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Banzuela PhilHealth Handout 2014
Banzuela PhilHealth Handout 2014
I. PERTINENT LAWS 1, 2
Republic Act 7875
Known as the National Health Insurance Act of 1995 or "An Act Instituting a National Health
Insurance Program For All Filipinos and Establishing the Philippine Health Insurance Corporation
For the Purpose"
Approved on February 14, 1995 by Pres. Fidel Ramos
Republic Act 9241
An Act amending RA 7875
Republic Act 10606
An Act further amending RA 7875
Section 11, Article XIII of the 1987 Constitution of the Republic of the Philippines
"The State shall adopt an integrated and comprehensive approach to health development which shall
endeavor to make essential goods, health and other social services available to all the people at
affordable cost. Priority for the needs of the underprivileged, sick, elderly, disabled, women and
other children shall be recognized. Likewise, it shall be the policy of the State to provide free medical
care to paupers."
Dr.Banzuela: memorize the numbers 7875, 9241, 10606. The NHI Act of 1995 is one of the most important laws Congress
has ever passed no kidding.
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In 1963, DOH secretary Francisco Quimson Duque, the father of the current DOH secretary, proposed
the National Health Service of the Philippines under the administration of President Diosdado
Macapagal
RA 6111 or the Philippine Medical Care Act was signed into law by President Ferdinand Marcos in
1969
Medicare Program Phase I was started in 1972. Target beneficiaries were SSS/GSIS members
Medicare Program Phase II was started in 1983. Target beneficiaries were low-income and nonsalary based populations not covered by Phase I. Tie-ups with LGUs and HMOs was done
In the early 1990s, The Health Finance Development Project (HFDP) a DOH project funded by USAIDMSH conducted several studies regarding social health insurance and was crucial in the creation of
PhilHealth
RA 7875 was signed into law on February 14, 1995
GSIS and SSS transfers the Medicare Program to PhilHealth in 1997
Abra was the first province in the country to adopt the Indigent Program, October 1, 1997
Decentralization of claims processing starts in Region VI, March 1999
Launching of the Individually Paying Program for the Informal Sector, October 1, 1999
Launching of the first OPD Package in Laguna and Capitation as provider payment scheme, July 2000
Introduction of Dialysis Package and OPD AntiTB/DOTS Benefits Package, April 1, 2003
Maternity Care Package for SVD and SARS package, May 1, 2003
For 2014, 14.7 million families are being enrolled through full National Government subsidy. The
provision of full National Government subsidy was made possible by an amendment introduced in
RA 10606 enacted into law in 2013.
PhilHealth and Kasambahay Law (Philhealth IRR 2013) based on RA 10361 passed Jan 18, 2013:
SECTION 21. Obligations of the Employer of Household Help or Kasambahay
To ensure that PhilHealth membership of the household help or kasambahay is sustained, employers
are required to:
a. Register their kasambahay with the Corporation and the kasambahays qualified dependents
under their PIN;
b. Report to the Corporation their kasambahay within thirty (30) calendar days upon
employment; and,
c. Give notice to the Corporation upon separation of the kasambahay and pay the corresponding
PhilHealth Premium contributions for the rendered services until the date of separation.
Employers of household-help who have registered with the SSS prior to July 1, 1999, are considered
automatically registered. They shall be required to update their records with the Corporation.
SECTION 22. Premium Payment of Household Help
The annual premium contributions of household helps shall be fully paid in accordance with the
provisions of Republic Act No. 10361 or the Kasambahay Law.
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2.
Capitation - a payment mechanism where a fixed rate, whether per person, family, household or
group is negotiated with the health care provider who shall be responsible for delivering or
arranging the delivery of health services required by the covered person under the conditions of a
health provider contract.
Fee-for-Service a fee pre-determined by Philhealth for each service delivered by a health care
proverider based on the bill. The payment ystem shall be based on a pre-negotiated schedule
promulgated by the Corporation.
