PhilHealth Programs and Benefits

Alexander A. PadillaPresident and CEO

Philippine Health Insurance Corporation13 August 2015

Employers Confederation of the Philippines (ECOP)

1. Creation of NHIP/PhilHealth2. PhilHealth’s Vision and Mission3. Membership4. Premium Contribution5. Benefits6. PhilHealth Organization

Outline of Presentation

PHILHEALTH @ 20

Created through Republic Act 7875 on Feb. 14, 1995

As amended by R.A. 9241 and R.A. 10606

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

M A N D A T E

§ Single Fund/Single Payor

§ Draws inspiration from concept of ‘bayanihan’

§ Coverage of about 88 percent of population

§ GOCC

§ Offshoot of Medicare

About PHILHEALTH

Vision and Mission

FormalEconomy

Indigent Members

Informal Economy

LifetimeMembers

SponsoredMembers

Bawat Pilipino MIYEMBRO

Senior Citizens

Dependent: Children • 20 years old and below• unmarried & unemployed• legitimate, illegitimate• adopted, stepchildren• foster child

Legal Dependents

Dependent: Legal Spouse• Who is not yet a member

Dependent: Disabled Child• 21 years old and above with total disability (congenital/acquired)

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

Covered Members and Dependentsas of June 30, 2015

Members Dependents Beneficiaries

13,368,671 14,204,553 27,573,224 Private 11,326,505 10,377,566 21,704,071 Government 1,982,042 3,782,546 5,764,588

Household Help/Kasambahay 59,482 43,421 102,903

Enterprise Owner & Family Drivers 642 1,020 1,662

3,602,640 4,163,236 7,765,876 Migrant Worker 1,086,439 976,336 2,062,775 Informal Sector Workers 2,107,443 2,702,689 4,810,132 Self-Earning Individual 396,898 471,890 868,788 Organized Group and Others 11,860 12,321 24,181

15,288,583 30,118,509 45,407,092 489,730 647,921 1,137,651

4,813,460 1,068,411 5,881,871 955,850 696,157 1,652,007

38,518,934 50,898,786 89,417,720 TOTAL

Lifetime Members

Members in the Informal Economy

Sector

IndigentsSponsored Members

Members in the Formal Economy

Senior Citizens

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.

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

Registration

As a general rule, the Corporation will not require documentary requirements unless warranted

Premium Contribution Rates

Member Type Premium Rate Remarks

FormalEconomy:Employed

Not to exceed 5% of employee’s monthly salary(Current rate is 2.5%)

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 allmembership categories with Php2,400 as thelowest premium rate, in order to ensure financialsustainability and viability;

§ To sustain and further enhance the NHIP benefits ofmembers;

§ Transitory provisions were established to providemembers enough time to adjust to the newpremium 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 PhilHealthoffices 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

Range of PhilHealth Benefits:

Bawat MIYEMBRO, Protektado

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 -Php14,500–25,700

• 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

2 Dengue, Severe ₱16,000.00

3 Pneumonia Moderate Risk ₱15,000.00

4 Pneumonia High Risk ₱32,000.00

5 Hypertensive Emergency / Urgency ₱9,000.00

6 Stroke - Infarction ₱28,000.00

7 Stroke - Hemorrhagic ₱38,000.00

8 Acute Gastroenteritis ₱6,000.00

9 Asthma in Acute Exacerbation ₱9,000.0010 Typhoid Fever ₱10,000.00

Inpatient Benefits – Surgical (partial list only)

Surgical Procedures1 Radiotherapy Linac ₱3,000.002 Radiotherapy Cobalt ₱2,000.00

3Maternity Care Package (PCF, Birthing Homes) ₱8,000.00Normal Spontaneous Delivery Package ₱5,000.00(Levels 1-3 Hospitals)

