................... ........................................ ........................... ........................... ........................... .......................... .......................... .......................... ..................... ........ 11 Who can enrol under these different programs? ...................... .................................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 11 What are the fundamental processes that each member should know? ....................... ..................................... ........................... .......................... .......................... .......................... ..................... ........ 13 13 What is my proof that I am already a registered member? .................................... ................................................. .......................... ........................... ........................... .......................... .......................... ..................... ........ 13 13
C. REGISTRATION/ENROLLMENT ............................................................................................................................................ 13 Who should enrol?........................... ......................................... ........................... .......................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 13 Is there any age limit for prospective members?..................... members?................................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 13 How do members enrol into the program? Where can they enrol?.......................... enrol?....................................... ........................... ........................... ........................... ........................... .......................... ............... 13 What are the documents required for the registration of employers (and their employees) in the Government Sector and Private Sector? .......................... ........................................ ........................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 16 How can LGUs enrol their underprivileged underprivileged constituents into the Sponsored Program? .......................... ........................................ ........................... .......................... ............... 16 Who can be declared as legal dependents? dependents? .......................... ....................................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... .......................... ..................... ........ 16 How do I activate my membership? membership?............................... ............................................ .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ................... .....16 Where else can I register?............................ .......................................... ........................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 17 Situationers for Registration/Enrolment Registration/Enrolment ..................................................................... ............................................................................................................ ....................................... 1 7 Can foreign nationals working in the Philippines Philippines enrol? .................... ................................. .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 17
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Can minors and orphaned children enrol? ............................. .......................................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ..................... ........ 17 In case of early retirement, can I already register as a Lifetime Member? ......................... ....................................... ........................... ........................... ........................... ................ ... 17 Is it true that retiring employees can now be automatically enrolled by the employer in the Lifetime Member Program?.......................... ........................................ ........................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... ....................... .......... 17 Can foreign spouses of Filipino nationals be declared as dependents? dependents? ..................... .................................. ........................... ........................... .......................... ......................... ............ 17 Can unmarried members declare nephews or nieces as dependents? dependents? ............................... ............................................. ........................... ........................... ........................... ................ ... 18 If both parents are members, can they both declare their children as dependents? dependents? ......................... ...................................... .......................... ....................... .......... 18 How can a member declare his spouse whose membership is inactive as a dependent? dependent? .......................... ....................................... ......................... ............ 18 If all siblings are active members, can each of them declare their parents as dependents? ......................... ...................................... ..................... ........ 18 Can disabled parents (physically or mentally incapacitated) incapacitated) who are below 60 years old be declared as dependents? dependents? .......................... ........................................ ........................... .......................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 18 Can my live in partner be declared as a legal dependent? dependent? How about our children? ..................... .................................. .......................... ......................... ............ 18 My daughter who‟s still my dependent (under 21) is about to give birth. Will my membership be able to cover her?.......................... ....................................... ........................... ........................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... .......................... ..................... ........ 18 Do I need to personally submit my registration documents or can I ask my representative representative to do so? ......................... ......................... 18
D. UPDATING MEMBERSHIP RECORDS .................................................................................................................................. 18 When should I update my MDR? How is this done?......................... ....................................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ................... ..... 18 How do I shift membership categories? ....................... .................................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... .......................... ........................... ................... ..... 19 Are we going to use the same PhilHealth Identification Identification Number (PIN) if we are shifting to another membership category?...................... category?................................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ...............
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................................................................................................ ............................ 1 9 Situationers for Updating Membership Records .................................................................... I was given a PhilHealth card by our LGU, but my name was misspelled and data provided were also erroneous. How do I correct this information? ...................... ................................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... ................ ... 19
E. CONTRIBUTIONS AND MEMBERSHIP RENEWAL .............................................................................................................. 19 Why must a member pay his premiums regularly? ........................... ......................................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ................... ..... 19 How much is the premium contribution rate? ........................ ..................................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ................... ..... 19 Why is there a need for an increase in premium contributions? ....................... ..................................... ........................... .......................... ........................... ........................... .......................... ....................... .......... 20 Are overtime pay, commissions, and allowances included in the computation of premium contributions of employees? .......................... ....................................... ........................... ........................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 20 Where can the members remit their contributions? ........................... ......................................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 20 Aside from paying through service offices and collecting agents, is there another way for me to pay my premiums easily? ......................... ....................................... ........................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... ........................... ........................... ................ ... 21 What if I want to view my payment history for Text 7442? ................. .............................. .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 21 When is the deadline for paying my premium contribution? contribution? .................................... ................................................. .......................... ........................... ........................... ........................... ........................... ................ ... 21 What is the effectivity date of PhilHealth coverage? ................................. .............................................. ........................... ........................... .......................... ........................... ........................... .......................... ....................... .......... 23 What are the t he requirements for eligibility? eligibility? When is a member eligible to claim? ........................... ........................................ ........................... ........................... .......................... ............... 23 How do I maintain my eligibility? eligibility? ......................... ...................................... .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 23
If I missed paying in the past quarters, can I still pay for this now to become eligible again? ......................... ....................................... ........................... ................ ... 24 What is the tolerable delay for paying premiums for a member to still be able to use his/her benefits? ......................... ................................. ........ 24
.......................................................................................................... ....................................... 2 4 Situationers: Contributions and Renewal ................................................................... Can contributions be refunded by the member who was not able to use it? ....................... ..................................... ........................... .......................... ......................... ............ 24 If I stopped paying my premium for a considerable amount of time, can I still use my benefits? Do I need to pay the missed contributions to be able to avail of the benefits again? ..................... ................................... ........................... .......................... .......................... ........................... ................... ..... 24 24 If an employed member who was separated from service last October 2011 wants to continue his membership as an Individually Paying Member in March 2012, can he retroactively pay the premiums for Nov-Dec 2011 and first quarter 2012, in March 2012? ......................... ....................................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... ....................... ..........25 A new governor/mayor was elected in our area. Am I still considered a member under the Sponsored Program even with this change in leadership? leadership? ...................................... ................................................... .......................... ........................... ........................... ........................... ........................... .......................... .......................... ....................... .......... 25 What if I have multiple jobs? Can I just pay my contributions once? ..................... ................................... ........................... .......................... ........................... ........................... ................ ... 25 25 I am an employed member, but I recently found out that my employer stopped paying our contributions even though he continues to deduct the premiums from our salaries. How do we go about this? ................... ................................. ....................... ......... 25 What if the member passes away? Can the dependents still use their benefits? ....................... .................................... .......................... ........................... ................... ..... 25 If a member has paid his premium for one year and he died during the first half of the year, can his dependents refund his premium? .......................... ....................................... .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 26 I already have a lifetime member card, but my current employer still continues to pay for my premiums. Can these premium contributions contributions be credited to my son/daughter‟s membership when I retire? ........................... ........................................ .......................... ............... 26 What if a Lifetime Member is re-hired, must he resume contributing to PhilHealth through salary deduction?...... 26 Is membership transferrable? transferrable? .......................... ........................................ ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... ....................... .......... 26 Are the payments for OWWA Contributions Contributions and PhilHealth premiums different?............................. different?.......................................... .......................... ....................... .......... 26 If I stopped paying my premium for a considerable amount of time, how will I reactivate my membership? Do I need to apply for a new membership/PIN? membership/PIN? ............................. ........................................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ................... ..... 26 How can a SP member continue PhilHealth membership when his/her PhilHealth ID expires? ......................... ...................................... ............... 26 I used to be employed, but am now self-employed. Can I still continue paying for my premiums? How do I go about this? ......................... ....................................... ........................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ..................... ........ 26 I am a PhilHealth PhilHealth member sponsored by an LGU; is it still necessary for me to pay my membership as an OFW? . 27 Why do I have to renew my PhilHealth membership membership every time I leave the country and work as an OFW? .............. .............. 27 What is the grace period of OFW membership renewal? .................... ................................. .......................... ........................... ........................... ........................... ........................... .......................... ............... 27 I am currently abroad and my coverage is about to expire. How do I continue paying for my PhilHealth in case there are no available payment centers where I am? .............................. ........................................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 27 If a member has dual citizenship, can he/she still renew his/her membership and avail of the benefits whenever he/she is in the Philippines? Philippines? .......................... ....................................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............27 I am already an immigrant here in the US. Can I still continue my membership with PhilHealth? .......................... .................................. ........ 27 Where can I pay my premium contributions? ................... ................................ .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 27
F. SPECIAL SECTION: SECTI ON: INCREASE IN PREMIUM PREM IUM FOR OFW MEMBERS ............................. ................................ ..................... 27 Why is there a need to increase the annual premium of OFW members? ...................... .................................... ........................... .......................... .......................... ........................... ................... ..... 27 27 What was the basis for pegging the new premium rate at P2,400 per year? .......................... ........................................ ........................... .......................... .......................... ....................... .......... 28
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Were OFW members consulted by PhilHealth before the increase was approved? .................................. ................................................ ........................... .......................... ............... 28 How much is the increase? When is this effective? ............................. ........................................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 28 When was the last time that premium contributions of OFW members increased?......................... ....................................... ........................... .......................... ....................... .......... 28 Can OFW members whose families were affected by Typhoon Sendong be exempted from paying the new premium rate? .......................... ....................................... ........................... ........................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ................... ..... 28 Where can they pay their premium contributions in the Philippines? How about abroad? ........................ ..................................... .......................... ....................... .......... 28 If an OFW‟s membership coverage expires expires while he is still abroad, will he be required to pay, through his kin in the Philippines, Philippines, the new rate when he renews his coverage? ...................... ................................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 28 28 How much is the premium if an OFW decides to pay in advance?................... advance?................................. ........................... .......................... ........................... ........................... .......................... ....................... .......... 29 What additional benefits can an OFW member expect from PhilHealth? PhilHealth? ..................................... .................................................. .......................... .......................... ........................... ................... ..... 29 Will the increase in premium mean additional benefits for OFWs and their dependents as well?.......................... ....................................... ..................... ........ 29 Are these benefits available to the OFW member even while he is abroad? ................... ................................. ........................... .......................... ........................... ........................... ................ ... 29 29 When can OFWs expect the increase in benefits?.......................... ....................................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... ....................... .......... 29 How do you plan to inform OFWs about the new premium rate in less than two weeks‟ time?............. time? .......................... .......................... ......................... ............ 29 Is PhilHealth making any representation with Philippine Embassies and consulates overseas to inform OFWs about the increased premium? .......................... ........................................ ........................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 30 Since PhilHealth has no physical presence overseas, how do you plan to discuss the new premium rates with OFWs and OFW organizations at this time?................................. ............................................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... ....................... .......... 30 Where can OFW-members refer their inquiries pertaining to the new premium rates? ............................. .......................................... .......................... ......................... ............ 30
G. SPECIAL SECTION: SEC TION: UMID CARD CA RD ACTIVATION ACTIVATI ON AND BIOMETRIC BIOME TRIC CAPTURE CAPTUR E............................... ............................... .....30 Why must I undergo biometric capture with PhilHealth? ............... ............................. ........................... .......................... ........................... ........................... .......................... .......................... ........................... ................... ..... 30 Can I choose not to have my biometric data captured by PhilHealth?........................... ......................................... ........................... .......................... .......................... .......................... ..................... ........ 30 30 What does „biometric capture‟ mean?.............. mean?........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... .......................... ........................... ................... ..... 30 Am I going to pay any fee for biometric capture? .................... .................................. ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 30 Where can I have my biometric data captured by PhilHealth?......................... ...................................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 30 30 If I missed the schedule of biometric capture in our office premises, can I proceed to any PhilHealth PhilHealth Branch for this? .... 31 Are there forms I need to fill out before biometric capture day? .................. ............................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 31 Is there a recommended attire for the biometric process? ..................... .................................. ........................... ........................... ........................... ........................... .......................... .......................... ....................... .......... 31 How will the biometric capture procedure go? ........................ ...................................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 31 Will the biometric capture process eat up a lot of my time from work? .......................... ........................................ ........................... .......................... .......................... ........................... ................... ..... 31 What do I need to bring on biometric capture day?......................... ....................................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ................... ..... 31 Are there things I must ensure before I proceed with biometric capture?.......................... ........................................ ........................... ........................... ........................... .......................... ............... 31 Can I update my MDR on the day of biometric capture through the UMID Mobile Team? .......................... ....................................... .......................... ..................... ........ 31 Once my biometric data have been captured, what are the next steps? ..................................... .................................................. .......................... .......................... .......................... ..................... ........ 31 Where can I call if I have further questions regarding the biometric capture?........................... capture?......................................... ........................... .......................... ........................... ................... ..... 31
..................................................................................................................................... ................................................................ 3 2 UMID Card Activation ..................................................................... Why must I activate my UMID card with PhilHealth? .......................... ....................................... .......................... ........................... ........................... .......................... ........................... ........................... ................ ... 32
Can I choose not to activate my UMID card with PhilHealth? ...................... ................................... .......................... ........................... ........................... ........................... ........................... ................ ... 32 What does „card activation‟ mean?............. mean? .......................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 32 What are the requirements to activate my UMID card with PhilHealth? PhilHealth? .......................... ........................................ ........................... .......................... ........................... ................... ..... 32 Where can I activate my UMID card with PhilHealth? ....................... .................................... .......................... .......................... ........................... ........................... .......................... ........................... ................... ..... 32 If I missed the schedule of card activation in our office premises, can I proceed to any PhilHealth Branch to have my UMID card activated?.................................. ................................................ ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... ....................... .......... 32 How long does the card activation process take? ............... ............................ ........................... ........................... ........................... ........................... .......................... .......................... .......................... ..................... ........ 32 Can I update my MDR on the day of card activation through the UMID Mobile Team? ....................... ..................................... ........................... ................ ... 33 What are the card activation procedures? ................. .............................. .......................... ........................... ........................... .......................... ........................... ........................... .......................... .......................... ..................... ........ 33 How will I use my PhilHealth-activated PhilHealth-activated UMID cards? ..................... ................................... ........................... .......................... ........................... ........................... .......................... .......................... ..................... ........ 33 What are the contact numbers if I have further questions regarding the UMID card activation?.......................... activation?.................................... .......... 33
H. BENEFITS AND BENEFITS AVAILMENT .............................................................................................................................. 33 What benefits can a member avail himself of under the NHIP? ........................... ........................................ .......................... ........................... ........................... .......................... .......................... ..................... ........ 33 33 Where can these benefits be availed of?........................ of?..................................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... ................ ... 39 How can these benefits be availed of? ................... ................................ ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 39 Do legal dependents enjoy the same benefits as the member? ........................... ........................................ .......................... ........................... ........................... .......................... .......................... ..................... ........ 40 What documents must a member submit to be able to avail of the benefits? ............................... ............................................ ........................... ........................... .......................... ............... 40 Where and when should these documents be submitted?.......................... ....................................... .......................... ........................... ........................... .......................... .......................... ........................... ................... ..... 40 How can the member avail himself of PhilHealth benefits if he has an existing coverage with a health maintenance organization?.............. organization?........................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ...............