3.
Case payment a health care payment system in which health care providers are given a fixed
amount for every specific case diagnosed. E.g. in PhilHealths DOTS package, a physician is given
P4,000/patient to cover for the patients drugs, his consultation fee and additional laboratory exams
needed.
4.
5.
Premium Contribution the amount paid by or in behalf of a member to the PhilHealth program for
coverage, based on salaries/wages in the case of formal sector employees, and on household
earnings and assets in the case of self-employed, or on other criteria as maybe defined by PhilHealth
in accordance with the guiding principles of Act I of RA 7875
6.
Dr.Banzuela: memorize who the legal dependents are. Remember that queridas are not covered by PhilHealth, but mga
anak sa labas are as long as they are below 21 years of age. If the children are physically/mentally handicapped, they are
still considered dependents even if they are more than 21 years of age. Note that parents greater than 60 years old or with
permanent disabilities are considered dependents also.
8.
a.
A health care institution, which is duly licensed and/or accredited, devoted primarily to the
[email protected]
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maintenance and operation of facilities for health promotion, prevention, diagnosis, treatment and
care of individuals suffering from illness, disease, injury, disability or deformity, drug addiction or in
need of obstetrical or other medical and nursing care. It shall also be construed as any institution,
building or place where there are installed beds, cribs or bassinets for twenty-four (24) hour use or
longer by patients in the treatment of disease, injuries, deformities or abnormal physical and mental
states, maternity cases or sanitarial care; or infirmaries, nurseries, dispensaries, rehabilitation
centers and such other similar names by which they may be designated; or,
b.
A health care professional, who is any doctor of medicine, nurse, midwife, dentist, pharmacist or
other health care professional or practitioner duly licensed to practice in the Philippines and
accredited by the Corporation; or,
c.
A health maintenance organization (HMO), which is an entity that provides, offers or arranges for
coverage of designated health services needed by plan members for a fixed pre-paid premium; or,
d.
9.
Indigent - a person who has no visible means of income, or whose income is insufficient for family
subsistence, as identified by the DSWD based on specific criteria set for this purpose in accordance
with the guiding principles set forth in Article I of the Act.
10. Philippine National Formulary - the essential drugs list of the Philippines which is prepared by the
Department of Health (DOH) in consultation with experts and specialists from organized professional
medical societies, the academe and the pharmaceutical industry and which is updated regularly.
Dr.Banzuela: Remember that only the drugs in the PNF are PhilHealth reimbursable drugs.
8. Preferred Health Care Institution - is a recognition conferred to a health facility that has been granted
advanced participation for beyond compliance with PhilHealth policies, demonstrated higher
financial risk protection, excellent quality of care and better service satisfaction to its
clients/patients.
9. Public Health Services the Government shall be responsible for providing public health services for
all groups such as women, children, indigenous, people, displaced communities and communities in
environmentally endangered areas, while the NHIP shall focus on the provision of personal health
services. Preventive and promotive health services are essential for reducing the need and spending
for personal health service.
10. Means Test A protocol administered at the barangay level to determine the ability of individuals
or households to pay varying levels of contributions to the Program, ranging from the indigent in the
community whose contributions should be totally subsidized by government, to those who can afford
to subsidize part but not all the required contributions for the Program.
11. Single Period of Confinement a series or successive confinements for the SAME illness/injuries not
separated from each other by more than 90 days. PhilHealth gives a member/dependent a 45-day
allowance, after which it would not pay anymore.
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The purpose of PhilHealth is to ensure the provision of affordable, available and accessible health
care services for ALL citizens of the Philippines.
