Phil Health Primer

8/12/2019 Phil Health Primer

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University Researcher, PhilHealth Research Study Group, UP Manila - National Institutes of Health

Dr Banzuelas PhilHealth Primerfor the Med Boards

by Enrico Paolo Chiong Banzuela, MDUP College of Medicine Class 2005Occupational Health SpecialistClinical Instructor, San Beda College of Medicine

I. PERTINENT LAWS 1, 2

Republic Act 7875

National Health Insurance Act of 1995 or "An Act Instituting a National Health InsuranceProgram For All Filipinos and Establishing the Philippine Health Insurance CorporationFor the Purpose"

Signed into law on February 14, 1995 by Pres. Fidel Ramos

Republic Act 9241 An Act 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 socialservices available to all the people at affordable cost. Priority for the needs of theunderprivileged, 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 and 9241. The NHI Act of 1995 is one of the most importantlaws Congress has ever passed no kidding.

II. HISTORY OF PHILHEALTH 4

In 1963, DOH secretary Francisco Quimson Duque, the father of the current DOH

secretary, proposed the formation of a National Health Service of the Philippines underthe administration of President Diosdado Macapagal

RA 6111 or the Philippine Medical Care Act was signed into law by President FerdinandMarcos in 1969

Medicare Program Phase I was started in 1972. Target beneficiaries were SSS/GSISmembers

Medicare Program Phase II was started in 1983. Target beneficiaries were low-incomeand non-salary based populations not covered by Phase I. Tie-ups with LGUs and HMOswere done

In the early 1990s, The Health Finance Development Project (HFDP) a DOH projectfunded by USAID-MSH conducted several studies regarding social health insurance andwas 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

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PhilHealths goal is universal coverage (defined as 85% of the Philippine population) bythe year 2010

Dr .Banzuela : Its impossible to cover 100% of the Philippine population; so PhilHealth has defineduniversal coverage as 85%. In 2004, PhilHealth claimed the coverage is 81% already due to extensiveenrolment of people in the Indigent program using the giveaway PhilHealth cards (though thesePhilHealth cards expired after one year their premium contributions have to be shouldered by theLocal Government Units or they must enroll in the Individually-Paying Program to continue receivingPhilHealth benefits)

Limited to paying for the utilization of health services by the covered beneficiaries orto purchasing health services in behalf of the beneficiaries

Prohibited from:1. Providing health care directly2. Buying and dispensing drugs and pharmaceuticals3. Employing physicians and other professionals for the purpose of directly

rendering care4. Owning or investing in health care facilities

Dr Banzuela: With P60 Billion to work with, (the DOH budget is around P10B only) 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 andcontrolled corporation

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 receiptfrom the health care institution and certification of the attending physician as to thefinal diagnosis, period of confinement and services rendered.

Sec.54 of RA 9241 Oversight Provision Congress shall conduct a regular review ofthe National Health Insurance Program which shall entail a systematic evaluation of thePrograms performance, impact or accomplishments with respect to its objectives orgoals. Such review shall be undertaken by the Committees of the Senate and the Houseof Representatives which have legislative jurisdiction over the Program. The NationalEconomic and Development Authority, in coordination with the National StatisticsOffice and the National Institutes of Health of the University of the Philippines shallundertake studies to validate the accomplishments of the program. The budgetrequired to undertake such study shall come from the income of PhilHealth.

V. PHILHEALTH BOARD OF DIRECTORS 3 All are appointed by the President of the Philippines Will each serve a 4-year term renewable for a maximum of two years except for

Cabinet secretaries Mandated to hold meetings at least once a month. Each would receive a per diem for

every meeting attended PhilHealth President/CEO qualifications:

o Filipino citizen with appropriate training and at least 5 years experience in thefiled of health care financing and corporate management

o Must NOT be involved in any health care institution as owner or member of itsboard



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National Health Insurance Programpine Health Insurance CorporationPhilip

EmployedIPP

SponsoredSector

NATIONAL HEALTHINSURANCE FUND INVESTMENT

FOREIGN GRANTSLOCAL GOVERNMENT

NATIONAL GOVERNMENT

VII. MEMBERSHIP3, 6

Initial members of the program in 1995

1. SSS/GSIS members, retirees, pensioners and their dependents under Medicare Program I2. Those enrolled in local government unit sponsored health insurance plans (who are

mostly indigents and lowly-paid workers) under the Medicare Program II3. Members of other government-initiated health insurance programs, community based

health care organizations, cooperatives or private non-profit health insurance planswho are subsequently accredited by PhilHealth

Current Members are classified as follows:1. Paying Members

a. Government employeeb. Private Sector employee including househelps and sea-based OFWsc. Individually-Paying Member including fishermen, farmers, businessmen,

professionals,(doctors, lawyers, etc.) land-based OFWs2. Indigent Member3. Privately-Sponsored Member4. Non-Paying Member or NPM (retiree-members of SSS/GSIS including personnel of AFP,

PNP, BFP and BJMP)

Dr .Banzuela : A doctor practicing in hospitals or clinics (even if hes a neurosurgeon earning P500,000 amonth) is considered an Individually-Paying Member and is required to pay a fixed premium contributionof only P100/monthly.