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Can a senior citizen avail himself of both the PhilHealth benefits and his senior citizen privilege when confined? ............. ............. 40 Can overseas Filipino worker-members reimburse their hospitalization expenses with PhilHealth? PhilHealth? ........................... ........................................ ................ ... 40 I‟ve been paying my premiums regularly, but I still haven‟t availed of any benefits. When will I be able to benefit from my membership? ......................... ....................................... ........................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ..................... ........ 40
.................................................................................................... .......................................... 4 1 Situationers: Benefits and Benefits Availment .......................................................... How will the member know if the PhilHealth benefit deducted from his total hospital bill is correct? ................. ......................... ........ 41 What if the amount deducted as PhilHealth benefit benefit is less than what PhilHealth actually paid to the provider for the member‟s confinement?............. confinement? .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 41 If siblings are all active members, can each of them file a claim for the confinement of their parents? ....................... ....................... 41 If both spouses are members, can each of them file a claim for the confinement of their children? .......................... ............................. ... 41 If the spouse‟s, child‟s or parent‟s name is not listed in the member‟s MDR at the time of confinement, how can the member avail himself of the benefits? ............................. .......................................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ..................... ........ 41 How can members separated or resigned from employment avail themselves of maternity benefits? ........................ ........................ 41
I. SPECIAL SECTION: SE CTION: CASE RATES RA TES FOR 23 MEDICAL MEDICA L AND SURGICAL PROCEDURES ............................. ........................... 42 What is case payment? ........................... ........................................ ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... .......................... .......................... ..................... ........ 42 How is this different from the old system? .......................... ....................................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... .......................... ....................... .......... 42
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Why shift to case rate payments? What advantages will this form of benefit payment bring, especially to the members? .......................... ....................................... ........................... ........................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ........................... ................ ... 42 Who are entitled to these new case rate packages? ................ .............................. ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 42 Can I avail of this benefit now?....................... now?.................................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... .......................... ....................... .......... 42 How will cases be reimbursed? ........................... ........................................ .......................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ................... ..... 42 What will happen to doctor‟s professional fees? .......................... ....................................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 42 How much will be allocated to the doctors‟ PF? ........................... ........................................ .......................... .......................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 42 What are the surgical cases under Case Rate that can be reimbursed in particular facilities? ................................ ............................................. ....................... .......... 42 How will hospitals be paid for 2 or more surgical case rates performed in a single confinement? .......................... ........................................ ................... ..... 43 How will the procedures be reimbursed if a procedure performed has laterality (e.g., cataract)?......................... ...................................... ....................... .......... 43 What will happen to major surgical procedures done in Level 1 hospitals?.......................... ....................................... ........................... ........................... .......................... ......................... ............ 43 Is Case Rate covered by the rule on single period of confinement? Will the 45 days allowance apply for case rates? ....... 43 If a member‟s total hospital fees for dengue I is beyond the case rate amount listed by PhilHealth, will the member shoulder the balance? .......................... ........................................ ........................... ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... .......................... ....................... .......... 43 A member is admitted for dengue I for three days, and another member is admitted for dengue I for five days, will they be entitled to the same case rate amount for dengue I of P8,000.00? ............................... ............................................. ........................... .......................... ........................... ........................... ................ ... 43 43 What medical cases under Case Rate can be reimbursed in Level 1 hospital? Level 2 hospitals?................................. hospitals?.............................................. ................ ... 43 For medical case rate, how will PhilHealth pay for a patient admitted for several conditions? ....................... ..................................... ........................... ................ ... 44 In case the member was transferred to another hospital, will PhilHealth pay for both facilities? .......................... ....................................... ....................... .......... 44 For cases not included in the Case Rates table, how will PhilHealth reimburse those cases? .............. ........................... ........................... ........................... ................ ... 44 44
J. SPECIAL SECTION: NO BALANCE BALAN CE BILLING POLICY ............................................ ................................ ................................ 44 What is “No Balance Billing” (NBB) and to whom it will be applicable? ......................... ....................................... ........................... .......................... .......................... .......................... ..................... ........ 44 Why is this being introduced only for Sponsored Program members? .......................... ........................................ ........................... .......................... .......................... .......................... ..................... ........ 44 What are the conditions for availment of benefits of SP members under the t he NBB policy?......................... ...................................... .......................... ....................... .......... 44 Is the NBB policy also applicable applicable to other PhilHealth membership types? .............. ............................ ........................... ........................... ........................... .......................... ......................... ............ 44 If the Sponsored member under NBB bought drugs and medicines or other supplies, will he be able to reimburse then? How? ......................... ...................................... ........................... ........................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ................... ..... 45 In case a sponsored member/dependent member/dependent was admitted in a government hospital where the only available room that time for the patient is a private room, can the sponsored member be admitted in any room or private room of a government hospital? Will the NBB policy still apply? ................... ................................ ........................... ........................... ........................... ........................... .......................... .......................... .......................... ..................... ........ 45 What if a sponsored member is admitted in a private hospital? Will the NBB policy still be applicable? applicable? ................. .............................. ................ ... 45 Are there sanctions for violations in NBB policy? ................ ............................. .......................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ..................... ........ 45
K. SPECIAL SECTION: ANIMAL BITE PACKAGE............................ ................................. ............................... ........................... 45
................................................................................................................ ..................................................... 45 45 Tamang Paggamot sa Kagat ng Hayop ........................................................... Ano ang unang dapat gawin kapag nakagat ng hayop? ................................ ............................................. .......................... ........................... ........................... ........................... ........................... ................ ... 45 Bakit kailangang magpabakuna kung nakagat ng aso? .................................. ............................................... .......................... ........................... ........................... ........................... ........................... ................ ... 45 Gaano katagal ba ang bisa ng bakuna? ............... ............................ ........................... ........................... .......................... .......................... ........................... ........................... ........................... ........................... .......................... ............... 45
Ilang beses ba akong bibigyan ng bakuna?......................... ...................................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... ....................... .......... 46 Kailan dapat magpabakuna? magpabakuna? Hihintayin pa bang mamatay ang aso bago magpabakuna? ................. ............................... ........................... ................ ... 46 Kailangan pa ba akong ma-confine kung nakagat ng aso? .................... .................................. ........................... .......................... ........................... ........................... .......................... ....................... .......... 46 Kailangan pa ba akong mabakunahan kung kumpleto naman sa bakuna ang asong kumagat? .................... ................................. ................ ... 46 Mga Paalala.......................... ....................................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... .......................... .......................... ........................... ........................... ........................... ................... ..... 46
...................................................................................... ................. 46 46 Tungkol sa Animal Bite Treatment Package ng PhilHealth ..................................................................... Ano po ba ang kasama sa Animal Bite Treatment Package?......................... ...................................... .......................... ........................... ........................... ........................... ........................... ................ ... 46 Ano ang kailangang ipakita o gawin para maka-avail ng package? ................... ................................. ........................... .......................... .......................... .......................... ..................... ........ 46 46 Saan ba pwedeng maka-avail ng package? Saan ako pwedeng pumunta para magpabakuna kung nakagat ng aso? ......................... ....................................... ........................... .......................... ........................... ........................... .......................... .......................... ........................... ........................... .......................... ........................... ........................... .......................... .......................... ..................... ........ 47 Kailangan ba akong bumili ng bakuna sa labas? Meron pa ba akong dapat bayaran kung may PhilHealth na?...... 47 47 Paano kung nakagat ako ulit? Ilang beses ako pwedeng makagamit makagamit ng PhilHealth para sa ganitong benepisyo?47 Covered din ba ang pamilya ko pag sila ay nakagat? ............................. .......................................... ........................... ........................... ........................... ........................... .......................... ......................... ............ 47 Paano kung hindi aso ang nakakagat? Kasama pa rin po ba ito sa benepisyo? .......................... ....................................... ........................... ........................... ................ ... 47
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A. THE ORGANIZATION What is PhilHealth? The Philippine Health Insurance Corporation (PhilHealth) is a Government-Owned and Controlled Corporation that was established to administer the National Health Insurance Program nationwide.
What is the National Health Insurance Program (NHIP)? The NHIP is basically the product that PhilHealth offers. This mandatory health insurance program of the government seeks to provide universal health insurance coverage and ensure affordable, acceptable, available, accessible, and quality health care services for all citizens of the Philippines.
What are the underlying principles/concepts behind the NHIP? Social health insurance is based on the principle of social solidarity . Social solidarity with respect to health care is expressed when people support each other by contributing financial resources to a pool that will pay for everyone‟s costs of care. In this set-up, PhilHealth acts as the body that pools all the resources together and makes it available to each member, thereby allowing the rich to support the poor, the healthy to support the sick, the young and working to support the elderly – all – all in the spirit of bayanihan .
What is PhilHealth‟s purpose of being? Bawat Pilipino, miyembro Bawat miyembro, protektado Kalusugan natin, segurado
This battle battle cry captures PhilHealth‟s primary purpose of being, which is to ensure that all Filipinos, especially those who cannot afford the cost of health care, are given real financial risk protection. For PhilHealth, real financial risk protection means that: 1. All Filipinos are enrolled into into the NHIP (100% (100% coverage) coverage) 2. Members are empowered to enjoy their enhanced benefits 3. Each member will be assigned to a primary care provider who shall address his/her health needs 4. Members have access to accredited facilities that are of superior quality 5. Every Filipino who desires to avail of the No Balance Billing (zero-copayment) policy will always have an opportunity to do so anywhere in the country. This reduces, if not totally eliminates, debilitating out-ofpocket health expenses that drive families deeper into poverty.
When was PhilHealth created? PhilHealth was established on February 14, 1995.
What are its enabling laws or legal bases? It was through Republic Act 7875 or the National Health Insurance Act of 1995 that PhilHealth was created. It was amended by Republic Republic Act 9241 9241 which was passed passed on February 10, 2004.
What is its vision? PhilHealth‟s vision is to provide adequate and affordable social health insurance coverage for all Filipinos.
What is its mission? Its mission is 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.
What is the role of PhilHealth‟s Board of Directors? Who composes it? The Board of Directors is responsible for providing the overall policy and strategic direction of the Corporation. It is composed of the following members representing key government agencies and sectors of our population: Board Chair, Secretary of Health Board Members Chairman, Civil Service Commission Secretary, Department of Interior and Local Government Secretary, Department of Social Welfare and Development Secretary, Department of Labor and Employment President and Chief Executive Officer, Social Security System President and General Manager, Government Service Insurance System Representative, Representative, Health Care Providers Sector Representative, Representative, Labor Sector Representative, Representative, Employers Sector Representative, Representative, Self-employed Sector Representative, Representative, Filipino Overseas Workers Chairman, National Anti-Poverty Council – Council – Basic Basic Sector
Hon. Enrique T. Ona, MD Hon. Francisco T. Duque III, MD, MSc Hon. Jesse M. Robredo Hon. Corazon J. Soliman Hon. Rosalinda D. Baldoz Hon. Emilio S. De Quiros, Jr. Hon. Robert G. Vergara Hon. Juan M. Flavier, MD Hon. Alexander A. Ayco, MD Hon. Dr. Eduardo P. Banzon Hon. Francisco Vicente F. Lopez, MD Hon. Jane M.N. Sta. Ana Hon. Florencia Dorotan
What is PhilHealth‟s classification as a government agency? Similar to the SSS, GSIS and PAG-IBIG, PhilHealth is a government owned and controlled corporation (GOCC). It is also an attached agency of the Department of Health (DOH).
What are its fund sources? Unlike the Department of Health and other agencies that are financed through taxes, PhilHealth primarily gets its funds from premiums being collected from its members. Out of the total amount collected, a percentage goes to its Corporate Budget.
Why does PhilHealth have to keep a reserve fund? f und? PhilHealth, as a social health insurance, uses a pay-as-you-go scheme . This simply means that out of collected funds, the Corporation is bound to allot funds for expenses to be incurred by members for a particular enrolment year. The reserve fund is is only kept in anticipation anticipation of calamities and other other situations where where members‟ use of benefits will likely exceed that of current/projected rates, therefore demanding for more resources to pay for expenses.
With what organizations is it affiliated? aff iliated? PhilHealth is a member of several organizations involved in social security, such as the International Social Security Association, ASEAN Social Security Association, and the Philippine Social Security Association (PHILSSA), among others.