PhilHealths goal is universal coverage or KALUSUGAN PANGKAHALATAAN (defined as 85% of the
Philippine population)
Dr.Banzuela: Its impossible to cover 100% of the Philippine population; so PhilHealth has defined universal coverage at
85%. In 2004, PhilHealth claims the coverage is 81% already due to extensive enrolment of people in the Indigent program
using the giveaway PhilHealth cards. (though these PhilHealth cards expired after one year their premium contributions
have to be shouldered by the Local Government Units or they must enroll in the Individually-Paying Program to continue
receiving PhilHealth benefits) As of 2013, coverage was pegged at 79%.
end goal of Bawat Pilipino, Miyembro, Bawat Miyembro, Protektado, Kalusugan Natin Segurado
all families in the DSWDs National Household Targeting System for Poverty Reduction (NHTS-PR)
are covered by PhilHealth (Philhealth IRR 2013)
Limited to paying for the utilization of health services by the covered beneficiaries or to purchasing
health services in behalf of the beneficiaries
Prohibited from:
1. Providing health care directly
2. Buying and dispensing drugs and pharmaceuticals
3. Employing physicians and other professionals for the purpose of directly rendering care
4. Owning or investing in health care facilities
Dr Banzuela: PhilHealth is not allowed to engage in public health, only personal health services. Repeat, only personal
health services. Most of its money goes to a reserve fund.
Exempted from paying corporate taxes because it is a government owned and controlled corporation
(GOCC)
Can sue and be sued in court
Has quasi-judicial powers can issue subpoenas, investigate, and decide upon complaints.
PhilHealth is NOT bound by the technical rules of evidence.
All government and private EMPLOYERS are required to register their employees with PhilHealth
within 30 days after hiring them.
Members and their dependents are eligible for confinements outside the country provided the
following are submitted within 180 days after discharge: official receipt from the health care
institution and certification of the attending physician as to the final diagnosis, period of confinement
and services rendered.
Sec.54 of RA 9241 Oversight Provision Congress shall conduct a regular review of the National
Health Insurance Program which shall entail a systematic evaluation of the Programs performance,
impact or accomplishments with respect to its objectives or goals. Such review shall be undertaken
by the Committees of the Senate and the House of Representatives which have legislative jurisdiction
over the Program. The National Economic and Development Authority, in coordination with the
National Statistics Office and the National Institutes of Health of the University of the Philippines
shall undertake studies to validate the accomplishments of the program. The budget required to
undertake such study shall come from the income of PhilHealth.
Dr Banzuela: The PhilHealth Research Study Group, with Dr.Jimmy Galvez-Tan and Dr. Ramon Paterno as its leaders, was
created at the National Institutes of Health to fulfill this Oversight Provision, in partnership with NEDA and NSO. NEDA is the
head agency. The validation framework, performance indicators and research agenda have been identified by the
interagency body and research is currently being conducted to validate PhilHealths performance.
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The National Health Insurance Fund, the money PhilHealth is working with, has 3 components:
o Basic benefit funds
o Supplementary benefit funds
o Reserve funds
Basic benefit funds shall finance the basic minimum package to be enjoyed by ALL members. The
National Government and the Local Government Unit pays for the premium contributions of
indigents. For non-indigents, premium prices for specific population shall be actuarially determined
based on a.) Variations in risk b.) Capacity to pay and c.) Projected costs of services utilized
Supplementary benefit funds shall finance the extension and availment of ADDITIONAL BENEFITS
not included in the basic minimum benefit package BUT approved by the Board. However, in
accordance with the principles of equity and social solidarity, after 5 years, such funds shall be
merged into the basic benefit fund.
Reserve funds is a portion of PhilHealths accumulated revenues not intended to meet the cost of the
current years expenditures; it shall not exceed a ceiling equivalent to the amount actuarially
estimated for two years of projected program expenditures. The funds are to be invested in interestbearing bonds, securities, deposits/loans/securities to any domestic bank and stocks of corporations.
Total Annual of PhilHealth shall not exceed SUM TOTAL of 4% of the total premium contributions
during the immediately preceding year, 5% of total reimbursements and 5% of investment earnings
generated during the immediately preceding year.
