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Philippine Health Insurance

BY: GROUP 3 BMLS 2I

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What is PhilHealth?

PhilHealth is a government owned &

controlled corporation. It is a national health

insurance program aiming to provide

affordable health care for the population with

site location, service and contact information.

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History of PhilHealth: THE call to serve the rural indigents echoed since

the early '60s when the Philippine MedicalAssociation introduced the MARIA Project whichprioritized aid to communities in need of medical

assistance. The Project would then be considereda valuable precursor to the Medicare program,from which a medical care plan for the entirePhilippines was created. On August 4, 1969,

Republic Act 6111 or the Philippine Medical CareAct of 1969 was signed by President Ferdinand E.Marcos which was eventually implemented inAugust 1971.

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History of PhilHealth: The Philippine Medical Care Commission (PMCC) was tasked to

oversee the implementation of the program which went for almosta quarter of a century.

In the 1990s, a vision for a better, more responsive governmenthealth care program was prompted by the passage of several bills

that had significant implications on health financing. The public'sclamor for a health insurance that is more comprehensive in termsof covered population and benefits led to the development ofHouse Bill 14225 and Senate Bill 01738 which became "TheNational Health Insurance Act of 1995" or Republic Act 7875, signedby President Fidel V. Ramos on February 14, 1995. The law paved

the way for the creation of the Philippine Health InsuranceCorporation (PhilHealth), mandated to provide social healthinsurance coverage to all Filipinos in 15 years' time.

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History of PhilHealth: PhilHealth assumed the responsibility of

administering the former Medicare program

for government and private sector employees

from the Government Service Insurance

System in October 1997, from the Social

Security System in April 1998, and from the

Overseas Workers Welfare Administration inMarch 2005.

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Who are covered by the PhilHealth?

Overseas Worker

Employed

Individually Paying

Sponsored

Lifetime

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Registration procedures, documentary and premium requirements for OFW:

Submit duly accomplished PhilHealth Membership RegistrationForm together with applicable documents for each qualifieddependent declared.

Also submit any of the following documents as proof of being anactive OFW:

Valid Overseas Employment Certificate (OEC) or E-receipt Valid overseas employment contract or certificate of

employment

Valid re-entry visa

Valid job contract

Pay the one-year premium ofPhp 900. For your convenience,premium payments covering the entire contract (equivalent to thenumber of years provided for in your contract) is highly encouraged.

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The following are automatically become PhilHealth members under theEmployed Sector Program as mandated by law:

Government Sector

Private Sector

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Registration procedures and documentary requirements for employed:

For newly hired employees without PIN yet:(Also applicable to existing employees similarlywithout PIN)

Fill out PhilHealth Membership Registration Form

Attach clear copy of supporting documents for qualifieddependents declared

Submit to the HR Department for them to forward theabove documents to PhilHealth together with Er2 Form

(Report of Employee-Members). After processing, PhilHealth will send the member,

through the employer, his/her PhilHealth IdentificationNumber or PIN and a copy of the Member Data Record

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Registration procedures and documentary requirements for employed: For newly hired employees with PIN already:

Report to your employer your PIN for them to

indicate the same in their Er2

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Registration procedures and documentary requirements for individually paying:

Fill out PhilHealth Membership Registration Form

Attach clear copy of supporting documents for

qualified dependents to be declared

Registrant will be issued his/her PhilHealth

Identification Number or PIN and the Member

Data Record or MDR and shall be asked to pay the

required premiums to the PhilHealth Cashier orat any of PhilHealth's accredited collecting banks

http://www.philhealth.gov.ph/forms/membership/pmrf.pdfhttp://www.philhealth.gov.ph/forms/membership/pmrf.pdf

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Premium Requirements:

Individually Paying Members (IPMs) earning an

average monthly income of P25,000 and below

pay P300 quarterly or P1,200 per year, while thoseearning above P25,000 pay P600 quarterly or

P2,400 per year. Premium contributions may be

paid quarterly, semi-annually and annually.

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Schedule of payment:

QUARTERLY: Pay until the last working day of the quarter being paid for.

Example:Period: January to MarchDeadline: March 31

SEMI-ANNUAL: Pay until the last working day of the first quarter of thesemester being paid for.

Example:Period: January to JuneDeadline: March 31

ANNUAL: Pay until the last working day of the first quarter of the year beingpaid for.

Example:Period: January to DecemberDeadline: March 31

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Premium Contribution Schedule for theEmployed Sector

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*Employee share represents half of the total monthly premium while the other half is

shouldered by the employer.

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What are the Benefits?

Inpatient coverage:

PhilHealth provides subsidy for room and board,

drugs and medicines, laboratories, operating room

and professional fees for confinements of not less

than 24 hours.

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What are the Benefits?

Outpatient coverage:

Day surgeries, dialysis and cancer treatment

procedures such as chemotheraphy and

radiotheraphy in accredited hospitals and free-

standing clinics.

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Special benefit packages:

Coverage for up to the fourth normal delivery

Newborn Care Package

TB treatment through DOTS

SARS and Avian Influenza Package

Influenza A (H1N1) Package

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Availment conditions and procedures:

Availment conditions The following must first be met to avail of your

PhilHealth benefits:

Payment of at least three monthly premiums within

the immediate six months prior to confinement. Confinement in an accredited hospital for at least 24

hours (except when availing of outpatient care andspecial packages) due to an illness or diseaserequiring hospitalization. Attending physicians must

also be PhilHealth-accredited. Availment is within the 45 days allowance for room

and board.

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Availment conditions and procedures:

Benefit availment procedures For outright/automatic deduction of benefits:

Submit to the billing section the following prior to discharge from the hospital:

Duly accomplished PhilHealth Claim Form 1 (original)

Clear copy of Member Data Record (MDR).

If dependent - patient is not listed yet in the MDR, submit applicable proof ofdependency.

Agree with your attending physicians on how much is left to be paidfor their services over the professional fee (PF) benefit.

Upon submission of all applicable documents, the billing section will

compute and deduct your benefits from your total hospital bill.

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Availment conditions and procedures: For direct filing/reimbursement:

Submit the following to PhilHealth or through the

hospital in addition to the documents mentioned

earlier within 60 calendar days after discharge:

PhilHealth Claim Form 2 (to be filled up by the

hospital and attending physicians)

Official receipts or hospital and doctor's waiver Operative record for surgical procedures

performed

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Availment conditions and procedures: For confinements abroad:

Submit the following within 180 days afterdischarge. Overseas confinements shall be paid basedon Level 3 hospital benefit rates.

PhilHealth Claim Form 1

MDR or supporting documents

Original official receipt or detailed statement ofaccount (written in English)

Medical certificate (written in English) indicating thefinal diagnosis, confinement period and servicesrendered.

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thank you!!!