How do I contact PhilHealth? There are many ways ways to reach PhilHealth: PhilHealth: Website: www.philhealth.gov.ph Email:
[email protected] Facebook: www.facebook.com/PhilHealth Twitter: www.twitter.com/teamphilhealth www.twitter.com/teamphilhealth Trunkline: 441-7444 (connecting all departments) departments) Call Center: 441-7442 Page 10 of 47 of 47
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B. MEMBERSHIP Who can be members of PhilHealth? All Filipino citizens are mandated mandated to enrol enrol into the National Health Insurance Program.
What are the different membership types at PhilHealth? There are currently five membership membership types/programs types/programs under the NHIP. NHIP. These are: 1. Sponsored Program 2. Individually Paying Program 3. Employed Sector Program 4. Overseas Workers‟ Program 5. Lifetime Member Program
Who can enrol under these different programs? As a general rule, remember that each Filipino is entitled to become part of the National Health Insurance Program. Your type of membership depends primarily on two things: 1) capacity to pay and 2) employment. Those who are below below 21 are generally generally considered as dependents, dependents, rather than primary members. members. Sponsored Program Under the Sponsored Program, indigents belonging to the lowest 40% (Quintiles 1 and 2) of the Philippine population in terms of income may enrol, including: 1. Families listed under the National Household Targeting System for Poverty Reduction (NHTS – (NHTS – PR) PR) of the Department of Social Welfare and Development (DSWD) (DSWD) 2. Families identified poor by the sponsoring Local Government Units (LGUs). (LGUs).
Individuals are encouraged to check whether they belong to the DSWD/LGU lists. Identified members and their dependents shall be considered part of the NHIP. Individually Paying Program Under the Individually Paying Program, the following may enrol: 1. Self-employed individuals . These are individuals who work for him/herself and are therefore both the employer and employee of their businesses. These include but are not limited to the following: a. Self-earning professionals (ex. doctors and lawyers) b. Business partners and single proprietors/proprietresses proprietors/proprietresses c. Freelancers, actors, actresses, directors, scriptwriters and news reporters who are not under an employer-employee relationship d. Professional athletes, coaches, trainers and jockeys e. Farmers and fisherfolk f. Workers in the informal sector (ex. ambulant vendors, watch-your-car boys, hospitality girls, tricycle drivers, etc.) 2. Separated from employment . These are individuals who were previously formally-employed (with employeremployee relationship) and are separated from employment. 3. 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. 4. All other individuals not covered under the previous categories mentioned, including but are not limited to the following: a. Parents who are not qualified as legal dependents, indigents or retirees/pensio r etirees/pensioners ners b. Retirees who did not meet the minimum of 120 monthly premium contributions to qualify as nonpaying members c. Children who are not qualified as legal dependents d. Unemployed individuals who are not qualified as indigents
Employed Sector Program Under the Employed Sector Program, the following may enrol: 1. 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, financial institutions with original charter, constitutional commissions, and is occupying either an elective or appointive position, regardless of status of appointment.
2. Private Sector. Employees who render services in any of the following: a. 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 b. Foreign corporations, business organizations, non-government organizations based in the Philippines c. Foreign governments or international organizations with quasi-state status based in the Philippines which entered into an agreement with with PhilHealth to cover cover their Filipino employees employees d. Foreign business organizations based abroad with agreement with PhilHealth to cover their Filipino employees e. Sea-based OFWs f. Household employees Overseas Workers Program Under the Overseas Workers Program, the following may enrol: 1. Active land-based OFWs who underwent the normal process of registration as an OFW at POEA Offices 2. OFWs who are currently abroad but are not yet registered with PhilHealth Lifetime Member Program Under the Lifetime Member Program, the following may enrol:
1. Old-age retirees and pensioners of the GSIS, including uniformed and non-uniformed personnel of the AFP, PNP, BJMP and BFP who have reached the compulsory age of retirement before June 24, 1997, and retirees under Presidential Decree 408 2. GSIS disability pensioners prior to March 4, 1995 3. SSS pensioners prior to March 4, 1995 4. SSS permanent total disability pensioners 5. SSS death/survivorship death/survivorship pensioners 6. SSS old-age retirees/pensioners retirees/pensioners 7. Uniformed members of the AFP, PNP, BFP and BJMP who have reached the compulsory age of retirement on or after June 24, 1997, being the effectivity date of RA 8291 which excluded them in the compulsory membership to the GSIS 8. Retirees and pensioners who are members of the judiciary 9. Retirees who are members of Constitutional Commissions and other constitutional offices 10. Former employees of the government and/or private sectors who have accumulated/paid at least 120 monthly premium contributions as provided for by law but separated from employment before reaching the age of 60 years old and thereafter have reached 60 years old 11. Former employees of the government and/or private sectors who were separated from employment without completing 120 monthly premium contributions contributions but continued to pay their premiums as Individually Paying Members until completion of the required 120 monthly premium contributions and have reached 60 years old as provided for by law 12. Individually Paying Members, including SSS self-employed and voluntary members, who continued paying premiums to PhilHealth, have reached 60 years old and have met the required 120 monthly premiums as provided for by law 13. Retired underground mine workers who have reached the age of retirement as provided for by law and have met the required premium contributions
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What are the fundamental processes that each member should know? Each member ought to be familiar with the following fundamental processes: 1. Enrolling or registering into the NHIP 2. Updating their records regularly 3. Paying for their premiums on-time 4. Getting their claims from PhilHealth 5. Knowing their benefits
What is my proof that I am already a registered member? After registering, each each member should should receive the following following important documents: documents: 1. PhilHealth ID – ID – contains contains the member‟s PIN (PhilHealth Identification Number) , name, picture, and signature. Remember that each member should have only one PIN. 2. Member Data Record (MDR) – (MDR) – contains contains the member‟s name, address and legal dependents listed in the PhilHealth database
C. REGISTRATION/ENROLLMENT Who should enrol? All Filipinos aged 21 years old and above (no longer qualified as dependents) must register and have their own PhilHealth ID Number or PIN. Once a legal dependent reaches 21 years of age, he/she must apply for his/her membership.
Is there any age limit for fo r prospective members? None, the NHIP promotes mandatory coverage for all Filipinos.
How do members enrol into the program? Where can they enrol? Sponsored Program Members whose names appear in the NHTS-PR NHTS-PR list or LGU‟s list of priority families are autom atically enrolled into the program. Their IDs may be claimed from the Local Social Welfare and Development Office. To date, the NHTS list has been distributed to providers and has been made available online through PhilHealth‟s website: http://www.philhealth.gov.ph/members/sponsored/nhts-pr_list.html .
If members feel like they should be part of the SP, he/she can approach their local DSWD office,which in turn, will evaluate and determine if he/she is qualified to join the program. The DSWD shall then endorse the list of possible beneficiaries to the Local Government Unit (LGU) or any Sponsor. Individually Paying Program In general, these are the steps that each member has to go through to register. The following section details the documents/protocols documents/protocols that are unique to each member type. STEP 1
STEP 2
STEP 3
Fill out the PMRF (2 copies)
Prepare supporting documents (see list below).
Go to the nearest PhilHealth Service Office to submit the docs and pay your premium.
1. Fill out two copies of the PhilHealth Member Registration Form (PMRF).
2. Attach a clear copy of the following supporting documents to this form (for the applying member and his/her qualified dependents): dependents): a. Member – Member – Birth/baptism Birth/baptismal al certificate or any ID card issued by a government official authority b. Dependents i. Spouse: Marriage certificate/contract certificate/contract ii. Children below 21: Birth certificate; court decree of adoption (for adopted children) iii. Parents 60 and above: Birth certificate 3. Submit these documents to the nearest PhilHealth Service Office for processing. 4. Upon submission of documents, the registrant will be issued his/her PhilHealth Identification Number (PIN) and a Member Data Record (MDR). 5. He/she shall then be asked to pay the required premium through the PhilHealth Cashier or any accredited collecting agent (banks, local government units, etc.) Online Registration STEP 1 Visit the PhilHealth website eregister.philhealth.gov.ph
STEP 2 Fill out and submit online registration form.
STEP 3 Go to the nearest PhilHealth Service Office to pay your premium.
1. Members also have an option to register online. Simply visit http://eregister.philhealth.gov.ph and go through the procedures indicated in the site. Employed Sector Program 1. For newly hired employees without PIN yet (Also applicable to existing employees without PIN): a. Fill out two copies of the PhilHealth Member Registration Form (PMRF). b. Attach a clear copy of the following supporting documents to this form (for the applying member and his/her qualified dependents): i. Member – Member – Birth/baptism Birth/baptismal al certificate or any ID card issued by a government official authority ii. Dependents 1. Spouse: Marriage certificate/contract certificate/contract 2. Children below 21: Birth certificate; court decree of adoption (for adopted children) 3. Parents 60 and above: Birth certificate c. Submit these documents to the company‟s HR Department that is in charge of forwarding the documents to PhilHealth together with the ER2 Form (Report of Employee-Members). Employee-Members). d. After processing, PhilHealth will send the member, through the employer, his/her PhilHealth Identification Number (PIN) and a copy of the Member Data Record (MDR).
2. Newly hired employees with PIN need only to report their PIN to their employers for them to be specified in their ER2 (and subsequently updated in PhilHealth‟s database). Overseas Workers Program When in the Philippines: 1. Submit the following documents to any PhilHealth office: a. Duplicate copies of PhilHealth Member Registration Form (PMRF) b. Supporting documents: i. Member – Member – Birth/baptism Birth/baptismal al certificate or any ID card issued by a government official authority ii. Dependents 1. Spouse: Marriage certificate/contract certificate/contract 2. Children below 21: Birth certificate; court decree of adoption (for adopted children) 3. Parents 60 and above: Birth certificate c. Any of the following as as proof of being an active active OFW: i. Valid Overseas Employment Employment Certificate Certificate (OEC) or E-receipt E-receipt Page 14 of 47 of 47
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ii. Valid overseas employment employment contract or certificate of employment employment iii. Valid re-entry visa iv. Valid job contract 2. Pay the one-year premium of PhP 1,200. If you have already paid PhP900 during your last transaction, please expect a notice from PhilHealth charging the additional PhP300 to complete your annual premium. When abroad: 1. Submit the following documents to any PhilHealth office: a. PhilHealth Premium Payment Slip (PPPS) b. Duplicate copies of the PhilHealth Member Registration Form (for i nitial registration) c. Supporting documents (birth certificate, baptismal certificate, POEA ECARD/SSS/Company ID, Passport or any valid ID) 2. Pay the one-year premium of PhP 1,200. If you have already paid PhP900 during your last transaction, please expect a notice from PhilHealth charging the additional PhP300 to complete your annual premium. Lifetime Members Program Members are qualified to enrol as lifetime members if they satisfy the following conditions: 1. They are 60 years years old and above, above, AND 2. They have given given at least ten years‟ worth of premiums premiums to the NHIP. NHIP.
To register, simply follow these steps: steps: 1. Submit the following to any PhilHealth Phil Health Office nearest you: a. Duly accomplished PhilHealth Membership Registration Form b. Two (2) latest latest 1" x 1" ID picture picture c. Certified True Copy (CTC) of the SSS or GSIS Retirement Certification or the following as applicable: For SSS Retirees/Pensioners: 1. 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 2. Printout of contributions issued by any SSS office indicating the latest contributions (if he/she retires after March 4, 1995. For GSIS Retirees - any of the following: 1. Certification/Letter of Approval of Retirement from the GSIS indicating the effectivity date of retirement; 2. Service Record issued by the employer/s indicating not less than 120 months of service excluding leave of absences without pay; 3. Certification/retirement Gratuity from the employer indicating not less than 120 months of service. 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: 1. Statement of Services issued by previous employer indicating not less than 120 months of service excluding leave of absences without pay; 2. Certification/Letter of Approval of Retirement from the GSIS indicating not less than 120 months of service; 3. General, Bureau or Special Order indicating the effectivity date of retirement.
d. Certified true copy (CTC) of Birth Certificate or any two of the following: 1. CTC of Baptismal Certificate 2. CTC of Marriage Contract/Certificate Contract/Certificate 3. Passport 4. Driver's License 5. SSS Members ID
6. Alien Certificate of Registration (ACR) (ACR) 7. Service Record/s 8. Employee ID 9. School records 10. Voter's ID 11. Senior Citizens ID 12. Duly notarized joint affidavit of two disinterested persons attesting to the fact of birth of the registrant e. Any other valid documents documents acceptable acceptable by PhilHealth 2. After submission and processing, member will be issued his/her PhilHealth Lifetime Member Card, which shall serve as a valid ID to be used used in all PhilHealth transactions. transactions.
What are the documents required for the registration of employers (and their employees) in the Government Sector and Private Sector? For Government Employers: 1. Employer Data Record or ER1 (in duplicate) 2. PMRF for each employee (in duplicate) For Private Employers: 1. Employer Data Record or ER1 (in duplicate) 2. Business Permit/license to operate and/or any of the following as applicable: 1. Single proprietorships – proprietorships – Department Department of Trade & Industry (DTI) Registration 2. Partnerships & Corporations Corporations – Securities – Securities & Exchange Commission (SEC) Registration 3. Foundations & Non-profit Organizations – Organizations – Securities Securities & Exchange Commission (SEC) Registration 4. Cooperatives – Cooperatives – Cooperative Cooperative Development Authority (CDA) Registration 5. Backyard industries/ventures and micro-business enterprises – Barangay Certification and/or Mayor‟s Permit Permit 3. PMRF for each employee (in duplicate)
How can LGUs enrol their underprivileged constituents into the Sponsored Program? LGUs that wish to enrol their constituents through the Partial Subsidy Scheme must go through the following steps: 1. Submission of letter of intent 2. Submission of certified list of enrolees and accomplished PMRF 3. Payment of premium contribution
Who can be declared as legal dependents? The following can be be declared as a principal member‟s member‟s legal legal dependents: 1. Legal spouse (non-member or membership is inactive) 2. Child or children b. Legitimate, legitimated, acknowledged and illegitimate (as appearing in birth certificate), adopted or step below 21 years of age, unmarried and unemployed c. 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 3. Parents (non-members or membership is inactive) who are 60 years old and above, including stepparents (biological parents already deceased) and adoptive parents (with adoption papers).
