PHILIPPINE HEALTH

INSURANACE CORP.
April Dawn L. Guzman
 HISTORY

• 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.
• The National Health Insurance Program (NHIP) administered by
the Philippine Health Insurance Corporation (PhilHealth) was
established in 1995 with the passage of Republic Act (RA) 7875.
• “To provide health insurance coverage to all Filipinos”
• 1997 - it assumed Medicare functions for government workers from the
GSIS and a year later, for the private sector workers, which was previously
administered by the SSS.
• PhilHealth started the Indigent Program. In partnership with Local
Government Units (LGUs), PhilHealth has enrolled millions of families who
otherwise have no access to health services. To date, all families in the
DSWD’s National Household Targeting System for Poverty Reduction
(NHTS-PR) are covered by PhilHealth.
• 1999 – PhilHealth started covering self-employed and the informal sector
• 2005 – PhilHealth assumed Medicare functions from the Overseas Workers
Welfare Administration (OWWA) for Overseas Filipino Workers
 National Health Insurance Program (NHIP)

RA 7875 – February 14, 1995

RA 9241 – February 10, 2004
RA 10606 – June 19, 2013
 Concept of Social Health Insurance
• Social Solidarity or Bayanihan, where:
The rich subsidizes the poor
The young subsidizes the old
The healthy subsidizes the sickly

Bayanihan Spirit: “working together to achieve common goal”

 MEMBERS
FORMAL ECONOMY
INFORMAL ECONOMY
INDIGENT
SPONSORED MEMBER
LIFETIME MEMBER
MEMBERS in the FORMAL ECONOMY:
Government Employee
Private Employee
All other workers rendering services, whether in government or private
offices, such as job order contractors, project-based contractors, and the like
Owners of Micro Enterprises
Owners of Small, Medium and Large Enterprises
Household Help
Family Drivers
 Members in the INFORMAL ECONOMY:

Migrant Workers
Informal Sectors
Self-Earning Individuals
Filipino with Dual Citizenship
Naturalized Filipino Citizens
Citizens of other countries working and/or residing in the Philippines
 LIFETIME MEMBER
• 1. Retirees/Pensioners from the Government Sector
• Old – age retires and pensioners of the GSIS, including 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 PD 408
• GSIS Disability Pensioners prior to March 4, 1995
• GSIS Retirees who have reached the age of retirement on or after March 4, 1995 and
have at least 120 months Philhealth premium contributions.
• Retirees and Pensioners who are members of the Judiciary who have reached the age
of retirement and have at least 120 months Philhealht contributions
• Retirees who are members of the Constitutional Commission and other Constitutional
Offices who have reached the age of retirement and have at least 120 months
PhilHealth contributions. m
• 2. Retirees/ Pensioners from the Private Sector
• SSS pensioners prior to March 4, 1995
• SSS Permanent Total Disability Pensioners prior to March 4,
1995
• SSS Death/ Survivorship Pensioners prior to March 4, 1995
• SSS Old – age retirees who have reached the age of retirement
on or after March 4, 1995 and have atleast 120 months
PhilHealth premium contributions
• 3. Uniformed Members of the AFP, PNP, BJMP and
BFP
• Uniformed personnelof theAFP, PNP, BJMP and BFP
who have reached thecompulsory ageof retirement
beforeJune 24, 1997, and retirees under Presidential
Decree 408.
• Uniformedmembers of theAFP, PNP, BJMP and BFP
who have reached thecompulsory ageof retirement
on or after June 24, 1997, being theeffectivitydate of
RA 8291 which excluded them in the compulsory
membership
• 4. Members of PhilHealth who have reached the age of
retirement as provided by law and have met the
required premium contributions of at least 120
months, regardless of their employer/s’ or sponsor’s
arrears in contributions and is not included in the
Sponsored program nor declared as dependent by their
spouse or children.
 PhilHealth Identification Number and Health
Insurance ID Card
• The PhilHealth shall assign a permanent and unique PhilHealth
Identification Number to every member including each and every dependent
of their.
• The absence of the ID Card shall not prejudice the right of any member to
avail of benefits or medical services under the Program.
• The ID card shall be recognized as a valid government Identification and
shall be presented and honored in transactions requiring the vverification of
a person’s identity.
 Replacement of Health Insurance Card
• A member may request of the Health Insurance Card due to loss or wear
and tear upon payment of fees for the issuance of a new card
REQUIREMENTS FOR REGISTRATION OF
MEMBERS AND DEPENDENT
A person intending to register with the Program regardless of
membership category shall submit to the Corporation a properly
accomplished prescribed Membership Registration Form, whereby the
member shall certify the truthfulness and accuracy of the information
provided including the list of declared qualified legal dependents. If
warranted, the Corporation may require submission of supporting
documents. The same process shall be maintained for
amendments/revision to any submitted data of the member and/or
dependents.
 EMANCIPATED INDIVIDUAL OR
SINGLE PARENT

