PHILHEALTH UPDATES

2
nd
Semi-Annual Hospital Managers Meeting

OUTLINE OF PRESENTATION

I. PhilHealth Directions in Relation to KP
Including Status of PhilHealth Membership,
Collection and Engagement
II. Implementing Rules and Regulations of RA
10606
III. New PhilHealth Programs
IV. Benefits Payment and Availment
V. Open Forum


Atty. Jerry F. Ibay
Regional Vice President
PhilHealth-CAR
Synergy for Universal Health Care
KP Vision
Financial Risk
Protection

Access to Improved
Health Facilities

Attainment of Health-
related MDG
Bawat Pilipino
Miyembro

Bawat Miyembro
Protektado

Kalusugan Natin
Segurado
1.0
Public Health
MDGs Achieved

1.1 - Reduce
Maternal and
Child
Mortality
1.2 - Control
and Eliminate
Infectious
Diseases
1.3 - Promote
a Healthy
Lifestyle and
Prevent NCDs
2.0
Financial Risk
Protection
Improved
2.1 - Expand
PhilHealth
Coverage
2.2 - Improve
PhilHealth
Benefit
Package
3.0
Quality Care
Delivery System
Accessible
3.1 - Upgrade
and Improve
Health Units
and Hospitals
3.2 - Deploy
Human
Resources for
Health
4.0
Health
Governance
Improved
4.1 Develop
Health
Systems
4.2
Maintain an
Effective
Health
Regulatory
System
Outcomes and Strategies of UHC
Outcome 2: Financial Risk Protection
Strategy 1: Expand PhilHealth Coverage
Action
Status TARGETS
2014 2015 2016
1. Enroll NHTS poor
& near-poor
families
5.2 M 14.7 M* 14.7 M

14.7 M

2. Increase hospitals
with point of care
enrollment
LGU

DOH
100

72
200

72

300

72

3. Enroll the
remaining
informal sector
80%
3.1M not
enrolled but can
pay premium
85

88

90

* Depends on NHTS list of DSWD
84%
76%
86%
Number and Percentage Distribution of Members
and Dependents as of September 2013, CAR
2011 2012 2013
LICENSED ENGAGED LICENSED ENGAGED LICENSED ENGAGED
ABRA 10 9 9 9 10 9
APAYAO 7 7 7 7 7 7
BAGUIO CITY 8 6 8 6 8 6
BENGUET 9 9 9 9 9 9
IFUGAO 8 8 8 8 8 8
KALINGA 9 8 7 7 8 8
MT. PROVINCE 7 7 7 7 7 7
TOTAL 58 54 55 53 57 54
Summary of
Licensed vs
Accredited/Engaged
Hospitals per
province per year:

Hospitals With Out-Patient Benefit Package
Services
OPB Services Province/City Hospital
TBDOTS Benguet
Baguio City
Benguet Gen. Hospital (BeGH)
Baguio Gen. Hospital & Medical Center (BGHMC)
St. Louis Hospital of the Sacred Heart (SLUHSH)
Notre Dame de Chartres Hospital
Hemodialysis Benguet
Baguio City
BeGH
BGHMC
SLUHSH
Notre Dame de Chartres Hospital
Pines City Doctors Hospital
Animal Bite Abra
Kalinga

Mt. Province
Abra Provincial Hospital
Kalinga Provincial Hospital
Western Kalinga District Hospital
Bontoc General Hospital
Luis Hora Memorial Regional Hospital

Hospitals With Out-Patient Benefit Package
Services
OPB Services Province/City Hospital
PCB Abra






Apayao




Baguio City
Abra Provincial Hospital

Bucay MunicipalHospital
Dolores Medicare and Community Hospital
La Paz District Hospital
Villaviciosa Medicare and Community Hospital

Amma Jadsac District Hospital
Flora District Hospital
Sta. Marcela Med. and Community Hospital
Far North Luzon Gen. Hosp. & Trng. Center

Baguio Gen. Hospital and Medical Center

Hospitals With Out-Patient Benefit Package
Services
Province/City Hospital
PCB Kalinga





Mt. Province




Kalinga Provincial Hospital
Juan M. Duyan District Hospital
Kalinga District Hospital
Pinukpuk District Hospital
Western Kalinga District Hospital

Bontoc General Hospital
Barlig District Hospital
Besao District Hospital
Paracelis District Hospital
Luis Hora Memorial Regional Hospital
Natonin Community Hospitals
* Above Packages to expire on December 31, 2013.
Premium Collection vs Benefit Availment, Jan.
September 2013
Collection Benefit Payment
P412,899,000 or 68% of
the annual collection
target