How do I activate my membership? In order to activate your membership, you must immediately remit your premium contribution. More details on this in the next section.
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Where else can I register? Aside from PhilHealth Offices, you may also enrol through our registration partners in SM malls, Bayad Centers, and mobile registration sites. The same procedures and requirements apply for these partners.
Situationers
for Registration/Enrolment
Can foreign nationals working in the Philippines enrol? Yes, the Implementing Rules and Regulations of RA 7875, as amended by RA 9241, provide for the inclusion to the NHIP the citizens of other countries residing and/or working in the Philippines. If the foreign f oreign national is employed, he/she shall be registered under the Employed Sector Program. Meanwhile, if he/she is self-employed or merely residing in the country, he may enrol as an Individually Paying Member. He/she only needs to accomplish the following documents and submit these to any PhilHealth office: 1. PhilHealth Member Registration Form (PMRF) 2. Photocopy of his/her Alien Certificate of Registration (ACR) issued by the Bureau of Immigration (BI) to prove his/her residency in the country.
Can minors and orphaned children enrol? Yes, minors are allowed allowed to enrol into the NHIP. They must must go through the following steps: steps: 1. Submit two (2) copies of the PhilHealth Member Registration Form (PMRF) which must be signed by the minor-enrolee and countersigned by the guardian. 2. A Notarized Affidavit Affidavit of Guardianship is is required as a supporting supporting document document for the purpose. purpose. 3. Upon submission of documents, the minor-enrolee has to pay the required contributions.
In case of early retirement, can I already register as a Lifetime Member? One is qualified to register as a Lifetime Member if the both of the following conditions are met: 1. He/she is already 60 years of age 2. Member has made at least 120 monthly contributions to PhilHealth and the previous Medicare Hence, if you retired for instance, at the age of 50, you must continue paying premiums as an Individually Paying Member until you reach the age of 60 and have made the required number of premium contributions. contributions.
Is it true that retiring employees can now be automatically enrolled by the employer in the Lifetime Member Program? Yes. As per PhilHealth Circular No. 28, s-2010, retiring employees employees in the government and private sectors must be enrolled into the Lifetime Member Program and their enrolment must be facilitated by their employers at least three (3) months prior to the date of retirement. The application for Lifetime Member Program shall be filed with PhilHealth as soon as the employee's retirement retirement application has been approved by the employer. The employer's Human Resource Management Office, through its authorized representative, shall ensure that the documentary requirements for registration are forwarded to PhilHealth for processing.
Can foreign spouses of Filipino nationals be declared as dependents? Yes, foreign nationals who are spouses of Filipino nationals can be declared as legal dependents. The principal member has to submit a copy of their marriage contract so that the foreign national-spouse can be included in the member‟s MDR.
Can unmarried members declare nephews or nieces as dependents? Nephews and nieces are not considered as qualified legal dependents of principal members under Section 1 of RA 9241.
If both parents are members, can they both declare their children as dependents? PhilHealth does NOT allow multiple declaration and application of PhilHealth entitlements of both spouses. We advise you to decide who among you will declare and provide for the PhilHealth coverage of your only child/children as dependents.
How can a member declare his spouse whose membership is inactive as a dependent? The active member-spouse member-spouse must submit the following at any PhilHealth Office: Office: 1. 2 copies of duly accomplished PhilHealth Member Registration Registration Form 2. Clear copy of Marriage Certificate/Contract with registry number (original copy to be presented for validation) 3. Request letter to be declared as legal dependent signed by the inactive/unemployed spouse After processing, PhilHealth will issue a new (updated) Member Data Record which indicates the name of the spouse (inactive) as legal dependent.
If all siblings are active members, can each of them declare their parents as dependents? Multiple declarations of dependents are not allowed. Members are advised to decide who among them will declare their parents as dependents.
Can disabled parents (physically or mentally incapacitated) who are below 60 years old be declared as dependents? No; only parents who are 60 years old and above are qualified as dependents.
Can my live in partner be declared as a s a legal dependent? How about our children? While the live in partner cannot cannot be declared as a legal dependent dependent (one of the supporting supporting documents required required is the marriage certificate), your children can still qualify as dependents. Simply update your MDR and submit the necessary supporting documents documents (i.e., birth certificate) for your children.
My daughter who‟s still my dependent (under 21) is about to give birth. Will my membership be able to cover her? Do I need to personally submit my registration documents or can I ask my representative to do so? There is no need for you to personally submit your registration documents. Your representative is allowed to submit your documents to PhilHealth for processing as long as you have affixed your signature/thumbmark (whichever is applicable) on the registration form.
D. UPDATING MEMBERSHIP RECORDS When should I update my MDR? How is this done? Ideally, members should update their MDR when: 1. They have to shift membership membership categories (e.g. individually individually paying to employed) employed) 2. They get married married
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3. New dependents shall be declared 4. There‟s incorrect information in the old MDR
To update your MDR, simply submit an updated PMRF to the nearest PhilHealth PhilHealth Office, along with with the necessary supporting documents (marriage certificate, birth certificate, etc.).
How do I shift membership categories? 1. Fill out two (2) copies of the PhilHealth Member Registration Form indicating the new membership category and submit these to any PhilHealth office 2. Await a copy of the member‟s updated MDR
Are we going to use the same PhilHealth Identification Number (PIN) if we are shifting to another membership category? Your PhilHealth Identification Identification Number (PIN) (PIN) is your PhilHealth number number for life. Hence, if you are are shifting to another membership category, you will be using the same PIN.
Situationers
for Updating Membership Records
I was given a PhilHealth card by our LGU, but my name was misspelled and data provided were also erroneous. How do I correct co rrect this information? If there‟s incorrect information in your ID/MDR, you will have to update your MDR by going through the following steps: 1. Submit two (2) copies of the PMRF with the corrected information to the nearest PhilHealth Office, along with the necessary supporting documents (birth certificate of any valid ID) 2. Wait for your updated updated MDR and ensure ensure that the information information has been been corrected
E. CONTRIBUTIONS AND MEMBERSHIP RENEWAL Why must a member pay his premiums regularly? Regularly contributing to the NHIP assures the member of hassle-free availment of hospitalization benefits when medical needs arise. This will also ensure the member‟s qualification/eligibility to register under the Lifetime Member Program upon reaching the age of 60 years old, provided he has paid at least 120 monthly premium contributions.
How much is the premium contribution rate? The premium contribution contribution that each each member has to pay is detailed in the the following table: Overseas Workers
Employed
Sponsored NHTS-PR
How much? Jan-June 2012 July-Dec 2012 2013 Who
P1200/year
LGU
Individually Paying Member (IPM) Professionals Low Income
P2400
P1200/year for 2-year lock in period) P2400/year
P300 monthly
P200 Monthly
P1200/year
Up to 3% of monthly basic salary (with P50,000 cap)
P2400/year Member
Employer
National
LGU
Member
Member
remits? When?
Annually
Monthly
Gov’t Annual
Annual/Biannual
Quarterly Semi-annually Annually
Monthly Quarterly Semi-annually Annually
Effective January 2012, premium contributions will increase to a minimum of P2400, depending on the membership category (with OFWs as an exception). Different arrangements are being crafted to give payers ample time to prepare for this increase. Here are the updates for the different programs:
1. Sponsored Program a.
2.
3. 4. 5.
Premiums of NHTS-PR poor amounting to P2400 by January 2012 will be fully subsidized by the National Government. b. Through the partial subsidy scheme , LGUs and other donors may provide the full/partial subsidy to finance the premiums of identified families within their jurisdiction. Premiums will increase to P2400 by July 2012. Prior to this increase, LGUs are given an option to avail of the two-year lock in deal (P1200/year for two years). Individually Paying a. For high income members (monthly salary > P25000), premiums will be pegged at P300/month or P3600/year. b. For low income members (monthly salary < P25000), premiums will be pegged at P200/month or P2400/year. Employed . The premium contribution of each employed member is up to 3% of their basic monthly salary (with P50000 cap). For this category, the employer and employee split the premium, which is directly deducted from the members‟ salaries and remitted to PhilHealth by the employer. Overseas Workers . By January 2012, premiums of overseas workers will increase from P900 to P1200. By January 2013, premiums for this segment will further increase to P2400. This has to be settled before the member leaves the country. Lifetime Members. Members under this category no longer have to pay their premiums, since they have already completed their 120 monthly contributions.
Why is there a need for an increase in premium contributions? PhilHealth is in a process of enhancing its benefits in order to provide bigger and better benefits and services to its members. Hence, we will need to increase our collections to be able to sustain this move.
Are overtime pay, commissions, and allowances included in the computation of premium contributions of employees? No, they are not included. included. The amount of monthly monthly premium contribution contribution of members shall be based on the employee‟s salary or wage which is the basic monthly compensation received for services rendered.
Where can the members remit their contributions? 1. PhilHealth has over 100 service offices all over the country wherein members can pay for their premiums. 2. PhilHealth has also accredited the following collecting agents: a. More than 1,000 CIS Bayad Centers b. Collecting Banks c. MLhuillier Philippines Pawnshops d. LBC Express outlets e. Offices of the Philippine Postal Corporation f. Selected Local Government Units 3. For Overseas Workers Program Members, i-Remit branches, other partner agents, and foreign offices of Philippine Veterans Bank (UK, Abu Dhabi and Qatar) also accept premium payments.
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Aside from paying through service offices and collecting agents, is there another way for me to pay my premiums easily? Yes. Currently, PhilHealth in collaboration with Smart, S mart, Inc. has come up with Text 7442, an easy-to-use service that will allow Smart/Talk N‟ Text pre-paid pre -paid subscribers to pay for their premiums through SMS. To avail of this service; just remember the following steps: 1. Type “PHIC (space) (space)
” and and send to 7442. 7442. (Example: PHIC 123456789012) 2. After this, you will receive a text message containing your PIN, and name (Last Name, First Name, Middle Name) as it appears in the PhilHealth database. (Example: PIN 12345679012 Lapuz, Harold, Chan) 3. If the name and PIN are correct, correct, type “PHIC (space) YES” to confirm your premium payment for the current month. Each transaction is worth one-month of premium plus a transaction fee. 4. After sending, you will receive a confirmation message, which contains your PIN and Reference Number for the transaction. Keep this reference number, as you‟ll need it to download your proof of payment.
What if I want to view my payment history for Text 7442? 1. Simply type “PHIC (space) HISTORY (space) ” and send to 7442 to view your payment history. 2. You may also download the payment history through www.philhealth.gov through www.philhealth.gov.ph .ph.. Your payment history will serve as your proof of payment when availing benefits.
When is the deadline for paying my premium contribution? con tribution? The following table summarizes when premiums premiums have to be in for each member member category: Membership Category Overseas Worker Employed Sponsored Individually Paying
Deadline for Paying Premium Before leaving the country or before the last contribution expires Tenth day of the following month Based on the agreement between the Sponsor and PhilHealth 1.Semi-Annually/Annually 1. Semi-Annually/Annually – last – last day of the third month of the first quarter 2. Quarterly – last – last day of the third month of a quarter 3. Monthly (through Text 7442) – 7442) – last last day of the month (See tables below)
For Individually Paying Quarterly 1. First Payment 2012 First Quarter Jan
Feb
Second Quarter March
April
May
Mar 31
Third Quarter
June
July
Aug
June 30
Fourth Quarter Sept
Oct
Nov
Sep 30
Dec Dec. 31
2. Second Payment 2012 First Quarter Jan Feb March
Second Quarter April May June June 30
Third Quarter July Aug Sept
Fourth Quarter Oct Nov Dec
Third Quarter
Fourth Quarter
3. Third Payment 2012 First Quarter Jan
Feb
Second Quarter March
April
May
June
July
Aug
Sept Sep 30
Oct
Nov
Dec
4. Fourth Payment 2012 First Quarter Jan Feb March
Second Quarter April May June
Third Quarter July Aug Sept
Fourth Quarter Oct Nov Dec Dec. 31
Semi-Annually 2012 First Quarter Jan Feb March Mar 31
Second Quarter April May June June
- First Payment -
Third Quarter July Aug Sept Sep30
2013 First Quarter Jan Feb March
Fourth Quarter Oct Nov Dec
- Second Payment -
2012 First Quarter Jan Feb March
Second Quarter April May May June June 30
Third Quarter July Aug Sept
- First Payment -
2013 First Quarter Jan Feb March
Fourth Quarter Oct Nov Dec Dec. 31
- Second Payment 2012
First Quarter Jan Feb March
Second Quarter April May May June
2013 Third Quarter July Aug Sept Sept. 30
Fourth Quarter Oct Nov Dec
- First Payment -
First Quarter Jan Feb March Mar 31
- Second Payment -
2012 First Quarter Jan Feb March
Second Quarter April May May June
2013 Third Quarter July Aug Sept
Fourth Quarter Oct Nov Dec Dec. 31
First Quarter Jan Feb March
- First Payment Annually J
F
M
A
M
2011 J J
A
S
O
N
D
J
F
M
A
M
J
2012 J
A
S
O
N
D
A
M
2011 J J
A
S
O
N
D
J
F
M
A
M
J
2012 J
A
S
O
N
D
S
O
N
D
J
F
M
A
M
J
2012 J
A
S
O
N
D
31
J
F
M
30
J
F
M
A
M
J
2011 J
A
31
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J
F
M
A
M
J
2011 J
A
S
O
N
D
J
F
M
A
M
J
2012 J
A
S
O
N
D
31
What is the effectivity date of PhilHealth coverage? PhilHealth benefit coverage starts upon payment of premium (no waiting period) and is valid for one year from the date of payment.