Requirements for Membership Registration (any of the following)1. Birth Certificate2. Baptismal Certificate3. GSIS/SSS Members ID4. Passport5. Any other valid ID/document acceptable to the Corporation

Requirements for Declaration of Dependents1. Marriage Contract/Marriage Certificate2. Birth/Baptismal Certificate



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3. Court Order on Adoption4. Birth/baptismal certificate of the member and dependent parents5. Marriage Contract of the parent and stepfather/stepmother and birth certificate of the

dependent stepchildren6. 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 supposedmembers except declaration of spouse

7. Certificate from the DSWD or Punong Barangay attesting to the fact of the relationshipof 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 tooperate)

1. For single proprietorships DTI registration2. For partnerships and corporations SEC registration3. For foundation and other non-profit organizations SEC registration4. For cooperatives Cooperative Development Authority (CDA) registration5. For backyard industries/ventures and micro-business enterprises Barangay

Certification and/or Mayors Permit

VIII. ACCREDITATION3 Requirements:

1. Health care institution must be operating for at least the past three years. This 3 yearrequirement is waved if:

a. Managing health care professional has had working experience in anotheraccredited health care institution for at least 3 years

b. Operates as a tertiary facilityc. Operates in a LGU where the accredited health care provider cannot

adequately or fully service its populationd. Other conditions set by the Corporation

2. Adequate quality human resources, equipment and physical structure3. All personnel must be members of the NHIP4. Physician must be registered members of PMA and/or its specialty organizations5. Health care providers must have their own ongoing formal program of quality assurance6. Must adopt all referral protocols, CPGs, payment mechanisms, health resource sharing

arrangements of the NHIP7. Must recognize and respect the rights of patients8. Must comply with all information system requirements set by the Corporation9. Must accept any and all corrective actions prescribed by the Corporation10. Must allow the Corporation to inspect and secure reproduction of certified true copies

of their medical and financial records and to visit, enter and inspect their respectivepremises and facilities

11. Must comply with all requirements and provisions of RA 7875 as amended by RA 9241

Additional Requirements for Hospitals1. Licensed by DOH2. Comply at all times with RA 4226 or The Hospital Licensure Act and its implementing

rules and regulations3. Must be a member of good standing of any national association of licensed hospitals in

the Philippines4. All secondary hospitals must establish a therapeutic committee and other committees

that will ensure rational drug use5. All tertiary hospital must establish therapeutics and infection control committees and

other committees that will ensure rational drug use



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Additional Requirements for HMOs and PPOs

1. Clearance to operate from DOH2. SEC registration3. Its lab, x-ray and diagnostic facilities must comply with the rules, regulations and

licensing requirements of DOH4. A Corporate HMO must be a member of good standing of any national association of

HMOs in the Philippines5. A Cooperative HMO must be a member of good standing of any regional or national

federation of cooperatives

Additional Requirements for CBHCOs1. Must be organized/owned/managed by an association of members of the community for

the purpose of improving the health status of the community through preventive,promotive and curative health services

2. SEC and/or CDA registered3. Its lab, x-ray and diagnostic facilities must comply with the rules, regulations and

licensing requirements of DOH

Additional Requirements for Physicians1. PRC license2. Must be PhilHealth members themselves3. Must submit certificate of good standing from respective national associations4. Must abide by the Code of Ethics as prescribed under Section 24, Paragraph 12 of the

Medical Act of 19595. Must comply with practice guidelines or protocols, peer review and payment

mechanisms of NHIP6. Must not charge over and above the professional fees provided by the NHIP for

members admitted to a PhilHealth bed7. Must comply with any other requirements set by the Corporation

Dr .Banzuela so basically, if you want to be accredited by PhilHealth as a health care provider, youneed three things: a PRC ID, membership in the Philippine Medical Association and PhilHealth

membership

IX. BENEFIT PACKAGE 2, 3, 5, 6

The Benefit package to be enjoyed by ALL members includes the following:

1. Inpatient hospital carea. Room and boardb. Services of health care professionalsc. Diagnostic, laboratory and other medical examination servicesd. Use of surgical or medical equipment and facilitiese. Prescription drugs and biologicals; subject to limitations stated in Section 37 of

RA 78752. Outpatient care

a.