4 Cesarean Section ₱19,000.005 Appendectomy ₱24,000.00

6 Newborn Care Package (Birthing Homes, PCF, Levels 1-3 Hospitals) ₱1,750.00

7 Dilatation & Curettage ₱11,000.008 Hemodialysis ₱4,000.009 Hysterectomy ₱30,000.00

10 Cataract Package ₱16,000.00

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) ₱600,000

5. Coronary Artery Bypass Graft Surgery (standard risk) ₱550,000

6. Surgery for Tetralogy of Fallot in Children(Blue Baby Syndrome)

₱320,000

Catastrophic Benefits (Z Benefits)

7. Surgery for Ventricular Septal Defect in Children ₱250,0008. 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)

₱120,000

₱175,000

9. Z MORPH (Mobility, Orthosis, Rehabilitation, Prosthesis Help)

- first right and/or left below the knee - both limbs

₱15,000₱30,000

10. Selected Orthopedic Implants (See next slide)

11. End-Stage Renal Disease Requiring Peritoneal Dialysis ₱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

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

Other Benefits

Availment Conditions:Members and their dependents are entitled to avail of the benefits if:

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

Automatic PhilHealth coverage

Lifetime coverage

Employed, Self-employed, Professionals, Sea-based OFWs,

Voluntary

Land-based OFWs

Sponsored/Indigent

Senior Citizens(not gainfully employed)

Lifetime

No Balance Billing (NBB) Policy

PhilHealth Circular No. 3 s-2014

For members and dependents of the following categories of membership:

a) Indigentb) Sponsored c) Household Helpd) iGroup Gold members with existing Group

Policy Contract (GPC)

* Confined in government health care institutions

NBB

Benefit PaymentJanuary 1 to June 30, 2015

Sector Amount of

PhilHealth Benefit(in million pesos)

% to Total

Government 4,041.72 9%Private 8,823.69 20%

Informal Economy 9,400.37 21%OFW 659.09 1%

NHTS/Sponsored 13,192.36 30%Lifetime Members 8,325.43 19%

Total 44,442.66 100%Source: Financial Statements

Kalusugan Natin, SEGURADOAccredited Health Care Institutions(as of June 30, 2015)

Hospitals: 1,145

Specialized outpatient clinics-Primary care facilities: 690-Ambulatory surgical clinics: 130-Free-standing dialysis clinics: 176

PCB1 providers: 2,253

TB DOTS providers: 1,546

MCP providers: 2,381

Animal bite treatment centers: 235

Outpatient malaria package providers: 135

Outpatient HIV treatment hubs: 19

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

General Practitioners: 15,304

Medical Specialists: 16,725

Dentists: 386

Midwives: 2,205

TOTAL: 34,620

17 REGIONALO F F I C E S

120L O C A LOFFICES

6,400 OFFICERSS T A F F

100,000,000F I L I P I N O S

The PhilHealth Organization

59 PHILHEALTHEXPRESS

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)

Registration of Employers

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 Mayor’s Permit.

(MOA with DILG)

PhilHealth as a Pre-Requisite(Section 34)

§ Any representative of the Corporation as dulyauthorized by the President and CEO or by theconcerned Regional Vice President shall have the powerto visit, enter and inspect facilities of health careproviders and employers during office hours, unlessthere is reason to believe that inspection has to bebeyond office hours

§ And where applicable, secure copies of their medical,financial, and other records and data pertinent to theclaims, accreditation, premium contribution and that oftheir patient or employees, who are members of theProgram.

§ (Section 221)

Visitorial Powers

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

• 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

Obligations of the Employer:

PhilHealth Updates

PhilHealth Circulars (Formal Economy) •(PhilHealth Circular No. 010-2015) SEC-IBR Post-Registration 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 Serviceshttp://www.philhealth.gov.ph/services/

ÆWebsite : www.philhealth.gov.phÆFacebook : www.facebook.com/PhilHealthÆTwitter : @teamphilhealthÆE-mail : actioncenter@philhealth.gov.phÆYouTube : www.youtube.com/teamphilhealthÆHealthlines : (02) 441-7442

Thank you!