PhilHealth- Philippine Health Insurance Corporation

1. Vision a. Adequate and Affordable Social Health Insurance Coverage for ALL Filipinos. 2. Mission a. To ensure adequate financial access of every Filipino to quality health care services through the effective and efficient administration of the National Health Insurance Program. 3. Core Values a. People and Partnership- The alliance we have made are the wheels of our program. Our members are at the core of our operations and it is our duty to serve the public. b. Harmony- Team PhilHealth moves as one, otherwise, we could not have reached nor surpassed our goals. c. Innovation- We support new and bright ideas to improve our operations, and apply the Balanced Scorecards into how we carry out our tasks. d. Leadership- The entire PhilHealth organization leads and drives the health system reforms in the country. e. Honor, Accountability and Transparency- We are the custodians of public coffers and we owe it to the people to keep the program afloat for future generations. f. Excellence and Lifetime Learning- We do not just meet targets; we surpass them because we are movers and shapers. We are the few who make things happen but we continue to learn new things. g. Health for All- We aim for universal coverage. Right now, we cover eight out of every ten Filipinos, and we aspire to sustain this coverage in the long-term. 4. Business Profile a. Nature Of Organization- Government Owned and Controlled Corporation (GOCC) b. Type Of Industry- Health Care Financing

c. Affiliations i. International Social Security Association ii. ASEAN Social Security Association iii. Philippine Social Security Association d. Funding Sources i. National and Local Government Units (for the annual premium of enrolled sponsored members) ii. Contribution of members into the Program e. Key Program Partners i. Institutional and Professional Health Care Providers ii. National Government Agencies iii. Local Government Units iv. Collecting Banks and Agents v. Private Organizations

5. History
a. THE call to serve the rural indigents echoed since the early '60s when the Philippine Medical Association introduced the MARIA Project which prioritized aid to communities in need of medical assistance. The Project would then be considered a valuable precursor to the Medicare program, from which a medical care plan for the entire Philippines was created. b. On August 4, 1969, Republic Act 6111 or the Philippine Medical Care Act of 1969 was signed by President Ferdinand E. Marcos which was eventually implemented in August 1971. c. The Philippine Medical Care Commission (PMCC) was tasked to oversee the implementation of the program which went for almost a quarter of a century. d. In the 1990s, a vision for a better, more responsive government health care program was prompted by the passage of several bills that had significant implications on health financing. e. The public's clamor for a health insurance that is more comprehensive in terms of covered population and benefits led to the development of House Bill 14225 and Senate Bill 01738 which became "The National Health Insurance Act of 1995" or Republic Act 7875, signed by President Fidel V. Ramos on February 14, 1995. i. The law paved the way for the creation of the Philippine Health Insurance Corporation (PhilHealth), mandated to provide social health insurance coverage to all Filipinos in 15 years' time.

f. PhilHealth assumed the responsibility of administering the former Medicare program for government and private sector employees from the Government Service Insurance System in October 1997, from the Social Security System in April 1998, and from the Overseas Workers Welfare Administration in March 2005. 6. Main Office: Citystate Centre, 709 Shaw Boulevard, Pasig City 1603, Philippines 7. Benefits

a. Inpatient coverage- PhilHealth provides subsidy for room and board, drugs and medicines, laboratories, operating room and professional fees for confinements of not less than 24 hours.
b. Outpatient coverage- Day surgeries, dialysis and cancer treatment procedures such as chemotherapy and radiotherapy in accredited hospitals and free-standing clinics. c. Special Benefit Packages i. Case Rates ii. TB Treatment through DOTS iii. SARS and Avian Influenza iv. Novel Influenza A(H1N1) d. Exclusions / Non-Compensables i. The following shall not be covered except when, after actuarial studies, PhilHealth recommends their inclusion subject to approval of its Board of Directors: 1. Fifth and subsequent normal obstetrical deliveries 2. Non-prescription drugs and devices 3. Alcohol abuse or dependency treatment 4. Cosmetic surgery 5. Optometric services 6. Other cost-ineffective procedures as defined by PhilHealth 8. Benefit Availment Conditions a. Eligibility Requirements i. The following must first be met to avail of your PhilHealth benefits:

