Social Health Insurance

in the Philippines

Jane M.N. Sta. Ana, R.N.

Member, Board of Directors

Philippine Health Insurance Corporation

History of NHIP
Started from the governments desire to provide its people with

access to effective medical care services

at an affordable price

1972 Medical Care Act

- the countrys first attempt at

universal social health insurance

1995 National Health Insurance Act - mandate of PhilHealth is

to provide universal social health insurance coverage
The law has been subsequently amended in 2004 through
Republic Act 9241 and in 2013 through Republic Act 10606.

Draws inspiration from the Filipino trait of

bayanihan or social solidarity
*Artwork by Filipino National Artist
Carlos "Botong" Francisco

Vision and Mission

Every Filipino is a member,

Every member is financially-risk protected,
Everyones health is assured.

Value-added benefits for every member,

Quality service for all.

Covered Members and Dependents

(as of June 2015)
Sector

Members in the
Formal Economy

Members

13,368,671

14,204,553

Beneficiaries

27,573,224

Private

11,326,505

10,377,566

21,704,071

Government

1,982,042

3,782,546

5,764,588

59,482

43,421

102,903

Household Help/Kasambahay
Enterprise Owner & Family Drivers 642

Members in the
Informal Economy

1,020

3,602,640

4,163,236

1,662

7,765,876

Migrant Worker

1,086,439

976,336

2,062,775

Informal Sector

2,107,443

2,702,689

4,810,132

396,898

471,890

868,788

Self-Earning Individual
Organized Group and Others

Indigents
Note:

Dependents

11,860

15,288,583

12,321

30,118,509

24,181

45,407,092

- Indigent count of members and dependents was based on DSWD Listahan database and are subject for further validation.
- 2015 Projected
Population is 101,449,681 based on May 2010 Census
by NSO.
Sponsored
Members
489,730
647,921
1,137,651

Senior Citizens

4,813,460

1,068,411

5,881,871

88% of 2015
projected population

Contributions
Premium Contribution

o Formal Sector income base (2.5% of the salary, equally

shared by the employer and employee, subject to a salary cap)
o Indigents - premium of P2,400 per year coming from proceeds
of the Sin Tax
o Informal Sector premium is set at P2,400 per year; this
sector includes Overseas Filipino Workers (OFWs)
o Lifetime members - entitled to lifetime coverage without having
to pay additional premiums. Automatic coverage for all senior
citizens (but those employed, would still have to continue with
premium payments)

Overseas Workers
Eligible to avail of the benefits on the day of enrollment (no
waiting period)
Member and his / her dependents in the Philippines can avail of
the benefits

After expiry of membership, member has one (1) month grace

period to ensure there is no gap in membership

Senior Citizens
All seniors are automatically covered in PhilHealth
The Office of the Senior Citizens Affairs (OSCA) for each city
and municipality issues an electronic list of senior citizens and
they are automatically enrolled as PhilHealth members. Senior
citizens can also apply directly to PhilHealth with any proof of
their age
Members are immediately eligible to avail of the benefits

17

REGIONAL
O F F I C E S

106

L O C A L
OFFICES

6,400

OFFICERS
S T A F F

We paid P1.5 billion every week in 2014,

now we are paying P2 billion every
week

P 55.46 B
2013

P 78.18 B

P 48.6 B

2014

June 2015

Accredited Institutional Providers

(as of June 2015)

Type of Ownership

Government

Private

Total

Accredited Facilities

742

1,105

1,847

99% of DOH-licensed hospitals are accredited by PhilHealth

Number of Accredited
Outpatient Clinics

Primary Care
Benefit Package

Maternity Care
Package

DOTS Package

2,253

2,381

1,546

Spectrum of PhilHealth Benefits

Primary Care
& MDGs
Primary Care Benefit
Maternity Care Package
Newborn Care Package
TB-DOTS Package
Animal Bite Package
Malaria Package
Outpatient HIV-AIDS Package

Case Rates

Inpatient cases
Day surgeries
Chemotherapy
Radiotherapy
Hemodialysis

Catastrophic
(Z benefits)
Acute Lymphocytic Leukemia
Early Breast Cancer
Prostate Cancer
Kidney Transplantation
Coronary Artery Bypass Graft
Total Correction of TOF
Closure of VSD
Cervical Cancer
Z Morph
Peritoneal Dialysis

Provider Payment Mechanisms of

PhilHealth Then and Now...
Fee-for-Service
Implemented during
the PMCC era carried
over by PhilHealth
Health care providers
are paid for every
unit of service
rendered

Reimbursement is
dependent on case type
and level of
hospitals/ facility

Partial Case
Rates (23 cases)

All Case Rates

(ACR)

Implemented last
September 2011
49% of the total
claims

Bundled payment (HCI

fee and PF)
Uniform rate across
member category and
type of hospital or
per type of facility

Implemented last
January 1, 2014

Sulit ang Benepisyo sa PhilHealth

No balance billing. Indigent members would not be paying extra if
they are confined in service wards in government facilities.

