PhilHealth Programs and Benefits

Alexander A. Padilla

President and CEO

Philippine Health Insurance Corporation
13 August 2015
Employers Confederation of the Philippines (ECOP)

Outline of Presentation
1.
2.
3.
4.
5.
6.

Creation of NHIP/PhilHealth
PhilHealths Vision and Mission
Membership
Premium Contribution
Benefits
PhilHealth Organization

PHILHEALTH @ 20
Created through Republic Act 7875
on Feb. 14, 1995
As amended by R.A. 9241 and R.A. 10606

MANDATE

To provide health insurance

coverage and ensure affordable,
acceptable, available and
accessible health care services
for ALL FILIPINOS

About PHILHEALTH

Single Fund/Single Payor

Draws inspiration from

concept of bayanihan

Coverage of about 88
percent of population

GOCC

Offshoot of Medicare

Vision and Mission

Bawat Pilipino MIYEMBRO

Formal
Economy

Informal
Economy

Sponsored Indigent
Members Members

Lifetime
Members

Senior
Citizens

Legal Dependents

Dependent: Children

Dependent: Legal Spouse

20 years old and below

unmarried & unemployed
legitimate, illegitimate
adopted, stepchildren
foster child

Who is not yet a member

Dependent: Parents
parents with permanent
disability thus fully dependent
on member

Dependent: Disabled Child

21 years old and above
with total disability
(congenital/acquired)

Covered Members and Dependents

as of June 30, 2015

Sector
Members in the
Formal Economy

Private
Government
Household Help/Kasambahay
Enterprise Owner & Family Drivers

Members in the
Informal Economy Migrant Worker
Informal Sector Workers
Self-Earning Individual
Organized Group and Others

Indigents
Sponsored Members
Senior Citizens
Lifetime Members
TOTAL

Members

Dependents

Beneficiaries

13,368,671

14,204,553

27,573,224

11,326,505
1,982,042

10,377,566
3,782,546

21,704,071
5,764,588

59,482

43,421

102,903

642

1,020

1,662

3,602,640

4,163,236

7,765,876

1,086,439
2,107,443
396,898
11,860

976,336
2,702,689
471,890
12,321

2,062,775
4,810,132
868,788
24,181

15,288,583
489,730
4,813,460
955,850

30,118,509
647,921
1,068,411
696,157

45,407,092
1,137,651
5,881,871
1,652,007

38,518,934

50,898,786

89,417,720

88%
of 2015
projected
population

Note:
- 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.

Registration

Members and Dependents

(as of end of April 2013; in millions)

A person intending to register as member should only

submit a properly accomplished Member Registration Form
(PMRF)
The member to certify the truthfulness and accuracy of the
information provided including the list of qualified
dependents

As a general rule, the

Corporation will not
require documentary
requirements unless
warranted

Premium Contribution Rates

Member Type

Formal
Economy:
Employed

Premium Rate

Not to exceed 5% of
employees monthly
salary
(Current rate is 2.5%)

Remarks

Shared equally by employee

and employer
* Remitted every month

2014 Collection for Formal

Economy (Private)

*Data in Billion Peso

*Against the potential collection of P40B

 Implementation of the adjusted rates across all

membership categories with Php2,400 as the
lowest premium rate, in order to ensure financial
sustainability and viability;
To sustain and further enhance the NHIP benefits of
members;
Transitory provisions were established to provide
members enough time to adjust to the new
premium adjustments.

Two (2) dates as deadlines for employers to pay the

premium contributions of their employees with a 5-day
window to:

Avoid long queues during the deadline

Reduce need for overtime of personnel
Lessen instances of late/delayed payments
Lessen the instances of IT-related technical issues during
high-volume transactions days (System slowdown,
hanging, etc.)

Updates on remittance and reporting

procedures*
For all small to extra-large enterprises starting
applicable month of June 2015 :
Mandatory use of the EPRS in the preparation and
submission of remittance reports
Mandatory payment in accredited collecting agents or
through e-Payment facilities

*Circulars 04-2015 and 09-2015

Exemptions
Micro-firms
Employers of Kasambahay and family drivers
Employers in geographically isolated and
disadvantaged areas (GIDA)
Areas without internet service (for EPRS) soft
copy reporting can still be filed with PhilHealth offices

More support to Employers

Computer
terminals in
PhilHealth
offices to
register with
EPRS

Continuous
EPRS
orientation
and provision
of technical
support

Interests and
surcharges
soon to be
integrated in
EPRS

Ease of Doing Business

Lessened journeys and waiting time for new
businesses registering with SEC, PhilHealth,
SSS and Pag-IBIG!
PhilHealth Employer Number (PEN) now
issued quickly and with great ease through the
Securities and Exchange Commission
Integrated Business Registration System

Post-registration musts*
Employer to receive e-mail advise to bring the
following to nearest PhilHealth office:
- Unified Registration Record (URR)
- Accomplished ER-1 and ER2