1. Payment of at least three monthly premiums within the immediate six months prior to confinement. For pregnancy-related cases and availment of the new born care package, dialysis (except those undergoing emergency dialysis service during confinement), chemotherapy, radiotherapy and selected surgical procedures, payment of nine (9) monthly premium contributions within the last 12 months shall be required except for those enrolled under the KASAPI program. 2. Confinement in an accredited hospital for at least 24 hours (except when availing of outpatient care and special packages) due to an illness or disease requiring hospitalization. Attending physicians must also be PhilHealth-accredited. 3. Availment is within the 45 days allowance for room and board. b. After the automatic deduction or reimbursement of your benefits, PhilHealth will send you (to the address you have indicated in your claim form) a benefit payment notice or BPN. The BPN is a report of actual payments made by PhilHealth relative to your confinement/availment. 9. Benefit Availment Procedures a. Outright/Automatic Deduction Of Benefits i. Submit to the billing section the following prior to discharge from the hospital: 1. Duly accomplished PhilHealth Claim Form 1 2. Proof of applicable premium payments 3. Clear copy of Member Data Record (MDR) 4. If patient is a qualified dependent but not is listed in the MDR, submit applicable proof of dependency. ii. Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit. iii. Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill.

b. Direct Filing/Reimbursement i. Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge: 1. PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians) 2. Official receipts or hospital and doctor's waiver 3. Operative record for surgical procedures performed c. Confinements Abroad i. Submit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates. ii. PhilHealth Claim Form 1 iii. Member Data Record (MDR) or supporting documents iv. Proof of applicable premium payments v. Original official receipt or detailed statement of account (written in English) vi. Medical certificate (written in English) indicating the final diagnosis, confinement period and services rendered 10.Members a. Overseas Worker Program (OWP) i. Active landbase Overseas Filipino Workers (OFW) who underwent the normal process of registration as an OFW at Philippine Overseas Employment Agency (POEA) Offices. ii. OFWs who are currently abroad but are not yet registered with PhilHealth. iii. Sea-based OFWs such as seafarers are considered locally Employed Members and not Overseas Worker members. iv. Member Registration Procedures

1. Submit duly accomplished PhilHealth Membership Registration Form together with applicable documents for each qualified dependent declared. 2. Also submit any of the following documents as proof of being an active OFW: a. Valid Overseas Employment Certificate (OEC) or Ereceipt b. Valid overseas employment contract or certificate of employment c. Valid re-entry visa d. Valid job contract v. Pay the one-year premium of Php 900. For your convenience, premium payments covering the entire contract (equivalent to the number of years provided for in your contract) is highly encouraged. b. Employed Sector i. Government Sector- Employees of the government, whether regular, casual or contractual, who renders services in any government branches, military or police force, political subdivisions, agencies, or instrumentalities, including government-owned and controlled corporations, financial institutions with original charter, constitutional commissions, and is occupying either an elective or appointive position, regardless of status of appointment. ii. Private Sector 1. Corporations, partnerships, or single proprietorships, nongovernment organizations, cooperatives, non-profit organizations, social, civic, or professional or charitable institutions, organized and based in the Philippines 2. Foreign corporations, business organizations, nongovernment organizations based in the Philippines 3. Foreign governments or international organizations with quasi-state status based in the Philippines which entered into an agreement with PhilHealth to cover their Filipino employees

4. Foreign business organizations based abroad with agreement with PhilHealth to cover their Filipino employees 5. Sea-based OFWs 6. Household employees iii. Member Registration Procedures 1. For Newly Hired And Existing Employees Without PIN Yet a. Fill out PhilHealth Member Registration Form b. Attach clear copy of supporting documents for qualified dependents declared c. Submit to the HR Department for them to forward the above documents to PhilHealth together with ER2 Form (Report of Employee-Members). d. PhilHealth will send the PhilHealth Identification Card or PIC and a copy of the Member Data Record to the member, through the employer 2. For Newly Hired Employees With PIN a. Report your PIN to your employer for them to indicate the same in their ER2 iv. Premium contributions are shared by the employee and the employer, the amount of which is determined using the table of contributions. After deducting half of the premium requirement from your monthly salary, total premiums are remitted by your employer to PhilHealth. c. Individually Paying i. Self-employed individuals - those who work for him/herself and is therefore both the employer and employee, including but not limited to the following: ii. Self-earning professionals like doctors and lawyers iii. Business partners and single proprietors / proprietresses iv. Actors, actresses, directors, scriptwriters and news reporters who are not under an employer-employee relationship