What are the requirements for eligibility? When is a member eligible to claim? In order to become eligible to claim benefits, a member must pay premium contributions regularly. If the member missed paying for a certain period, he/she and his/her dependents may not be able to use the benefits. The table below summarizes the eligibility requirements:
Sponsored Members
Individually Paying Members
Date of hospitalization/availment hospitalization/availment must be within the the effectivity period indicated in the member‟s ID and MDR. 1. There There are certain confinement confinement cases wherein wherein three months worth of premium within the last six months (3/6) prior to confinement is acceptable. ’
2. For pregnancy-related cases, dialysis, chemotherapy,
Lifetime Member Employed Members Overseas Workers
radiotherapy and other selected surgical procedures, the member must have paid nine months worth of premium within within the last twelve months months (9/12) prior to confinement in order to become eligible. The member just has to show their Lifetime ID Card; no need to pay premiums anymore. Three months worth of premium within the last six months (3/6) prior to hospitalization Date of hospitalization/availment hospitalization/availment must be within the coverage period specified in the member‟s MDR
Just remember the the 3/6, 9/12, 9/12, and effectivity period period requirements and you‟re good to go.
How do I maintain my eligibility? The key to maintaining eligibility is paying your premiums premiums on-time . If there are gaps in premium contribution, eligibility will also be affected. Here are several tips for each member category to ensure that you‟ll always be able to use your benefits:
1. Sponsored Members
If the member‟s card is about to expire already, the member must proactively inquire whether the Sponsor Sponsor will renew his/her membership. If not, the member may opt to register as an Individually Paying Member. 2. Individually Paying Member Ensure that each calendar quarter has been paid. If possible, pay your premiums yearly for your own convenience. 3. Overseas Workers Program Member Premiums must be remitted prior to your membership‟s expiration. If your contract abroad has already terminated, make sure that you shift member category from OWP to IPM (or other applicable categories) to be able to pay premiums again. 4. Employed Members
For seasonal employment or if you‟re going to take a leave without pay, just head to the nearest PhilHealth Service Office to pay your contributions during those months wherein you will not be compensated. You may continue paying your premiums as an Individually Paying Member (IPM). To pay your premiums as an IPM, visit any PhilHealth office and present a copy of the RF-1 from your employer indicating that you are on leave without pay or a Certification from your employer indicating the same. Once you get separated from employment, make sure that you shift category to IPM.
If I missed paying in the past quarters, can I still pay for this now to become eligible again? This is an example of a retroactive payment. Unfortunately, Unfortunately, PhilHealth does not accept retroactive payments to avoid abuse of benefits. This policy has to be in place to avoid those instances when members only choose to pay when they get sick or need to avail of benefits benefits (and conversely stop paying when when they don‟t need it), which will be unfair for those who pay their premium contributions regularly.
What is the tolerable delay for paying premiums for a member to still be able to use his/her benefits? None. PhilHealth strictly follows its policies on premium payment and benefit availment.
Situationers: Contributions and Renewal
Can contributions be refunded by the member who was not able to use it? No. PhilHealth is a social health insurance program, wherein members‟ members‟ premiums are pooled into a single fund used to pay for the benefits of sick members. Even if a member is not able to use benefits or does not get sick within a particular enrolment enrolment year, funds are kept in the pool. pool.
If I stopped paying my premium for a considerable amount of time, can I still use my benefits? Do I need to pay the missed contributions to be able to avail of the benefits again? No. Only active members are eligible to avail avail of PhilHealth benefits. benefits. Member should have have paid at least three months premium contributions contributions within the immediate six six month period prior to medical confinement. However, payment of at least nine months within the last 12 months shall be asked of Individually Paying Members availing of the following procedures/packages: • Pregnancy -related -related cases • Dialysis (except those undergoing emergency dialysis service during confinement) • Chemotherapy • Cataract Extraction • Radiotherapy • Selected surgical procedures Individually Paying Members and Employed Members will now be required to have at least nine (9) months contributions within twelve (12) months prior to the month of availment for all confinements including availment of outpatient benefits). On retroactive payments:
As per PhilHealth Circular No. 06, series of 2001, retroactive payments are not allowed except when a member can show proof of sufficient regularity of premium contributions or payment of nine (9) consecutive months or three consecutive quarters within the last 12 months prior to the missed quarter. If you meet this condition, you Page 24 of 47 of 47
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shall be given a grace period of one month immediately after the missed quarter to pay retroactively including the current calendar quarter. For newly enrolled members (with less than 12 months totalled from date of enrolment), retroactive payment for the missed quarter including the current calendar quarter shall also be allowed within the month immediately following the missed period. This privilege is granted granted only once every 12 months. months.
If an employed member who was separated from service last October 2011 wants to continue his membership as an Individually Paying Member in March 2012, can ca n he retroactively pay the premiums for Nov-Dec 2011 and first quarter 2012, in March 2012? Yes, for the employed member who wants to continue his membership as IPM but failed to immediately pay his/her premium within the quarter of separation, he/she shall be given a grace period of one calendar quarter immediately after the unpaid quarterly period to retroactively settle his obligation.
A new governor/mayor was elected in our area. Am I still considered a member under the Sponsored Program even with this change in leadership? It is the validity period that determines your membership status. Yes, you are still considered a member even if a new governor/mayor was elected, so long as your membership has not yet expired. To ensure the renewal of your membership post-validity date, you can go to the local office of the DSWD thatis in charge of evaluating and determining if you are qualified to join the program. The DSWD shall then endorse your name to the Local Government Unit (LGU) or any Sponsor for enrolment.
What if I have multiple jobs? Can I just pay my contributions once? Section 18-20 of the Implementing Rules and Regulations of RA 7875, as amended, mandates employers to enroll their employees, deduct from their salaries the required premium contribution, and remit the same, together with the corresponding employer share, to PhilHealth. As each employer has to adhere to this law, those who are engaged in multiple employment should consequently be deducted of their corresponding employee employee share by each and every employer with which they are currently employed.
I am an employed member, but I recently found out that my employer stopped paying our contributions even though he continues to deduct the premiums from our salaries. How do we go about this? If the employer failed to remit their employees‟ employees ‟ contributions, the employer will have to reimburse PhilHealth‟s payment forclaims filed by concerned employees or his/ her qualified dependent/s. Employees should report through writing if they suspect that their employers are not remitting contributions to the Corporation so that appropriate action will be taken against them.
What if the member passes away? Can the dependents still use their benefits? In case the member member dies, his/her membership membership privileges privileges also terminate. However, dependents dependents of Sponsored Members may still avail of the PhilHealth benefits for the unexpired portion of the member‟s contribution.
If a member has paid his premium for one year and he died during the first f irst half of the year, can his dependents refund his premium? If the member has dependents, they can avail of PhilHealth benefits for the unexpired portion portion of the member‟s contributions. However, similar to other members, they are not allowed to refund his premium that has already been channeled to the health insurance pool.
I already have a lifetime member card, but my current employer still continues to pay for my premiums. Can these premium contributions be credited to my son/daughter‟s membership membership when I retire? Since you are considered to formally employed, your employer is really mandated to continue paying for your premiums. However, payments made are non-transferrable non-transferrable and cannot be credited to your son/daughter‟s membership when you retire.
What if a Lifetime Member is re-hired, re- hired, must he resume contributing to PhilHealth through salary deduction? A Lifetime Member who acquires regular employment shall temporarily cease to be covered under the Lifetime Member Program, and shall instead be covered under the formally employed segment. After separation from his/her regular employment, he can resume his membership as Lifetime Member.
Is membership transferrable? No, membership is non-transferrable. non-transferrable.
Are the payments for OWWA Contributions and PhilHealth premiums different? Yes, they are different. OWWA contributions serve as a life insurance of the OFW abroad while PhilHealth premiums ensure the health benefits of the OFW and his/her dependents in case of illness or injury requiring hospitalization.
If I stopped paying my premium for a considerable amount of time, how will I reactivate my membership?? Do I need to apply for a new membership/PIN? membership There is no need to apply for a new PIN. Using your old PIN, simply carry out the following steps: steps: 1. Fill out two (2) copies of the PhilHealth Member Registration Form indicating the new membership category and submit these to any PhilHealth office 2. Await a copy of the member‟s updated MDR, and proceed to any of PhilHealth‟s accredited collecting agent to pay for the applicable premium using the same PhilHealth Phil Health identification number (PIN).
How can a SP member continue PhilHealth membership when his/her PhilHealth ID expires? To continue his/her PhilHealth membership once his/her ID expires and granting that it has not been 'renewed', a Sponsored Member should enroll as an Individually Paying Member and pay his/her premiums within the calendar quarter or before the expiry date as reflected in the PhilHealth Identification Card.
I used to be employed, but am now self-employed. Can I still continue paying for my premiums? How do I go about this? In case you get separated from employment, you may continue your PhilHealth membership by becoming an Individually Paying Member and paying the applicable premium. Simply accomplish the PhilHealth Member Registration Form (PMRF) and tick the box "For Updating" and the appropriate box of the membership category to which you are shifting. Make sure you continuously and religiously pay your premiums so as to avoid suspension of benefits.
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I am a PhilHealth member sponsored by an LGU; L GU; is it still necessary for me to pay my membership as an OFW? If a member is sponsored by an LGU and the membership is still active, the member shall pay for his/her PhilHealth membership as an OFW when the coverage of his/her sponsored membership expires. If in case the member already paid his/her membership as an OFW while his/her sponsored membership is still active, the member is advised to go to any PhilHealth office to make necessary adjustments on his/her membership coverage.
Why do I have to renew my PhilHealth membership every time I leave the country and work as an OFW? It's not actually renewal of membership but an updating of your premiums, which shall be equivalent to the length (in years) of your fresh contract. It will also ensure your continuous eligibility to PhilHealth benefits.
What is the grace period of OFW membership renewal? OFWs are allowed to pay the applicable premium within one (1) month from the date of expiry. Payment within this period shall retroactively commence the coverage of membership from date of expiration.
I am currently abroad and my coverage co verage is about to expire. How do I continue paying for my PhilHealth in case there are no available payment centers where I am? a m? You may ask your relatives in the Philippines to pay your premiums on your behalf to avoid any lapses or delays. They only need to present a valid ID and an authorization letter from you as the member and any document that would attest that that you are still an active active OFW.
If a member has dual citizenship, can he/she still renew his/her membership and avail of the benefits whenever he/she is in the Philippines? Yes. Those with dual citizenship still have the option to continue paying for their PhilHealth coverage also as individually paying members. Entitlement to benefits if confined in the Philippines will depend on such factors as the member‟s qualifying qualifying contributions and the accreditation of the health care providers.
I am already an immigrant here in the US. Can I still continue my membership with PhilHealth? Yes. You can still continue paying for your PhilHealth coverage as an Individually Paying Member and not as an Overseas Worker Member.
Where can I pay my premium contributions? If abroad, you may pay at any PhilHealth Overseas Accredited Payment Centers. In the Philippines, you or your immediate family or representative may pay at any PhilHealth any PhilHealth Offices and Accredited Collecting Partners.
F. SPECIAL SECTION: INCREASE IN PREMIUM FOR OFW MEMBERS Why is there a need to increase the annual premium of OFW members? The increase in premium across all paying sectors is in line with our continuing efforts to enhance our existing benefit packages, sustain the provision of better benefits to our members and provide true financial protection for our members to be able to fully achieve the objectives of Universal Health Care (UHC). The increase, which is inevitable if we want to meet our UHC goals by 2013, does not only apply to our OFW-members but also to the Employed, Sponsored and Individually Paying members as well.
What was the basis for pegging the new premium rate at P2,400 per year? One of the studies studies conducted conducted by our Actuarial Actuarial Services Sector several several years ago, ago, revealed revealed that the premium of the OFWs should already be set at P 1,800.00 to P 2,000.00 per year, but we decided to still peg the annual rate for OFWs at P 900.00, 900.00, the same rate they they have been enjoying since we we took over the Medicare program from the OWWA in 2005. 2005. However, with the new directions of the present administration to provide provide true financial protection for our members wherein PhilHealth will fully subsidize the roll out of primary care benefits that will entitle members to basic quality health care services, the prevailing rate of P900.00 has to be increased to P 2,400.00.
Were OFW members consulted by PhilHealth before the increase was approved? The planned increase had been extensively discussed and debated on within our Board of Directors where the OFW sector is adequately represented. We have commenced our media guestings and tapped print materials (newspapers, etc.) informing the public about the new rates and we shall continue organizing round-table discussions with our key stakeholders to address whatever other issues they may have on the matter.
How much is the increase? When is this effective? For the NHTS-identified poor, premiums have increased to P 2,400 by January 1, 2013 (see Circular 007, s2012). Premiums for members, sponsored by local government units (LGUs), for Individually Paying Members (IPMs) and OFWs will also increase to P 2,400 by July 1, 2012. For the formal employed sector, premium rates will be pegged at 3% of the basic monthly salary by January 1, 2013 with a maximum salary base of P 50,000.00. 50,000.00. This means that that employers whose monthly salary is P50,000 & above will be paying P750.00 P750.00 and the employer employer will provide a counterpart amount of P 750.00 per month.
When was the last time that premium contributions of OFW members increased? As far as OFWs are concerned, the annual rate of P 900.00 has been in place since PhilHealth took over the Medicare Program from the OWWA in 2005 and no adjustments have been introduced since then, despite the series of increases in benefit packages that we have implemented across all member-types over the years.