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VII. MEMBERSHIP 3, 6
Initial members of the program in 1995
1. SSS/GSIS members, retirees, pensioners and their dependents under Medicare Program I
2. Those enrolled in local government unit sponsored health insurance plans (who are mostly indigents
and lowly-paid workers) under the Medicare Program II
3. Members of other government-initiated health insurance programs, community based health care
organizations, cooperatives or private non-profit health insurance plans who are subsequently
accredited by PhilHealth
Current Members are classified as follows:
1. Paying Members
a. Government employee
b. Private Sector employee including househelps and sea-based OFWs
c. Individually-Paying Member including land-based OFWs
2. Indigent Member
3. Privately-Sponsored Member
4. Lifetime Member/Covered Member (those who have reached the age of retirement and has made at
least 120 monthly contributions). This will include but is not limited to retirees of government
sector, private sector and uniformed members of the AFP, PNP, BMJP, BFP
Requirements for Membership Registration (any of the following)
1. Birth Certificate
2. Baptismal Certificate
3. GSIS/SSS Members ID
4. Passport
5. Any other valid ID/document acceptable to the Corporation
Requirements for Declaration of Dependents
1. Marriage Contract/Marriage Certificate
2. Birth/Baptismal Certificate
3. Court Order on Adoption
4. Birth/baptismal certificate of the member and dependent parents
5. Marriage Contract of the parent and stepfather/stepmother and birth certificate of the dependent
stepchildren
6. Joint affidavit of two disinterested persons and other relevant information (date of birth, etc.)
attesting to the fact of the relationship of the dependents to the supposed members except
declaration of spouse
7. Certificate from the DSWD or Punong Barangay attesting to the fact of the relationship of the
dependents to the supposed members
8. Any other valid ID or document acceptable to the Corporation
Requirements for Registration of Employers (together with their business permit/license to operate)
1. For single proprietorships DTI registration
2. For partnerships and corporations SEC registration
3. For foundation and other non-profit organizations SEC registration
4. For cooperatives Cooperative Development Authority (CDA) registration
[email protected]
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5.
VIII. ACCREDITATION 3
Accreditation for Health Care Institutions
1. Health care institution must be operating for at least the past three years. This 3 year requirement is
waved if:
a. Managing health care professional has had working experience in another accredited health
care institution for at least 3 years OR a graduate of hospital adminitration or any related
degree
b. Operates as a tertiary facility
c. Operates in a LGU where the accredited health care provider cannot adequately or fully
service its population
d. Service capability is not currently available in the LGU
2. Adequate quality human resources, equipment and physical structure
3. Licensed/Certified by the DOH as applicable
4. Comply with provisions of perfomance commitment. They must have their own ongoing formal
program of quality assurance that satisfy PhilHealths standards
Accreditation Requirements for Physicians, Dentists, Nurses, Midwives, Pharmacists and other
Licensed Health Care Professionals
1.
2.
3.
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The following are NOT included in the benefit package unless PhilHealth recommends otherwise after
actuarial studies:
1. non-prescription drugs and devices
2. drug/alcohol abuse or dependency treatment
3. cosmetic surgery
4. optometric services
5. fifth and subsequent normal obstetrical delivery
6. cost ineffective procedures which shall be defined by PhilHealth
Note: in RA 7875, normal obstetrical deliveries, out-patient psychotherapy and counseling for mental
disorders and home & rehabilitation services used to be part of excluded personal health services. After RA
9241 amended RA 7875, PhilHealth could now include these services in the minimum basic package.
The following are entitled to the above-mentioned benefits:
1. A member who has paid 3 months worth of premium contributions within 6 months before his
availment of the benefits OR paid in full the required premium for the year. He should have a
PhilHealth ID and he should NOT be currently subject to legal penalties by PhilHealth
2. SSS/GSIS retirees and pensioners prior to March 4, 1995
3. PhilHealth Members who have reached the age of retirement and have made at least 120 monthly
contributions.