Any person below 21 years of age, married or unmarried

but with a child, shall be enrolled as a member
 REMITTANCE OF PREMIUM
CONTRIBUTION AND EFFECTIVITY.
Remittance of contribution shall be mandatory for all members. It shall
be made to PhilHealth officers or to any of the accredited collecting
agents. Failure to timely remit the appropriate premium contribution
shall be subject to interest and penalties as prescribed by the corporation
without prejudice to other applicable penalties herein provided.

• Membership shall take effect upon enrollment and payment of the

required premium contribution.
 REGISTRATION OF EMPLOYERS:
• . All government and private sector employers are required to
register with the Corporation and each shall be issued a
permanent and unique PhilHealth Employer Number (PEN)

• Employers may register with the PBR. Should the employer be

unable to register through the PBR, the Corporation shall require
the following documentary requirements, whichever is applicable:
1. For single proprietorships – Department of Trade and Industry
(DTI)
2. For partnerships and corporations – Securities and Exhange
Commission
3. For foundations and other non-profit organizations – SEC
registration;
4. For cooperatives – Cooperative Development Authority (CDA)
5. For Backyard industries/ventures and microbusiness enterprises
– Barangay Certification and/or Mayor’s Prmit.
 OBLIGATIONS OF THE EMPLOYER
All government and private employers are required to:
a) Register their employees andtheir qualified dependentsby submitting a
list of their employees complete with their salary base andother
documents as may be required
b) Report to the Corporation its newly-hired employees within thirty (30) calendar days
from assumption to office
c) Give notice to the Corporation of an employee’s separation within thirty (30)
calendar days from separation.
d) d. Keep true and accurate work records for such period and containing such
information as the Corporation may prescribe.
e) Allow the inspection of its premise including its books and other pertinent records.
 ENTITLEMENT TO BENEFITS:
Atleast 3 consecutive monthly contributions within immediate 6
months prior to admission
Paid in full the requirement premium for the calendar year
The 45 – days allowance for room and board has not been
consumed yet
Confinement in an accredited hospital not less than 24 hours
 Continuation of Entitlement to Benefits in
Case of Death of Member.

• In case of death of the member, the dependents of the

deceased member shall continue to avail of the benefits
for the unexpired portion of the coverage or until the
end of the calendar year, whichever comes first.
 MANDATED BENEFITS:
1. INPATIENT HOSPITAL CARE
• Room and board
• Service of health care professionals
• Diagnostic, laboratory, and other medical examination services
• Use of surgical or medical equipment and facilities
• Prescription drugs and biologicals (subject to the limitations stated
in section 37)
• Inpatient Health education packages
2. OUT PATIENT CARE
• Diagnostic, laboratory, and other medical examination
services
• Personal preventive services
• Prescription drugs and biologicals (subject to the
limitations set in Section 37
• Limited to drugs in the Philippine National Drug
Formulary and other PhilHealth Board approved drugs
• Services of health care professionals
 3. Emergency and transfer services;
4. Health Education Packages; and
5. Such other health care services that the Corporation
and the DOH shall determine to be appropriate and
cost-effective
 EXCLUSIONS
 Non-prescription drugs and devices
Alcohol abuse or dependency treatment
Cosmetic surgery
Optometric services
Fourth and subsequent normal obstetrical deliveries
Cost-ineffective procedures as be defined by the Corporation