v. Professional athletes, coaches, trainers and jockeys vi. Farmers and fisherfolks vii. Workers in the informal sector such as ambulant vendors, watch-your-car boys, hospitality girls, tricycle drivers, etc. viii. Separated from employment - those who were previously formally employed (with employer-employee relationship) and are separated from employment. ix. Employees of international organizations and foreign governments based in the Philippines without agreement with PhilHealth for the coverage of their Filipino employees in the program. x. All other individuals not covered under the previous categories mentioned, including but are not limited to the following: xi. Parents who are not qualified as legal dependents, indigents or retireess/pensioners xii. Retirees who did not meet the minimum of 120 monthly premium contributions to qualify as non-paying members xiii. Children who are not qualified as legal dependents xiv. Unemployed individuals who are not qualified as indigents xv. Member Registration Procedures 1. Fill out PhilHealth Membership Registration Form
2. Attach clear copy of supporting documents for qualified dependents to be declared 3. Registrant will be issued his/her PhilHealth Identification Number or PIN and the PhilHealth Member Registration Form or PMRF and shall be asked to pay the required premiums to the PhilHealth Cashier or at any of PhilHealth's accredited collecting banks

xvi. Individually Paying Members (IPMs) earning an average monthly income of P25,000 and below pay P300 quarterly or P1,200 per year, while those earning above P25,000 pay P600 quarterly or P2,400 per year. Premium contributions may be paid quarterly, semi-annually and annually.

Schedule of payment:

Quarterly Pay until the last working day of the quarter being paid for. Example: Period: January to March Deadline: March 31

Semi-annual

Annual

Pay until the last Pay until the last working working day of the first day of the first quarter of quarter of the year the semester being paid being paid for. for. Example: Period: January to June Deadline: March 31 Example: Period: January to December Deadline: March 31

d. Sponsored Program i. The Sponsored Program is open to qualified indigents belonging to the lowest 25% of the Philippine population. Families that will be given health insurance coverage are identified through the family data survey using the framework of Community-based Information System - Minimum Basic Needs or CBIS-MBN. The CBIS-MBN is being conducted by the Department of Social Welfare and Development through its local social welfare development offices. ii. Also qualified under this program are families who are listed in the National Household Targeting System for Poverty Reduction (NHTS-PR) of the Department of Social Welfare and Development are qualified under this category. iii. The Sponsored Program is being made possible through the partnership of PhilHealth and sponsors such as local governments (LGUs), private individuals and corporations and members of Congress, among others. iv. The National Government (through PhilHealth) and the abovementioned sponsors jointly pay the annual premium of Php 1,200 for each enrolled family. e. Lifetime i. The following shall be entitled to PhilHealth's lifetime coverage as Lifetime Members:

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 pensioners 6. SSS old-age 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 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. ii. Member Registration Procedures 1. Submit the following to any PhilHealth Office nearest you: a. 1. Duly accomplished PhilHealth Membership Registration Form b. 2. Two (2) latest 1" x 1" ID picture c. 3. Certified True Copy (CTC) of the SSS or GSIS Retirement Certification or the following as applicable: 2. For SSS Retirees/Pensioners: a. Printout of Death, Disability and Retirement (DDR) from any SSS office indicating that the type of claim is retirement in nature and the effectivity date of pension; and b. Printout of contributions issued by any SSS office indicating the latest contributions (if he/she retires after March 4, 1995. 3. For GSIS Retirees - any of the following: a. Certification/Letter of Approval of Retirement from the GSIS indicating the effectivity date of retirement; b. Service Record issued by the employer/s indicating not less than 120 months of service excluding leave of absences without pay; c. Certification/retirement Gratuity from the employer indicating not less than 120 months of service. d. For AFP, PNP, BFP and BJMP Retirees/Pensioners those who are in active military service until they retire at age 56 and those separated by retirement or other reasons prior to the said age but have reached the age of 60, shall submit any of the following:

e. Statement of Services issued by previous employer indicating not less than 120 months of service excluding leave of absences without pay; f. Certification/Letter of Approval of Retirement from the GSIS indicating not less than 120 months of service; g. General, Bureau or Special Order indicating the effectivity date of retirement. 4. Certified true copy (CTC) of Birth Certificate or any two of the following: a. CTC of Baptismal Certificate b. CTC of Marriage Contract/Certificate c. Passport d. Driver's License e. SSS Members ID f. Alien Certificate of Registration (ACR) g. Service Record/s h. Employee ID i. j. School records Voter's ID

k. Senior Citizens ID l. Duly notarized joint affidavit of two disinterested persons attesting to the fact of birth of the registrant

5. Any other valid documents acceptable by PhilHealth iii. Member will be issued his/her PhilHealth Lifetime Member Card which is a valid ID to be used in all PhilHealth transactions.