4. Enrolled indigents
Special Benefit Package
1. Case Rates
2. TB Treatment through DOTS
3. SARS and Avian Influenza
4. Novel Influeza A (H1N1)
Case Rates
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http://www.philhealth.gov.ph/members/special_package/case_rates.htm
http://www.philhealth.gov.ph/members/special_package/tbdots_benefits.htm
Page 10 of 17
The amount of premium contribution shall NOT exceed 5% of the members respective monthly
salaries to be shared equally by the employer and employee. The members monthly contribution
shall be automatically deducted by the employer from the formers salary, wage or earnings.
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http://www.philhealth.gov.ph/news/updates/2014/citizens_charter_2013_revised.pdf
http://www.philhealth.gov.ph/news/updates/2014/citizens_charter_2013_revised.pdf
2.
3.
4.
Members of the informal economy from the lower income segment who do not qualify for full
subsidy under the means test rule of the DSWD shall be subsidized by the LGUs or through cost
sharing mechanisms between/among LGUs, and/or legislative sponsors, and/orother sponsors
and/or the member, including the National Government.
The premium contributions of orphans, abandoned and abused minors, out-of-school youths,
street children, persons with disability (PWD), senior citizens and battered women under the
care of the DSWD, or any of its accredited institutions run by NGOs or any nonprofit private
organizations, shall be paid by the DSWD and the funds necessary for their inclusion in the Program
shall be included in the annual budget of the DSWD;
The needed premium contributions of all barangay health workers, nutrition scholars, barangay
tanods, and other barangay workers and volunteers shall be fully borne by the LGUs concerned;
The annual required premium for the coverage of un-enrolled women who are about to give birth
shall be fully borne by the National Government and/or LGUs and/or legislative sponsors or the
DSWD if such woman is an indigent as determined by it through the means test. (PhilHealth IRR)
*the female spouse identified by the DSWD which is considered the primary member for indigent families
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Administrative Penalties
Penalties for PhilHealth member fraudulently claiming benefits: Fine between P5,000-P10,000 and/or
supension for 3-6 months.
Penalties for employer who does not deduct and remit contribution: not less than P5,000 x number of
employees involved
XIII. STATISTICS AS OF DECEMBE 31 20139
http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
Page 14 of 17
http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
REGISTERED MEMBERS:
Private: 33%
Sponsored Program - 31%
IPP (Individually Paying Program): 17%
OWP (Overseas Workers Program): 10%
Lifetime: 2%
ACCREDITATION (HOSPITAL TYPE)
Private (1052 Institutional Health Care Providers): 60%
Government (1053 Institutional Health Care Providers): 40%
9 out of 10 DOH-licensed hospitals are accredited by PhilHealth
http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
Page 15 of 17
http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
Sponsored Program (Number of Claims Paids) Jan 1- Dec 31, 2013
Case Rates: 62%
Fee for Service: 38%
No Billing Balance: 30%
Not NBB: 70%
Support Value
Support Value: 54%
Out of Pocket: 46%
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XIV. SOURCES
1.
2.
3.
4.
5.
RA 7875
RA 9241 and 10606
PhilHealth Implementing Rules and Regulation 2013
The PhilHealth Chronicles
You and your Medicare Benefits A Primer on the Most Commonly Asked Questions on the National
Health Insurance Program
6. PhilHealth Website
7. PhilHealth Annual Reports 1996-2004
8. PhilHealth Stats and Charts 1996-2004
9. http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
10. http://www.philhealth.gov.ph/news/updates/2014/citizens_charter_2013_revised.pdf
11. http://www.philhealth.gov.ph/members/special_package/case_rates.htm
To My Dear Students:
You are destined to become Doctors.
Have faith.
See you at the oathtaking!
From Broli, Bogie, and Rocky =)
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