Primary Care Benefit (PCB) Package. For Sponsored Members,

they receive a primary care package for basic laboratories and
consultations and would soon include medicines for select chronic
conditions.

TSEKAP Preventive &

Diagnostic Services
Consultation
BP and Body Measurements
Breast Exam and Breastfeeding
Education
Prostatic CA Screening
Counselling for Smoking
Cessation and lifestyle
modification
Risk profiling for Hypertension
and Diabetes

CBC
Urinalysis
Chest x-ray
FBS
Lipid Profile
Creatinine
ECG
Blood glucose monitoring

TSEKAP Medicines

Asthma: Salbutamol, Fluticasone,

URTI: Amoxicillin, Erythromycin, Paracetamol, Lagundi
Pneumonia: Amoxicillin, Erythromycin, Co-amoxyclav
UTI: Ofloxacin, Cotrimoxazole, Co-amoxyclav
Ischemic Heart Disease: Atenolol, Isosorbide Mononitrate
Diabetes: Gliclazide
Hypertension: Enalapril Amlodipine
Dyslipidemia: Simvastatin
Gout: Colchicine, Allopurinol

P1,000 cap per family

Top Surgical Case Rates

Surgical Procedures
1

Radiotherapy Linac

3,000.00

Radiotherapy Cobalt

2,000.00

Maternity Care Package (PCF, Birthing Homes)

8,000.00

Normal Spontaneous Delivery Package

(Levels 1-3 Hospitals)

6,500.00

Cesarean Section

19,000.00

Appendectomy

24,000.00

Newborn Care Package

(Birthing Homes, PCF, Levels 1-3

1,750.00

Dilatation & Curettage

11,000.00

Hemodialysis

4,000.00

Hysterectomy

30,000.00

10

Cataract Package

16,000.00

Top Medical Case Rates

Medical Conditions
1

Dengue Fever

10,000.00

Dengue, Severe

16,000.00

Pneumonia Moderate Risk

15,000.00

Pneumonia High Risk

32,000.00

Hypertensive Emergency / Urgency

9,000.00

Stroke - Infarction

28,000.00

Stroke - Hemorrhagic

38,000.00

Acute Gastroenteritis

6,000.00

Asthma in Acute Exacerbation

9,000.00

10

Typhoid Fever

10,000.00

Type Z Benefits
Type Z Benefits. PhilHealth provides substantial support for
conditions which normally are very expensive.

Pediatric
Leukemia

P210,000

Breast Cancer

P100,000

Prostate Cancer

P100,000

End Stage Renal

Requiring Kidney
Transplant

P600,000

Coronary Artery
Bypass

P550,000

Tetralogy of Fallot

P320,000

Closure of
Ventricular Septal
Defect

P250,000

Cervical Cancer
Chemoradiation

P175,000

Z Morph (lower limb

prostheses)

P15,000

Working with Nurses

PhilHealth
Customer Assistance,
Empowerment and Relations Staff

Working with Nurses

A Circular is currently being finalised that
would provide for the accreditation of nurses
as maternity care providers, antenatal care
and newborn packages

Key Priorities


Sustained coverage of the population in the

program;

Increased financial risk protection that

contributes to poverty reduction; and

Improved health outcomes through wider

access to health services and better benefits.

Challenges
1. Health expenditure remains low the Philippines
remain as a low spender on health compared to other regional
and middle income economies.

2. Out of pocket spending is still high the rising cost of health

care services largely contributes to the growing OOP spending.
3. Poverty incidence has not caught up with overall
improvements the countrys poverty rate remained one of the
highest in the region despite the decent economic growth.
4. Recurrent shocks from climate change are highly expected
climate hazards are becoming a constant threat to the social and
environmental determinants of health.

www.philhealth.gov.ph