P875,362,714.18 or
71%% of the annual
budget for benefit
payment
2013 Annual Premium Target Collection
P603,084,000.00
2013 Annual Budget for Benefit Payment
P603,084,000.00
PFPR Paid to Different Hospitals as November 19, 2013
Province/Hospital Amount Released
Abra
1. Bucay Municipal Hospital P16,400.00
2. Dolores Medicare and Community Hospital P41,600.00
3. La Paz District Hospital P65,459.86
Apayao
1. Far North Luzon Gen. Hospital & Training Center P123,000.00
Kalinga
1. Kalinga Provincial Hospital P258,500.00
2. Juan M. Duyan District Hospital P181,500.0
3. Kalinga District Hospital P172,000.00
4. Pinukpuk District Hospital P222,500.00
5. Western Kalinga District Hospital P176,250.00
PFPR Paid to Different Hospitals as November 19, 2013
Province/Hospital Amount Released
Mt. Province
1. Bontoc General Hospital P958,760.00
2. Barlig District Hospital P115,784.51
3. Besao District Hospital P351,636.67
4. Paracelis District Hospital P14,250.00
5. Luis Hora Memorial Regional Hospital P9,250.00
Grand Total P2,706,891.31
15
No. of Families Premium @ P2,400
DSWD Poor
(Submitted
for 2014 GAA)
Principal Families 5.48 million PhP 13.15 billion
Other families in the list 4.74 million PhP 11.38 billion
TOTAL 10.22 million PhP 24.53 billion
No. of Families Premium @ P2,400
DSWD Near
Poor
Principal Families 2.41 million PhP 5.78 billion
Other families in the list* 2.08 million PhP4.99 billion
TOTAL 4.49 million PhP 10.77 billion
PAMANA and BANGSAMORO 17, 500
Php 42.00
million
Grand Total 14.72 million
PhP 35.34 billion
(35,337,657,600)
Funding Requirements to Cover the Poor and Near Poor
16
Funding Requirements to Cover the Poor and Near Poor
LGU
NHTS-PR
Poor Core
Families/
Members
(HH
Heads)
Additional
Core
Families/Q
ualified
Members
(21 years
old and
Above)
TOTAL PROPOSED BUDGET
Additional
Core
Families/Q
ualified
Members
(DSWD
NEAR
POOR)
Additional
Core
Families/Q
ualified
Members
(21 years
old and
Above)
TOTAL PROPOSED BUDGET
Identified
Poor HHs
Identified
Poor HHs
Total Poor
Families
Budget for
NHTS Poor 2014
Identified
Near Poor
HHs
Identified
Poor HHs
Total Near
Poor
Families
Budget for
Near Poor
2014
Philippines
5,477,150 4,740,577

10,217,727 24,522,544,800 2,407,511 2,081,286

4,488,797

10,773,112,80
0
CAR 77,107 97,733 174,840 419,616,000 39,403 34,063 73,466 176,318,400
REGION I 248,057 238,910 486,967 1,168,720,800 115,675 100,001 215,676 517,622,400
REGION II 118,349 102,525 220,874 530,097,600 151,883 131,302 283,185 679,644,000
REGION III 353,771 306,606 660,377 1,584,904,800 119,400 103,221 222,621 534,290,400
797,284 745,774 1,543,058 3,703,339,200 426,361 368,587 794,948 1,907,875,200
14.56% 15.73% 15.10% 15.10% 17.71% 17.71% 17.71% 17.71%
EXPANDED COVERAGE as Stated in RA 10606
Enroll the remaining vulnerable groups
Women about to give birth (and as determined by means test recognized by
DSWD) (Sec 21, RA 10606)

Barangay health workers, nutrition scholars, and other volunteer workers of
the LGU. (Sec 20, RA 10606)

Workers rendering services in government offices such as job order, project-
based contractors, and the like (paragraph 3, Sec. 5, Rule I, Title III of the
IRR of RA 10606)

Require PhilHealth membership
Make PhilHealth membership a mandatory requirement for doing
business or issuing professional or business license or permit like (paragraph
3, Sec. 6 of RA 10606)

Point of Care
Cover the unenrolled poor and protect them from the financial risks of ill-
health at point of care.


Outcome 2: Financial Risk Protection
Strategy 2: Improve Benefit Package
Action
Status TARGETS
2014 2015 2016
1. Implement No-Balance
Billing
LGUs: 6%

DOH: 11%
15

50
35

80
50

90
2. Increase access to primary
Care Benefit Package
5.4 M
NHTS Families
14.7 M* 14.7 M 14.7 M
3. Implement Case Rates to
all conditions
12 Surgical
11 Medical
Conditions
All surgical and medical
conditions
4. Expand Catastrophic Care
Package (Type Z)
8 conditions

12 20 25
* Depends on NHTS list of DSWD
Preventive and curative care

Ensure No-Balance Billing (NBB) implementation - No other out-of-pocket expenses will be
charged from sponsored members confined in government facilities beyond the prescribed benefit
package rates of PhilHealth.

Primary Care Benefit I diagnostic examination including complete blood count, urinalysis,
fecalysis, sputum microscopy, fasting blood sugar, lipid profile, chest x-ray and primary preventive
services

Primary Care Benefit II outpatient medication for hypertension, diabetes and dyslipidemia

Special Benefit Packages TB treatment through DOTS, Maternity Care Package, Malaria
Treatment, HIV/ AIDS treatment, Animal Bites

Z-Benefit Packages health packages for catastrophic conditions

Implementation of All Case rate payments as a more efficient provider payment mechanism.
IMPROVED BENEFIT PACKAGE
Continuing PhilHealth Efforts and Activities in
the Hospitals
Deployment of PhilHealth Customer Assistance
Relations Empowerment Staff (PCARES)
Best Efforts to reduce turn-around time in processing
claims. (CAR is the 3
rd
place nationwide - fastest TAT
in claims processing, 2012)
Priority Lane for NBB Claims through the Reg Tag
Corner
Study/Survey Regarding Membership Status of
Patients Admitted in Hospitals
The Benguet General Hospital Project Iwas RTH
Planned Activities For 2013 and Beyond
Point of Care Engagement of Hospitals
Increase Hospitals Implementing NBB
Orientation of the ACR by Province starting 4
th

week of November 2013
Expansion of Study/Survey on Membership
Status of Admitted Patients in Private
Hospitals