BUT may be included by the Board after actuarial studies

 EXCEPTION TO THE 24hr.
CONFINEMENT
Emergency case as defined by PhilHealth
Patient died
Patient was transferred to another hospital
AVAILMENT PROCEDURES
 Claims Prescription Period Guidelines
All claims for payment of services rendered shall be filed within
60 calendar days from the date of discharge of the patient.
¾All claims returned for completion of requirements shall be re-
filed within 60 calendar days from receipt of notice.
¾All requests for payment adjustments must be made within 60
days from date of receipt of check payment or of the benefit
payment notice.
 Confinement in a Non-Accredited Hospital is
possible IF :
The case is Emergency,
¾The Hospital has a current Department of Health
(DOH) License,
¾And transfer/referral to a PhilHealth accredited
hospital is physically impossible
BENEFIT SCHEDULE
 CLAIM BENEFIT FOR CONFINEMENT
ABROAD
• Entitlement to Benefits:
• -Member or his/her qualified dependents
• -Confinement/ Surgery or OPD Benefits

• Benefit & Claims Filing

• -180 calendar days fr.dateof discharge
• -always payable to member
• -based on applicable benefit schedule, case type for a Tertiary level hospital
 CONFINEMENT ABROAD

• Documentary Requirements:
• 1. PH Form 1
• 2. Photocopy of MDR
• 3. Medical certificate/Abstract (with English translation
• 4. SOA with itemized charges and/or ORs(proof of hospital
bill and PF)
 CURRENT PHILHEALTH BENEFIT
PACKAGE
• Day or Ambulatory Surgery Procedures and Surgeries
• General , Eye, ENT, Urological, Gynecologic, Orthopedic and other surgeries

ALSO INCLUDES:
 DIALYSIS CARE for End Stage Renal Disease
 CHEMOTHERAPY and RADIOTHERAPY for Cancer cases
 MATERNITY CARE up to 3rdNormal Deliveries (NSD)
 NEWBORN CARE PACKAGE (NCP)
MATERNITY CARE PACKAGE
 MATERNITY CARE PACKAGE

Eligibility:
 First prenatal visit of the member or dependent must not
exceed the four (4) month age of gestation (AOG)of the
current pregnancy
IPP: All pregnancy related cases
 9monthly contributions within the immediate
 12months prior to delivery
 MATERNITY CARE PACKAGE
EXCLUSION:
• IF first 2 pregnancies resulted in:
• Cesarean section
• VBAC
• Breech delivery
• Preterm delivery
• Stillbirth
*Counted as part of limitation of NSDpackage to the first 2 deliveries
 MATERNITY CARE PACKAGE

• CLAIMS FILING
• Claims for the first payment must be filed within 60 days from
date of discharge
• For the second payment, claim must be filed within 90 days
from date of discharge
 NEWBORN CARE PACKAGE

• For ALL QUALIFIED DDEPENDENTS

• FIXED PAYMENTS for
• NEWBORN SCREENING
• FIRST DOSE OF HEPATITIS B VACCINATION at
BIRTH
• BCG
 NEWBORN CARE PACKAGE
• Php 1,000 benefit divided into:
 Php 250 for HEPA B Vaccine
 Php 500 for NEWBORN SCREENING
 Php 250 for others

• PROVIDERS: Hospital, RHU’s/HC’s, Lying – In

• REQUIRMENT FOR ACCREDITATION:
• NSF Certified issued by DOH or NSRC
DOTS PACKAGE
RULES OF PROCEDURE ON
ADMINISTRATIVE CASES
AGAINST HEALTH CARE
PROVIDERS AND MEMBERS
 WHO MAY FILE?

• Any person natural or juridical, may file a complaint

against health care providers and/or members. The
corporation shall howver have the authority to motu
propio direct the conduct of a fact-finding investigation
and the filng of a case against HCP’s and/or members
 GROUNDS FOR A COMPLAINT
AGAINST A MEMBER
• A written complaint against a member may be filed
for the commission of any offenses
 Where to File?

• The written complaint against a health care

providerand/or member may be filed with any
PhilHealth RegionalOffice (PRO) - Legal Office
or directly with the Fact-Finding Investigation and
Enforccement Department (FFIED) – Central Office.
 BAWA’T PILIPINO, MIYEMBRO;
BAWA’T MIYEMBRO, PROTEKTADO;
KALUSUGAN NATIN, SEGURADO