To get the following in return:

- Certificate of Registration
- Employer Data Record

Kasambahay payments*
Premium sharing:
- Salary below P5,000 - premium of P200 to
be solely borne by employer
-P5,000 and up - subject to current contribution
schedule; equally shared by employer and
employee
Should be made at PhilHealth offices only
Payment through collecting partners to be made
available soon!
*Circular 16-2015

Bawat MIYEMBRO, Protektado

Range of PhilHealth Benefits:
1. Outpatient Benefits
2. Inpatient Benefits
3. Catastrophic & Other Special Benefits

1. Outpatient Benefits
(Partial list only)

TB Treatment through DOTS - Php4,000

Voluntary Surgical Contraception Procedures -Php4,000
OPB Malaria Package -Php600
Outpatient Blood Transfusion -Php14,50025,700
Outpatient HIV/AIDS Treatment - Php30,000
Animal Bite Treatment Package -Php3,000
Moderate Leptospirosis Package -Php11,000

2. Inpatient Benefits - Medical Case (partial list only)

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

Inpatient Benefits Surgical (partial list only)

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

5,000.00

Cesarean Section

19,000.00

Appendectomy
Newborn Care Package

24,000.00

(Levels 1-3 Hospitals)

6
7

Dilatation & Curettage

1,750.00
11,000.00

Hemodialysis

4,000.00

Hysterectomy

30,000.00

10

Cataract Package

16,000.00

(Birthing Homes, PCF, Levels 1-3 Hospitals)

3. Catastrophic Benefits (Z Benefits)

1. Acute Lymphocytic / Lymphoblastic Leukemia
(standard risk)

210,000

2. Breast Cancer (stage 0 to IIIA)

100,000

3. Prostate Cancer (low to intermediate risk)

100,000

4.

End-state renal disease eligible for requiring

kidney transplantation (low risk)

5.

Coronary Artery Bypass Graft Surgery (standard

550,000
risk)

6.

Surgery for Tetralogy of Fallot in Children

(Blue Baby Syndrome)

600,000

320,000

Catastrophic Benefits (Z Benefits)

7.

Surgery for Ventricular Septal Defect in Children

8. Cervical Cancer:
Chemoradiation with Cobalt and Brachytherapy (low
dose) or Primary surgery for Stage IA1, IA2 IIA1
Chemoradiation with Linear Accelerator and
Brachytherapy (high dose)
9. Z MORPH (Mobility, Orthosis, Rehabilitation,
Prosthesis Help)
- first right and/or left below the knee
- both limbs
10. Selected Orthopedic Implants (See next slide)
11. End-Stage Renal Disease Requiring Peritoneal
Dialysis

250,000
120,000
175,000

15,000
30,000

270,000

Selected Orthopedic Implants

IMPLANTS

Rates per side

(left or right)

Total Hip Prosthesis , cemented*

105,000

Total Hip Prosthesis , cementless**

175,000

Partial Hip Prosthesis, bipolar

85,000

Multiple screw fixation (MSF)* **

65,000

Compression Hip Screw Set (CHS)

80,000

Proximal Femoral Locked Plate (PFLP)

80,000

Intramedullary Nail with Interlocking Screws

55,000

Locked Compression Plate (LCP) Broad/Metaphyseal/ Distal Femoral LC

55,000

Other Benefits

PhilHealth members and their

qualified dependents who are 50
years old and above may avail of
pneumococcal vaccine at a
discounted rate of P600.00
through any of the Vaccine
Access Points (VAPs)
NCR : Caloocan / Makati / Mandaluyong / Manila / Pasay / Quezon City / San Juan City / Muntinlupa
Luzon : Cavite / Laguna / Bataan / Batangas / Quezon / Bicol / Ilocos / Cagayan Valley / CAR
Visayas :

Bacolod / Iloilo/ Roxas / Leyte / Samar / Cebu

Mindanao: CARAGA / Central, Northern and Western Mindanao

Availment Conditions:

Members and their dependents are entitled to avail of the benefits if:
Employed, Self-employed,
Professionals, Sea-based OFWs,
Voluntary

Land-based OFWs

Paid at least 3 months premium

contributions within immediate 6 months
prior to the first day of confinement
Within the validity period of premium
payments
Within validity period of membership

Sponsored/Indigent
Automatic PhilHealth coverage
Senior Citizens
(not gainfully employed)
Lifetime coverage
Lifetime

NBB

No Balance Billing
(NBB) Policy
PhilHealth Circular No. 3 s-2014

For members and dependents of the following

categories of membership:
a)
b)
c)
d)

Indigent
Sponsored
Household Help
iGroup Gold members with existing Group
Policy Contract (GPC)

* Confined in government health care institutions

Benefit Payment
January 1 to June 30, 2015

Sector
Government
Private

Amount of
PhilHealth Benefit % to Total
(in million pesos)