Can OFW members whose families were affected by Typhoon Sendong be exempted from paying the new premium rate? No. However, PhilHealth Advisory No. 01-03-2012, extended the the deadline of premium premium payment of members affected by Typhoon Typhoon Sendong up to March 31, 2012. 2012.
Where can they pay their premium contributions in the Philippines? How about abroad? Overseas Worker-members may pay at the POEA, or at any of our Service Offices nationwide or through any of our accredited collecting agencies locally or overseas.
If an OFW‟s membership coverage expires while he is still abroad, will he be required to pay, through his kin in the Philippines, the new rate when he renews his coverage? An OFW-member may ask ask his kin in the Philippines Philippines to pay for his membership membership renewal provided he sends sends his kin the following: 1. Copies of the required documents such as: a. Valid overseasemployment overseasemployment certificate certificate b. Valid working visa/re-entry visa/re-entry permit c. Valid job employment employment contract d. Certificate of employment from employer abroad e. Valid company ID issued issued by employer abroad abroad
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2.
Cash remittance from member abroad at least 2 months prior to the date of renewal or payment. If the membership expired last December 31, 2011, the OFW, through his kin, will be required to pay the new rate of P1,200.00, if he pays anytime between January 1 and June 30, 2012.
How much is the premium if an OFW decides to pay in advance? OWP members can avail themselves of a lower premium, equivalent to P 1,200.00 per year, if they pay two (2) years‟ w orth orth of PhilHealth premium betweenJanuary betweenJanuary 1 to December 31, 2012. 2012.
What additional benefits can an OFW member expect from PhilHealth? OFWs can expect the following improvements in the benefit packages soon:
Basic benefit package Inpatient and outpatient benefits Expansion of No Balance Billing to other member types like OFWs & employed sector when confined in government hospitals Special rates for 20 identified catastrophic cases, such as cancer, etc. Shift in reimbursement policies (Fee for Service to Case Rates) Outpatient primary care package (1,000 pesos worth of benefits per member) Obligated preventive and diagnostics services Out-patient drugs and medicines (anti-hypertensive, anti-diabetics and antibiotics) and outpatient diagnostics and specialist care Supplemental benefit package – package – PhilHealth PhilHealth Plus and Catastrophic Fund Special Benefits : rehabilitation package, vaccination package (rabies), enhanced peritoneal dialysis benefit package, health promotion (smoking cessation)
Will the increase in premium mean additional benefits for OFWs and their dependents as well? Yes. Not only will there be an increase in benefits, but also an improvement in frontline services and access to these benefits.
Are these benefits available to the OFW member even while he is abroad? Only some of the upcoming hospitalization benefits and other selected services will be available to the OFW while he is abroad since some some packages are are and will be offered by local health health facilities. However, all qualified legal legal dependents of OFW-members can avail themselves of these benefits locally.
When can OFWs expect the increase in benefits? Benefit enhancements are targeted to be released by June 2012.
How do you plan to inform OFWs about the new premium rate in less than two weeks‟ time? PhilHealth intends to go full blast in its IEC initiative. The following will be conducted: Send advisories to all recruitment agencies, PDOS providers and accredited collecting agents abroad Distribute flyers at POEA Post tarpaulin at POEA Conduct orientation meetings with OFWs at POEA Conduct meeting with OFW organizations Tri-media exposures Post advisory at OWP and in the the official Facebook and Twitter accounts accounts
Is PhilHealth making any representation with Philippine Embassies and consulates overseas o verseas to inform OFWs about the increased premium? We will communicate communicate and send advisories advisories to all Philippine Posts abroad to help help spread the word about about the new premium rates.
Since PhilHealth has no physical presence overseas, how do you plan pla n to discuss the new premium rates with OFWs and OFW organizations at this time? We will seek the the assistance of our Embassies Embassies and Consulates Consulates in discussing discussing this increase increase together with the leaders of OFW organizations while we send individual e-mail and text messages to our OFW contacts.
Where can OFW-members refer their inquiries pertaining to the new premium rates? OFW members can refer their inquiries to the following: PhilHealth Call Center 4417442 4417442 Mobile Numbers 09189635396/09175129149 OFW members can also e-mail us at: 1. [email protected] 2. [email protected] 3. [email protected] 4. [email protected] 5. [email protected]
G. SPECIAL SECTION: UMID CARD ACTIVATION AND BIOMETRIC CAPTURE Why must I undergo biometric capture with PhilHealth? Submitting yourself to biometric capture will prepare you for the eventual generation of the Common Reference Number (CRN) which will help facilitate the subsequent issuance of your Unified Multi-Purpose Identification (UMID) card.
Can I choose not to have my biometric data captured by PhilHealth? Choosing not to have your biometrics taken at this time might inconvenience you later on, especially when PhilHealth starts issuing the UMID UMID card to the members in the Informal Sector. Only those who have submitted submitted themselves to biometric capture will be prepped for UMID card issuance, thus, we advise you to proceed with your biometric capture.
What does „biometric capture‟ mean? Biometric capture means that your biometric data will be captured and matched with your PhilHealth member data, to ascertain your identity in preparation for the the issuance of the CRN later on. Among the biometric data data that will be taken are as follows: facial image i mage (photo), electronic signature and fingerprints. fingerprints.
Am I going to pay any fee for biometric capture? No, PhilHealth is not charging any transaction fee for biometric capture.
Where can I have my biometric data captured by PhilHealth? The PhilHealth UMID Mobile Team will be in your office premises on a schedule to be agreed upon with your Human Resource Department Department (HRD). The schedule will be announced by your HRD days before the the UMID Mobile Team will set up shop in your office for the biometric capture.
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If I missed the schedule of biometric capture ca pture in our office premises, can I proceed to any PhilHealth Branch for this? You may call the UMID Project Management Management Office to ask for the next schedule schedule at your office premises, or if the UMID Mobile Team has a scheduled biometric capture activity near your office l ocation.
Are there forms I need to fill out before biometric capture day? It is advisable for you to fill out the UMID Registration Form (URF) before going to the biometric capture station.
Is there a recommended attire for the biometric process? Since the biometric capture activity will be held at your office premises during business hours, it is expected that you come properly dressed in business or office attire.
How will the biometric capture procedure go? The biometric capture capture procedure is very very simple. Simply follow these these steps: 1. Fill up the UMID Registration Form (URF) 2. Submit the URF to the UMID Team for encoding 3. Check if the encoded data are correct 4. Have your photograph taken 5. Sign on signature pad 6. Press the required fingers on the fingerprint scanner 7. Receive the registration receipt/claim stub from the UMID Team member.
Will the biometric capture process eat up a lot lo t of my time from f rom work? No, the biometric capture process itself takes only about 6 minutes.
What do I need to bring on biometric capture day? You have to bring one (1) valid ID card, meaning, this should have your photo photo and your signature. You must also bring either a copy of your Member Data Record (MDR) or your PhilHealth ID/Number Card.
Are there things I must ensure before I proceed with biometric capture? Make sure that your MDR is updated with PhilHealth prior to biometric capture activity and the UMID Registration Form properly filled up.
Can I update my MDR on the day of biometric capture through the UMID Mobile Team? Updating of MDR cannot be made on the day of the biometric capture. It is advised that you update your MDR before the day of the biometric capture.
Once my biometric data have been captured, what are the next steps? Your biometric data will be processed then forwarded to Central Verification System (CVS) for CRN generation and for UMID card issuance later on.
Where can I call if I have further questions regarding the biometric capture? Further questions on the UMID Biometric Capture may be referred to the UMID Project Management Office at 441-7444 extension 7671 or 7672.
UMID
Card Activation
Why must I activate my UMID card ca rd with PhilHealth? Activating your UMID UMID card will prepare you you for PhilHealth‟s shift to paperless paperless transactions. transactions. Your UMID card will will eventually enable you to access health care services at accredited facilities without having to submit documentary requirements anymore.
Can I choose not to activate my UMID card with PhilHealth? Opting not to activate your UMID card with PhilHealth might render inconvenience for you at point-of-service, i.e., at the hospital billing section if you or your legal dependent is hospitalized. Once PhilHealth goes into paperless transactions, its accredited hospitals only need to swipe the members‟ UMID cards to check on their eligibility to avail themselves of PhilHealth benefits. If your UMID card is not yet PhilHealth-activated, you will be required to submit documentary requirements to support your claim for benefits.
What does „card activation‟ mean? Activation of your UMID card with PhilHealth means that your Member Data Record (MDR) will be loaded electronically into your UMID card. The MDR contains your basic information as a PhilHealth member, such as your PhilHealth ID number, date of birth, civil status, address, employer, and your list of legal dependents. Your premium contribution payments for the last two years (2010 and 2011) will also be loaded into your UMID card during card activation.
What are the requirements to activate my UMID card with PhilHealth? Do I need to pay any fee for card activation? No, PhilHealth is not charging any transaction fee for card activation. Are there forms I need to fill out before card activation day? day? None, you will not be required to fill fil l out any forms prior to nor during card activation day. What do I need to bring on card activation day? You only need to bring your UMID card. card. Are there things I must ensure before I proceed with activating my UMID card? First, make sure that your UMID card is already activated with the GSIS. There are GSIS kiosks in selected local government units where your UMID card may be activated.Second, make sure that your MDR is updated; otherwise, the MDR that is currently posted in our database will be loaded into your UMID card once card activation takes place.
Where can I activate my UMID UMI D card with PhilHealth? The PhilHealth UMID Mobile Team will be in your office premises on a schedule to be agreed upon with your Human Resource Department. The schedule will be announced by your HRD days before the UMID Mobile Team will set up shop shop in your office for the the card activation. activation.
If I missed the schedule of card activation in our office premises, can I proceed to any PhilHealth Branch to have my UMID card activated? a ctivated? You may call the UMID Project Management Office to ask for the next scheduleat your office premises, or if the UMID Mobile Team has a scheduled card activation near your office location so you can activate your card.
How long does the card activation process take? The card activation activation process takes takes only about five (5) (5) minutes. Since you you will only be required to proceed proceed to the card activation venue on your appointed day and time, you need not spend hours at the venue to wait for your turn.
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Can I update my MDR on the day of card activation through the UMID Mobile Team? The UMID Mobile Team will be busy handling the card activation process and they will not be able to attend to your MDR updating requirements. requirements. We advise you to do this at least three three (3) days before the schedule schedule of card activation. Your HRD can help you update your PhilHealth records.
What are the card activation procedures? The card activation activation procedure is very simple. Simply follow these these steps: 1. Tap your UMID card on card reader 2. Press any of your registered fingers into the fingerprint scanner 3. Validate your Member Member Data shown onscreen onscreen 4. If data are accurate, choose „Overwrite Data on Card‟; otherwise, choose „Cancel‟ 5. Press finger on fingerprint scanner to signify end of procedure 6. Remove card from card reader
How will I use my PhilHealth-activated UMID cards? Procurement of kiosks through which the PhilHealth-activated UMID cards can be read is underway. Once these are installed at selected locations locations nationwide, you can check on your your PhilHealth data anytime, anywhere. anywhere. You can also use the UMID card to track the status of your PhilHealth claim, to verify if a dependent has been declared in your MDR, or verify if i f your premium contributions have been posted.
What are the contact numbers if I have further questions regarding the UMID card activation? Further questions on the UMID card activation may be referred to the UMID Project Management Office at 4417444 extension 7671 and 7672.
H. BENEFITS AND BENEFITS AVAILMENT What benefits can a member avail himself of under the NHIP? PhilHealth offers a roster of benefits to ensure that members are given true financial risk protection. This section provides a glimpse of these benefits that each member can enjoy. Basic Benefit Package for Hospitalization This package is available to all member-types based on the hospital category and type of illness of the patient. It covers: 1. Allowance for Room Room and Board 2. Allowance for Drugs Drugs and Medicines 3. X-ray, laboratory and others 4. Professional fees 5. Use of the Operating Room complex
This package varies according to several factors – hospital level, case type of disease, relative value unit, and doctor‟s qualifications. 1. Case Types (varies according to severity of illness) a. Case Type A – A – simple simple illnesses b. Case Type B – B – moderate moderate cases c. Case Type C – C – severe severe cases d. Case Type D – D – extremely extremely severe illnesses 2. Relative Value Unit (RVU). Benefit allowances for operations vary according to their complexity; this complexity is reflected in the Relative Value Unit or RVU. The more complex the procedure, the higher the RVU and the corresponding benefit allowances.