11.Qualified Dependents

a. the following also enjoy PhilHealth coverage without additional premiums for each dependent:
i. Legal spouse (non-member or membership is inactive) ii. Child/ren - legitimate, legitimated, acknowledged and illegitimate (as appearing in birth certificate) adopted or step below 21 years of age, unmarried and unemployed. Also covered are child/ren 21 years old or above but suffering from congenital disability, either physical or mental, or any disability acquired that renders them totally dependent on the member for support. iii. Parents (non-members or membership is inactive) who are 60 years old, including stepparents (biological parents already deceased) and adoptive parents (with adoption papers).

b. All of your qualified dependents shall be entitled to a separate coverage for up to 45 days per calendar year. However, their 45 days allowance will be shared among them. c. Your dependents need to be declared and/or updated with PhilHealth to include them in your PhilHealth Member Registration Form or PMRF, your official membership profile with PhilHealth. Your updated MDR will make your benefit availments easier and convenient.

Case Rates

Since September 1, 2011, the following medical cases and surgical procedures are being paid through case rate:
Medical Cases
1. Dengue I (Dengue fever, DHF grades I&II) 2. Dengue II (DHF grades III & IV) 3. Pneumonia I ( moderate risk) 4. Pneumonia II (high risk) 5. Essential Hypertension 6. Cerebral Infarction (CVA-I) 7. Cerebral Hemorrhage (CVA-II) 8. Acute Gastroenteritis (AGE) 9. Asthma 10. Typhoid Fever 11. Newborn Care Package in Hospitals and Lying in Clinics 8,000 16,000 15,000 32,000 9,000 28,000 38,000 6,000 9,000 14,000 1,750

Surgical Cases
1. Radiotherapy 2. Hemodialysis 3. Maternity Care Package (MCP) 4. NSD Package in Level I Hospitals 5. NSD Package in Levels 2 to 4 Hospitals 6. Caesarean Section 7. Appendectomy 8. Cholecystectomy 9. Dilatation and Curettage 10. Thyroidectomy 11. Herniorrhaphy 12. Mastectomy 13. Hysterectomy 14. Cataract Surgery 3,000 4,000 8,000 8,000 6,500 19,000 24,000 31,000 11,000 31,000 21, 000 22,000 30,000 16,000

Premium Contribution Table

Salary Bracket Salary Range Salary Base Total Monthly Premium Employee Share Employer Share *Employee share represents half of the total monthly premium while the other half is shouldered by the employer. 1 4,999.99 and below 5,000.00 5,999.99 6,000.00 6,999.99 7,000.00 7,999.99 8,000.00 8,999.99 9,000.00 9,999.99 4,000.00 100.00 50.00 50.00

5,000.00

125.00

62.50

62.50

6,000.00

150.00

75.00

75.00

7,000.00

175.00

87.50

87.50

8,000.00

200.00

100.00

100.00

9,000.00

225.00

112.50

112.50

10,000.00 10,999.99 11,000.00 11,999.99 12,000.00 12,999.99 13,000.00 13,999.99 14,000.00 14,999.99 15,000.00 15,999.99 16,000.00 16,999.99 17,000.00 17,999.99 18,000.00 18,999.99 19,000.00 19,999.99 20,000.00 20,999.99 21,000.00 21,999.99 22,000.00 22,999.99 23,000.00 23,999.99 24,000.00 24,999.99 25,000.00 25,999.99 26,000.00 26,999.99 27,000.00 -

10,000.00

250.00

125.00

125.00

11,000.00

275.00

137.50

137.50

12,000.00

300.00

150.00

150.00

10

13,000.00

325.00

162.50

162.50

11

14,000.00

350.00

175.00

175.00

12

15,000.00

375.00

187.50

187.50

13

16,000.00

400.00

200.00

200.00

14

17,000.00

425.00

212.50

212.50

15

18,000.00

450.00

225.00

225.00

16

19,000.00

475.00

237.50

237.50

17

20,000.00

500.00

250.00

250.00

18

21,000.00

525.00

262.50

262.50

19

22,000.00

550.00

275.00

275.00

20

23,000.00

575.00

287.50

287.50

21

24,000.00

600.00

300.00

300.00

22

25,000.00

625.00

312.50

312.50

23

26,000.00

650.00

325.00

325.00

24

27,000.00

675.00

337.50

337.50

27,999.99 25 28,000.00 28,999.99 29,000.00 29,999.99 30,000.00 and up 28,000.00 700.00 350.00 350.00

26

29,000.00

725.00

362.50

362.50

27

30,000.00

750.00

375.00

375.00