4,041.72
8,823.69

9%
20%

Informal Economy
OFW
NHTS/Sponsored
Lifetime Members

9,400.37
659.09
13,192.36
8,325.43

21%
1%
30%
19%

Total

44,442.66

100%

Source: Financial Statements

Kalusugan Natin, SEGURADO

Accredited Health Care Institutions
(as of June 30, 2015)

Hospitals: 1,145

MCP providers: 2,381

Specialized outpatient clinics

Animal bite treatment centers: 235
-Primary care facilities: 690
-Ambulatory surgical clinics: 130
Outpatient malaria package
-Free-standing dialysis clinics: 176 providers: 135
PCB1 providers: 2,253

Outpatient HIV treatment hubs: 19

TB DOTS providers: 1,546

Vaccine access points: 110

Kalusugan Natin, SEGURADO

Accredited Health Care Providers
(as of June 30, 2015)

Contracted for Z Benefit Packages:

-Breast CA: 20
-Prostate CA: 14
-Kidney transplant: 6
-Acute Lymphocytic Leukemia: 13
-Coronary Artery Bypass Graft: 4
-Tetralogy of Fallot: 2
-Ventricular Septal Defect: 2
-Cervical CA: in process

Kalusugan Natin, SEGURADO

Accredited Health Care Professionals
(as of June 30, 2015)

General Practitioners: 15,304

Medical Specialists: 16,725
Dentists: 386
Midwives: 2,205
TOTAL: 34,620

The PhilHealth Organization

17

REGIONAL
OFFICES
LOCAL
OFFICES

59

120

PHILHEALTH
EXPRESS

6,400

OFFICERS

STAFF

FILIPINOS

100,000,000

Registration of Employers
Employers need not present
documents when the register via
the Philippine Business Registry
(PBR).
Should they be unable to
register via the PBR, the
Corporation shall require
documentary requirements.
(Section 13)

PhilHealth as a Pre-Requisite
(Section 34)
The law mandates national agencies and LGUs to require proof
of PhilHealth membership before doing business or issuing
professional or business license or permit.
However, before the end of 2014, all employers, owners or
operators of business establishments with no record of
remittance deficiency shall no longer be required to submit a
certificate or proof of payment of PhilHealth premium
contributions as a documentary requirement in renewing their
business permits/licenses and securing a Mayors Permit.
(MOA with DILG)

Visitorial Powers
Any representative of the Corporation as duly
authorized by the President and CEO or by the
concerned Regional Vice President shall have the power
to visit, enter and inspect facilities of health care
providers and employers during office hours, unless
there is reason to believe that inspection has to be
beyond office hours
And where applicable, secure copies of their medical,
financial, and other records and data pertinent to the
claims, accreditation, premium contribution and that of
their patient or employees, who are members of the
Program.
(Section 221)

Obligations of the Employer:

Register with PhilHealth
Provide updates as to correction/change of
business name, temporary suspension/resumption
of operation, termination/dissolution, change of
ownership, closure
Register their employees and their qualified
dependents

Obligations of the Employer:

Report to the Corporation newly-hired and
separated employees
Timely and correct payment of premium remittance
Timely/regular submission of reports
Keep true and accurate work records

PhilHealth
Updates

PhilHealth Circulars (Formal Economy)

(PhilHealth Circular No. 010-2015) SEC-IBR PostRegistration Guidelines in PhilHealth
(PhilHealth Circular No. 009-2015 and PhilHealth Advisory
06-02-2015) Mandatory Payment of Premium Contributions of
Employers and Employees in PhilHealth Accredited Collecting
Agents
(PhilHealth Circular No. 004-2015) Payment and Reporting of
Premium Contributions of Employers and Employees
(PhilHealth Circular No. 003-2015) Recovery of Payments for
Properly Filed Claims by Employed Members but without
Qualifying Contributions

PhilHealth Circulars (Formal Economy)

(PhilHealth Circular No. 0005 s.2014) Issuance and
Voluntary Availment of the Health Insurance Cards by the
Member of the Formal Economy
(PhilHealth Circular No. 0001 s. 2014) New Payment
Schedule for Premium Contributions
(PhilHealth Circular No. 027 s. 2013) on the CY 2014
Premium Contribution

Issuance and Voluntary Availment of the

Health Insurance Cards by the Member of
the Formal Economy

Online Services

http://www.philhealth.gov.ph

Member Inquiry

Search Case Rates

Online Services
http://www.philhealth.gov.ph/services/

Thank you!
Website
Facebook
Twitter
E-mail
YouTube
Healthlines

:
:
:
:
:
:

www.philhealth.gov.ph
www.facebook.com/PhilHealth
@teamphilhealth
actioncenter@philhealth.gov.ph
www.youtube.com/teamphilhealth
(02) 441-7442