3. Doctor‟s Qualifications – Professional Professional fees vary for general practitioners, general practitioners with training, and specialists. The Peso Conversion Factor (PCF) also varies for the PF of the surgery they conducted. The following tables tables show the existing existing coverage based based on the combination combination of the factors factors mentioned above: above:
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Case Rates for Medical and Surgical Cases Members may also avail of the PhilHealth benefits for Case Rate Payment for eleven (11) leading medical cases and twelve (12) surgical cases: Medical Cases Dengue I Dengue II Pneumonia I Pneumonia II Essential Hypertension Cerebral Infarction Cerebro-vascular accident with hemorrhage Acute Gastroenteritis Gastroenteritis Typhoid Fever Asthma Newborn Care Package Surgical Procedures Radiotherapy Hemodialysis Maternity Care Package NSD, Level 1 NSD, Levels 2-4 Caesarean Section Appendectomy Cholecystectomy Dilatation and curettage Thyroidectomy Herniorrhaphy Mastectomy Hysterectomy Cataract surgery
P 8,000.00 P 16,000.00 P 15,000.00 P 32,000.00 P 9,000.00 P 28,000.00 P 38,000.00 P 6,000.00 P 14,000.00 P 9,000.00 P 1,750.00 P 3,000.00 P 4,000.00 P 8,000.00 P 8,000.00 P 6,500.00 P19,000.00 P 24,000.00 P 31,000.00 P 11,000.00 P 31,000.00 P 21,000.00 P 22,000.00 P 30,000.00 P 16,000.00
Outpatient Packages - Primary Care Benefit and MDG Benefits Primary Care Benefit The Primary Care Benefit provides a per-household per-household capitation of PhP500 for families assigned to a particular outpatient provider provider (i.e., accredited rural health units and health centers). centers). This amount covers: 1. Provision of preventive services (consultation, BP measurement, counselling, etc.) 2. Diagnostic services 3. Drugs and medicines (for asthma, upper respiratory tract infection, acute gastroenteritis and urinary tract infection)
In the future, a second component of this package will be rolled out, giving an additional PhP 400 for outpatient medicines covering diseases like hypertension and diabetes. Moreover, this is coupled with a performance incentive incentive of PhP100 which rewards data quality, and eventually, the actual quality of care being given to patients. MDG Benefits Benefit Amount Covered Goal 4: Reduce Child Mortality Newborn Care Package PhP1,750
Description This package for newborn dependents covers the following: 1. Necessary/essential Necessary/essential newborn care – P500 2. Newborn screening test – P550 3. Newborn hearing screening test – P200 4. Professional fee – P500
Goal 5: Improve Maternal Health Normal Spontaneous PhP6,500 – 8,000 Delivery (NSD) Package
The NSD Package is the benefit provided by PhilHealth for the coverage of normal deliveries of the first four births in accredited government and private hospitals. For Level 1 Hospitals, this c overs: 1. Prenatal care – P1,500 2. Facility including professional fee – P6,500 For Levels 2-4 Hospitals, this covers: 1. Prenatal care – P1,500 2. Facility including professional fee – P5,000
Maternity Care Package (MCP)
The MCP Package is the benefit provided by PhilHealth for the coverage of normal deliveries of the first four births in non-hospital facilities (lying-in clinics, maternity clinics, birthing homes and RHUs). This covers: 1. Facility fee (including professional fee) – P6,500 2. Member’s prenatal care fee – P1,500 Goal 6: Combat HIV/AIDS, Malaria, and other Diseases Outpatient HIV/AIDS PhP30,000 This benefit aims to increase the proportion of the population having access to Treatment Package, effective HIV/AIDS treatment and patient education measures. This covers: 1. All necessary diagnostics – P3,000/year 2. Professional fee – P2,000/year (P400 per single check-up) 3. Retrovirals – P2,500/month Outpatient Malaria PhP600 The case rate for this package covers the following services that the patient Package requires: 1. Diagnostic malaria smears and other laboratory procedures 2. Drugs and medicines 3. Consultation services, including patient education and counselling Outpatient AntiPhP4,000 This case rate shall be paid to accredited DOTS facilities, and shall cover diagnostic Tuberculosis/DOTS work-up, consultation services, and anti-TB drugs that the patient requires in an Benefit Package outpatient set-up. Payment will be split as follows: 1. Intensive Phase of DOTS Treatment – P2,500 2. Maintenance Phase – P1,500 Animal Bite Package PhP3,000 Effective May 3, 2012, this benefit package aims to support the National Rabies (Rabies Post-exposure Prevention and Control Program by defraying the cost of post-exposure prophylaxis) prophylaxis (PEP) treatment to animal bite patients who are PhilHealth beneficiaries. This package covers: 1. Drugs (vaccine, immunoglobulin, and antibiotics) and supplies – P2,700 2. Health staff service fee – P300 SARS and Avian Php50,000 – Amount of coverage: Influenza Package 100,000 1. For members and their qualified dependents – P50,000 per case 2. For healthcare workers (forefront and high risk) – P100,000 per case
Novel Influenza A(H1N1) Package
PhP8,000
This amount covers: 1. Professional fees – P2,500 (pay to doctor) 2. Hospital charges – P42,500 (pay to hospital) 3. Official receipts amounting to P12,000 (P5,000 – pay to member) Treated as Case Type A under Fee-For-Service (see pp. 34-36).
Other Benefits AnEnhanced Outpatient Package for OWP members and dependents is also available in participating DOHretained hospitals nationwide.We also cover dialysis, day surgeries and chemotherapy in accredited facilities.
All lifetime members can can also take advantage advantage of the 60% 60% discount on the the pneumococcal pneumococcal vaccine vaccine beginning June 1, 2012 in PhilHealth-accredited PhilHealth-accredited hospitals.
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Where can these benefits be availed of? Members and their qualified dependents may avail of the benefits in any PhilHealth accredited hospitals, ambulatory clinics, rural health units/health centers, and free standing clinics nationwide. PhilHealth will also reimburse overseas confinements and shall be paid based on Level 3 Hospitals benefit rates.
How can these benefits be availed of? Availment Conditions Conditions Employed and KASAPI Members
Individually Paying Members
OWP Members
Sponsored Program Members Lifetime Members
Payment of at least 3 monthly premiums within the immediate six months prior to confinement Payment of at least 3 monthly premiums within the immediate six months prior to confinement (for some confinement cases). Payment of 9 months premiums within the immediate immediate 12 month period period prior to confinement (for selected surgical procedures and pregnancy-related cases. Confinement should be within the effectivity period stated in the Member Data Record or PhilHealth Official Receipt (MDR). Confinement should be within the effectivity period as stated in the PhilHealth Identification Card and Member Data Record (MDR) The only requirement is the PhilHealth Lifetime Member Identification Card
Automatic Deduction Deduction of of Benefits Automatic deduction deduction of benefits simply means that the benefits are automatically automatically deducted deducted from the hospital hospital bill prior to the patient‟s discharge. For this option, simply follow these steps: steps:
1. Prior to discharge from the hospital, submit the following documents to the hospital‟s billing section: a. Duly accomplished PhilHealth Claim From 1(original) 1(original) b. Clear Copy of Member Data Record (MDR) c. If your dependent is the patient, and he/she is not yet listed in the MDR, submit an applicable proof of dependency 2. Agree with your attending attending physicians physicians on the professional professional fee that shall be covered. 3. Upon submission of all documents, the billing section will compute and deduct your benefits from your total hospital bill. Direct Filing/Reimbursement If benefits were not availed of at the hospital, members still have this option to reimburse what they spent during their last confinement. Simply submit the following documents to the nearest PhilHealth office within sixty (60) days after discharge: 1. PhilHealth Claim Form 1 filled out by member 2. PhilHealth Claim Form 2 filled out by hospital and attending physician 3. MDR/PhilHealth ID 4. Proof of premium payment 5. Official receipts for hospital services and professional fees 6. Official receipts for medicines and procedures paid for outside the hospital while confined 7. Statement of account 8. Waiver from the the hospital and physician physician stating that that benefits were not claimed at the the point of service service 9. Copy of operative record (for surgical procedures) 10. PhilHealth Claim Form 3 11. Results of laboratory and diagnostic exam for case rates claims
Do legal dependents enjoy the same benefits as the member? Yes, members and dependents will enjoy the same benefit packages. Members have 45 days in a year to avail the benefits while his/her dependents will have another set of 45 days which will be shared among them.
What documents must a member submit to be able to avail of the benefits? The following documents documents are needed needed to avail of the automatic automatic deductions of the benefits from from the hospital:
PhilHealth Claim Form 1 (For employed members, Part II must be signed by the employer) Photocopy of MDR and other other supporting document if the patient is not reflected as dependent in the MDR For IPMs: Proof of premium contribution (PhilHealth Agent Receipt, PhilHealth OR, MLhuillier Kwarta Padala SOF/RT, duly validated Bayad Center Payment Form, LBC Payment/Acknowledgement Payment/Acknowledgement Receipt) For LP and Sponsored members:Photocopy members:Photocopy of PhilHealth ID Card For KASAPI members: Copy of Certificate of Premium Payment from PhilHealth
Where and when should these documents be submitted? Members need to submit said documents to the hospital billing section to avail of outright /automatic deductions of benefits.
How can the member avail himself of PhilHealth benefits if he has an existing coverage with a health maintenance organization? For PhilHealth members who have an existing coverage with a health maintenance organization (HMO), PhilHealth benefits should be the first peso to be deducted from the hospital bill. The HMO will cover the expenses after the deduction of PhilHealth benefits.
Can a senior citizen avail himself of both the PhilHealth benefits and his senior citizen privilege when confined? Yes. The senior citizen citizen privilege is a separate separate benefit and the 20% discount must first be be deducted from your your hospital bill prior to the application of PhilHealth benefits.
Can overseas Filipino worker-members reimburse their hospitalization expenses with PhilHealth? Confinement due to sickness or for an operation is compensable with PhilHealth even if it is done abroad. Members are given 180 days or 6 months to file your claim for reimbursement at any PhilHealth office near your local residence. a. b. c. d.
PhilHealth Claim Form 1 accomplished and signed by the member or his authorized representatives; Photocopy of MDR or latest receipt; Medical certificate with complete complete diagnosis, period of confinement and and services rendered; Statement of Account and/or Official Receipts with itemized charges; and other supporting documents. (Items c & d should be translated in ENGLISH)
I‟ve been paying my premiums regularly, but I still haven‟t availed of any benefits. When will I be able to benefit from my membership? Perhaps you have managed to stay healthy, therefore not needing to be admitted in the hospital, which is why you have not yet availed of any benefits. Depending on your membership type (applicable for Sponsored, OWP, Lifetime), you may still avail of preventive services and vaccines in the outpatient setting to improve your health.
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Situationers: Benefits and Benefits Availment How will the member know if the PhilHealth benefit deducted from his total to tal hospital bill is correct? Members are sent a benefit payment notice or BPN to report the actual payments made by PhilHealth relative to their confinement/availment. confinement/availment. The BPN is sent to the address indicated by the member in their claim form. Should there be discrepancies in the payments and the actual benefits deducted from your hospital and doctors' bills, you may present your BPN, your copy of the hospital's Statement of Account/Billing Statement, and Official Receipts to your health care provider for appropriate action to be taken.
What if the amount deducted as PhilHealth benefit is less than what PhilHealth actually paid to the provider for the member‟s confinement? Members are sent a benefit payment notice or BPN to report the actual payments made by PhilHealth relative to their confinement/availment. The BPN is sent to the address indicated by the member in his claim form.Should there be discrepancies in the payments and the actual benefits deducted from your hospital and doctors' bills, you may present your BPN, your copy of the hospital's Statement of Account/Billing Statement, and Official Receipts to your health care provider for appropriate action to be taken.
If siblings are all active members, can each of them file a claim for the confinement of their parents? No. PhilHealth does not allow multiple declaration and application of PhilHealth entitlements. The siblings should decide who will declare and provide for the PhilHealth coverage of their parents.
If both spouses are members, can each of them file f ile a claim for the confinement of their children? No. PhilHealth does not allow multiple declaration and application of PhilHealth entitlements of both spouses.
If the spouse‟s, child‟s or parent‟s name is not listed in the member‟s MDR at the time of confinement, how can the member avail himself of the benefits? If the dependent gets hospitalized and he/she is not listed in the principal member‟s MDR yet, the member may submit a clear copy of the following as proof of dependency: 1. Spouse - marriage contract/certificate 2. Children - birth certificate 3. Parents - birth certificate of member and patient or Senior Citizen's ID
How can members separated or resigned from employment avail themselves of maternity benefits? After separation from employment, the member must immediately enrol/shift his/her membership from employed to Individually Paying Program (IPM) to avoid the gap on his/her PhilHealth contributions. As an IPM member the following documents must be submitted to the billing section of the hospital: 1. Fully accomplished PhilHealth Claim Form 1 (CF 1) 2. Clear copy of Member Data Record (MDR) 3. Proof of premium payments - nine (9) monthly premium contributions within the immediate twelve (12) months prior to availment of benefits. If the delivery date may cover the contributions during employment, secure copy of RF-1 (reflecting (reflecting the member‟s name) with proof of payment from previous employer or “Certificate of Contribution” from any PhilHealth Office.
I. SPECIAL SECTION: CASE RATES FOR 23 2 3 MEDICAL AND SURGICAL PROCEDURES What is case payment? Case payment (also called per-case payment) is a different way of paying providers for services offered to our members.
How is this different from the old o ld system? Unlike the fee-for-service fee-for-service system wherein fees for drugs, supplies, and doctors‟ fees differ differ depending on the patient‟s case or hospital where the patient was admitted, case payment offers a fixed rate for each treated case. For example, cases of appendicitis would be reimbursed at the same rate in all hospitals. It is very similar to the concept concept of “pakyawan,” since all items/services necessary necessary for a case is already covered by a single rate.
Why shift to case rate payments? What advantages will this form of benefit payment bring, especially to the members? With case rates, hospital charges are no longer a mystery! Since rates remain the same in all facilities, you will immediately know how much subsidy you can get from PhilHealth for particular diseases and surgical procedures. At the same time, this simpler method will help PhilHealth speed up its processes, which means that your claims will be released faster. faster.
Who are entitled to these new case rate packages? pack ages? By virtue of being a member, you and your dependents are entitled to the new case rate packages.
Can I avail of this benefit now? Yes! The new case payments payments already took effect last September 1, 2011 2011 in all accredited accredited providers.
How will cases be reimbursed? Reimbursement for the said case rates shall be made directly to the facility. This payment given to the hospital already covers hospital and professional fees.
What will happen to doctor‟s professional fees? Professional fees of all accredited doctors who attended or managed a specific case are already included in the calculated case rates.
How much will be allocated to the t he doctors‟ PF? 1. Forty percent (40%) of the total amount for each surgical case rate 2. Thirty percent (30%) (30%) for each each medical case rate 3. For hemodialysis, P500 per session is allocated
What are the surgical cases under Case Rate that can be reimbursed in particular facilities? Level-I Hospitals: a. D & C (Completion and Fractional Curettage) b. Normal Spontaneous Delivery Note: The said case shall be reimbursed as NSD package in Level Level I hospitals (P8,000) c. Newborn Care Package Ambulatory Surgical Surgical Clinics Clinics (ASCs): a. D & C (Fractional Curettage) b. Herniorrhaphy c. Laparoscopic cholecystectomy cholecystectomy d. Cataract
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Freestanding Freestanding Dialysis Centers a. Hemodialysis
How will hospitals be paid for 2 or more surgical case rates ra tes performed in a single confinement? PhilHealth shall reimburse all packages if two or more different surgical case rates are performed in separate operative sessions even within a confinement period.
How will the procedures be reimbursed if a procedure performed has laterality (e.g., cataract)? The hospital shall be paid once if the procedure performed has laterality (e.g., cataract), whether done in one or different operative session in a single confinement or different confinement within 90 days.
What will happen to major surgical procedures done in Level 1 hospitals? If the procedure is an emergency, payment shall be paid through a fee-for-service scheme based on RVU 30 but if the procedure is considered as non-emergency the claim shall be denied.
Is Case Rate covered by the rule on single period of confinement? Will the 45 days allowance apply for case rates? Yes, the rule on single period of confinement still applies except for hemodialysis and radiotherapy packages, where availment is on a per session basis basis but subject to 45-days allowance in a year.
If a member‟s member‟s total hospital fees for dengue I is beyond the case rate amount listed by PhilHealth, will the member shoulder the balance? Yes. The member shall shoulder the amount in excess of what we will provide under the new case rate packages, except for those covered under the NBB policy in government accredited facilities.
A member is admitted for dengue I for three days, and another member is admitted for dengue I for five days, will they be entitled to the same case rate amount for dengue I of P8,000.00? Yes. Whether a member uses up three days or ten days for a particular medical condition, condition, they will still be entitled to the same amount. PhilHealth will reimburse to the health care facility the case rate amount indicated in the list.
What medical cases under Case Rate can be reimbursed in Level 1 hospital? Level 2 hospitals? a. Dengue I (Dengue Fever and Dengue Hemorrhagic Fever Grades I and II) b. Dengue II (Dengue Hemorrhagic Fever Grades III and IV) Note: The said cases managed in Level I hospitals shall only be reimbursed as Dengue I package package c. Pneumonia I (Moderate Risk Pneumonia) d. Pneumonia II (High Risk Pneumonia) Note: The said case managed in Level I hospitals shall only be be reimbursed as Pneumonia I package e. Essential Hypertension f. Cerebral Infarction (CVA I) g. Cerebro-vascular Cerebro-vascular Accident with Hemorrhage (CVA II)
h. i. j. k.
Note: The said case managed in Level I hospitals shall only be be reimbursed as CVA I package Asthma Typhoid Fever Acute Gastroenteritis Gastroenteritis NSD Note: In level I hospitals the benefit amount is Php 8000 while in Levels 2-4 hospitals the benefit is Php 6500.
For medical case rate, how will PhilHealth pay for a patient admitted for several conditions? PhilHealth shall reimburse the medical case rates based on the main condition. Therefore, cases with several comorbidities shall have no additional payment.
In case the member was transferred to another hospital, will PhilHealth pay for both facilities? The member is entitled to one package and this will be reimbursed to the referral facility. Cost incurred at the referring facility will be shouldered by the member and the claim filed by the facility will be denied except MCP.
For cases not included in the Case C ase Rates table, how will PhilHealth reimburse those cases? PhilHealth will continue to reimburse those cases through the existing benefit table of fee for service scheme.
J. SPECIAL SECTION: NO BALANCE BILLING POLICY What is “No Balance Billing” (NBB) and to whom it will be applicable? NBB means that no other fees shall be charged or paid for by the PhilHealth patients beyond the identified case rates. NBB policy generally covers the Sponsored member/dependents of PhilHealth.
Why is this being introduced only for Sponsored S ponsored Program members? Among our primary objectives for introducing the case rate packages is to provide optimal financial risk protection, especially to the most vulnerable groups which are the poorest of the poor. Through PhilHealth Board Resolution 1441 series of 2010, the NBB policy was adopted for the most common medical and surgical conditions experienced in the country which are identified/specified under the new case payments.
What are the conditions for availment of benefits of SP members under the NBB policy? The NBB policy applies applies only to all PhilHealth PhilHealth Sponsored Program members and their their dependents that avail of the specified cases under the following conditions: When they are admitted in government government facilities/hospitals facilities/hospitals in defined NBB NBB Beds When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in accredited government hospitals and non-hospital facilities When availing of existing outpatient packages, including Maternity Care Package and Newborn Care Package, TB-DOTS, Malaria, HIV-AIDS, and Animal Bite P ackage
Is the NBB policy also applicable to other PhilHealth membership types? The NBB policy shall also apply to any other membership type (Employed, Individually Paying, Overseas Workers, Lifetime) who will avail themselves themselves of the Maternity Care Care Package (MCP) (MCP) and Newborn Care Package Package in all accredited (MCP) non-hospital providers (e.g. maternity clinics, birthing homes).
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If the Sponsored member under NBB bought drugs and medicines or other supplies, will he be able to reimburse then? How? Yes. If the Sponsored member/dependent member/dependent purchased necessary items items and services during confinement, the health facility is required to attach the official receipt/s detailing the purchases in the claim application for the said confinement.
In case a sponsored member/dependent member/dependent was admitted in a government hospital where the only available room that time for the patient is a private room, roo m, can the sponsored member be admitted in any room or private room of a government hospital? Will the NBB policy still apply? Yes, with the discretion of the hospital. The sponsored member can still be admitted in any available room and the NBB policy applies.
What if a sponsored member is admitted in a private hospital? Will the NBB policy polic y still be applicable? The NBB policy will not apply, unless the the private hospital hospital voluntarily implements implements it. The sponsored member and his/her dependents will pay the excess of the hospitalization costs including the PF for the attending physician/s after deduction of the applicable case rates.
Are there sanctions for violations in NBB policy? polic y? Yes, accredited providers that violate the NBB policy shall be given appropriate sanctions and penalties by the Corporation.
K. SPECIAL SECTION: ANIMAL BITE PACKAGE Tamang Paggamot sa Kagat ng Hayop Ano ang unang dapat gawin kapag nakagat ng hayop? Bago magtungo sa pinakamalapit na Animal Bite Treatment Center, kailangang linisin ng maigi ang sugat na natamo mula sa kagat ng hayop. Gawin ang mga sumusunod na hakbang: a. b. c. d.
Kumuha ng malinis na tela at diinan ang sugat hanggang sa humupa ang pagdurugo. Linisin ang sugat nang sabon at tubig. Lagyan ng alcohol, povidone-iodine (halimbawa: betadine) o kahit anong panlinis ang sugat. Takpan ang sugat nang malinis at tuyong gauze. Maari ring magpahid ng antibiotic ointment upang maiwasan ang impeksiyon. e. Matapos linisin ang sugat, magpunta agad sa pinakamalapit na Animal Bite Treatment Center.
Ang hayop na nangagat nangagat ay kinakailangang kinakailangang obserbahan sa loob ng dalawang linggo.
Bakit kailangang magpabakuna kung nakagat ng aso? Ang rabies ay isang sakit na nakamamatay. Tanging ang pagbabakuna lamang ang paraan upang maiwasan ang pagkakaroon ng impeksiyon sa rabies.
Gaano katagal ba ang bisa ng bakuna? Panghabambuhay na ang bisa ng bakuna kung nakumpleto ang dosaheng kinakailangan. Gayunpaman, kapag nakagat muli ng aso ang taong nakakumpleto ng bakuna, kinakailangan pa rin ng booster doses.
Ilang beses ba akong bibigyan ng bakuna? Karamihan ng pasyente ay kinakailangan kinakailangan lamang mabigyan ng 3 dose ng bakuna. Ngunit may mga pasyenteng pasyenteng nangangailangan ng pang-apat ng dose: a. kung ang nakakagat na hayop ay napatunayang may rabis b. kung ang nakakagat na hayop ay namatay nang hindi nagagawan ng eksaminasyon c. kung ang nakakagat na hayop ay may sintomas ng rabis d. kung ang nakakagat na hayop ay hindi maaring obserbahan ng 14 na araw
Kailan dapat magpabakuna? Hihintayin pa bang mamatay ang aso a so bago magpabakuna? Kahit na buhay pa ang asong nakakagat, maiging kumunsulta na agad sa pinakamalapit na Animal Bite Treatment Center para mabakunahan. Kailangan pa rin ng pasyente ng tatlong dose ng bakuna kahit na nanatiling buhay ang aso.
Kailangan pa ba akong ma-confine kung nakagat ng aso? Hindi lahat ng nakagat ay kinakailangang ki nakailangang ma-confine. Kung galos o hindi naman malalim ang sugat, kinakailangan lamang na malinisan ang sugat at mabigyan ng bakuna.
Kailangan pa ba akong mabakunahan kung kumpleto naman sa bakuna ang asong kumagat? Oo, sapagkat iba ang bakuna ng aso sa bakuna na para sa tao. Kahit kumpleto ang bakuna ng asong kumagat, kinakailangan pa ring mabakunahan ang pasyente upang masiguro ang proteksiyon laban sa rabies.
Mga Paalala a.
Ipaalam sa baranggay o munisipyo kung may mga asong gala sa inyong lugar na maaaring mangagat at maging sanhi ng rabies. b. Pabakunahan ang inyong alagang aso at wag pabayaang pagala-gala sa labas ng bahay o bakuran.
Tungkol sa Animal Bite Treatment Package ng PhilHealth Ano po ba ang kasama sa Animal Bite Treatment Package? a. b. c. d. e.
Bakuna laban sa rabies Rabies immunoglobulin Paggamot sa sugat Bakuna para sa tetano Antibiotics kung kinakailangan
Ito ay maaring ibigay sa mga sumusunod na kasong maituturing na Category III Rabies Exposure na naidulot ng hayop (aso, pusa, baka, baboy, kabayo, kambing, paniki at unggoy) o pasyenteng napatunayang napatunayang may rabies. a. Kagat/kalmot ng hayop na tumagos sa balat at nagdurugo b. Kagat o pagpasa ng laway/fluids (sa mata, ilong, maseselan na bahagi ng katawan at bukas na sugat) ng pasyenteng mayroong rabies c. Paghawak ng bangkay ng hayop na may rabies o pagkain ng laman ng hayop na mayroong rabies d. Kalmot at sugat (kahit na hindi nagdurugo) na natamo sa ulo at leeg
Ano ang kailangang ipakita o gawin para maka-avail ng package? Kapag nakagat ng aso, magpunta lamang sa kahit anong Animal Bite Treatment Center na PhilHealth-Accredited. PhilHealth-Accredited. Upang makagamit ng package, kailangang magpadala ng patunay na ikaw ay miyembro ng PhilHealth (gaya ng MDR). Kailangan ding tiyakin na ikaw ay eligible para sa benepisyo: a. Para sa mga employed at IPP, kinakailangang may kontribusyon na 3 buwan sa loob ng nakalipas na anim na buwan. b. Para sa sponsored at OWP, tiyaking hindi pa expired ang inyong membership o within the period of validity ang pag-avail ng package.
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c.
Para sa lifetime member, ipakita lamang ang inyong PhilHealth ID card.
Saan ba pwedeng maka-avail ng package? packa ge? Saan ako pwedeng pumunta para magpabakuna kung nakagat ng aso? Pumunta lamang sa kahit anong PhilHealth-Accredited na Animal Bite Treatment Center upang makagamit ng benepisyong ito.
Kailangan ba akong bumili ng bakuna sa labas? Meron pa ba akong dapat bayaran kung may PhilHealth na? Kung ikaw ay isang sponsored member, wala nang kailangan pang bilhin na gamot o bakuna. Sagot na dapat ng Animal Bite Treatment Treatment Center Center ang lahat ng kakailanganin kakailanganin sa paggamot paggamot ng kagat. Para sa ibang miyembro ng PhilHealth, hanggang PhP3,000 lamang na halaga ng bakuna, gamot at gamit ang kasama sa package. Kapag naubos na ang PhP 3,000, kailangan ng bayaran o bilhin ng miyembro ang natitirang gamit, gamot o bakuna. Tandaan na kinakailangang makumpleto ang 3 o 4 na dose ng bakuna upang ito ay maging mabisa.
Paano kung nakagat ako ulit? Ilang beses ako pwedeng pwedeng makagamit ng PhilHealth para sa ganitong benepisyo? Hangga‟t ikaw ay lehitimong miyembro miyembro ng PhilHealth, maaari kang makagamit ng benepisyong ito kapag ikaw ay nakagat ng hayop. Para sa mga kailangan para maka-avail ng package, package, tingnan ang sagot sa question question #2.
Covered din ba ang pamilya ko pag sila ay nakagat? Ang miyembro at ang lahat ng kanyang qualified dependents na nakalista sa MDR ay maaaring maka-avail ng package.
Paano kung hindi aso ang nakakagat? Kasama pa rin po ba ito sa benepisyo? benepisyo? Hindi lahat ng kagat ng hayop ay may rabies. Tanging ang kagat ng aso, pusa, baka, baboy, kabayo, kambing, paniki at unggoy unggoy lamang ang kasama sa benepisyo. benepisyo. Ang kagat ng daga, guinea pig o kuneho kuneho ay hindi nangangailangan ng bakuna laban sa rabies kung kaya‟t hindi kasama sa benepisyo.