Services of health care professionalsb. Diagnostic, laboratory and other medical examination servicesc. Personal preventive servicesd. Prescription drugs and biologicals, subject to limitations stated in Section 37 of

RA 78753. Health Education Packages4. Emergency and transfer services5. Other health care services that PhilHealth shall determine to be appropriate and cost-

effective



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The following are NOT included in the benefit package unless PhilHealth recommendsotherwise after actuarial studies:

1. non-prescription drugs and devices2. drug/alcohol abuse or dependency treatment3. cosmetic surgery4. optometric services5. fifth and subsequent normal obstetrical delivery6. cost ineffective procedures which shall be defined by PhilHealth

Note: in RA 7875, normal obstetrical deliveries, out-patient psychotherapy and counseling formental disorders and home & rehabilitation services used to be part of excluded personalhealth services. After RA 9241 amended RA 7875, PhilHealth could now include these servicesin the minimum basic package. PhilHealth currently pays up to 2 normal spontaneous vaginaldeliveries.

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. He should have a PhilHealth ID and he should NOTbe currently subject to legal penalties by PhilHealth

2. SSS/GSIS members more than 65 years old and have paid at least 120 monthlycontributions

3. Enrolled indigents

UNIFIED MEDICARE BENEFITS

For all Members and Dependents under the National Health Insurance Program

HOSPITAL CATEGORY BENEFITS

PRIMARY SECONDARY TERTIARY

ROOM AND BOARD

Not exceeding 45 days for eachmember & another 45 days to beshared by his dependents

200 300 400

DRUGS & MEDICINES

Per single period of confinement

a. Ordinaryb. Intensivec. Catastrophic

1,5002,500

0

1,7004,0008,000

3,0009,000

16,000

X-RAY, LAB, ETC.

Per single period of confinement

a. Ordinaryb. Intensivec. Catastrophic

350700

0

8502,0004,000

1,7004,000

14,000

PROFESSIONAL FEES Per single period of confinementshall not exceed:

P 150/day for General PractitionerP 250/day for Specialist

a. OrdinaryGeneral PractitionerSpecialist

6001,000

6001,000

6001,000

b. IntensiveGeneral Practitioner

9001,500

9001,500

9001,500



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Specialist

b. CatastrophicGeneral PractitionerSpecialist

9001,500

9001,500

9002,500

OTHERS

Operating Room a. RVU of 30 and belowb. RVU of 31 to 80c. RVU of 81 and above

38500

6701,1402,160

1,0601,3503,490

Surgeon Maximum of 16,000

Anesthesiologist Maximum of 5,000

Compensable Outpatient Services:

Ambulatory surgeries and procedures including dialysis,radiotherapy and chemotherapy

TB DOTS

Classification of Cases1. Catastrophic Cases

Illnesses or injuries such as cancer cases requiring chemotherapy and/orradiotherapy, meningitis, encephalitis, cirrhosis of the liver, myocardial infarction,cerebrovascular attack, rheumatic heart disease grade III, renal conditionsrequiring dialysis or transplant, massive hemorrhage

Surgical Procedures or multiple surgical procedures done in one sitting with totalRelative Unit Value of 20 and above such as coronary bypass, open heart surgery orneurosurgery

2. Intensive Cases All confinements in the ICY other than those classified as catastrophic

Other similar serious illnesses or injuries such as cancer, pneumonia, moderatelyand far advanced PTB including its complications, cardiovascular attack, diseases ofthe heart, COPD, liver disease, typhoid fever, H-fever, kidney disease, septicemia,diarrhea with severe dehydration, severe injuries, black water fever

Surgical procedure or multiple surgical procedures done in one sitting with a totalRelative Unit Value of 8-19.99

3. Ordinary Cases Illnesses/injuries other than those enumerated above shall be considered as

ordinary cases

X. PREMIUM CONTRIBUTIONS3, 6

The amount of premium contribution shall NOT exceed 3% of the members respectivemonthly salaries to be shared equally by the employer and employee. The membersmonthly contribution shall be automatically deducted by the employer from theformers salary, wage or earnings.

At present, ones premium contribution is 2.5% of the salary base (SB) divided equallyat 1.25% each for the employee and the employer. The salary cap is set at P25,000,above which ones monthly premium contribution remains the same, e.g. Onesmonthly contribution remains at a total of P625 even if ones salary is P25,000, P50,000or P500,000 a month.



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For the Formal/Employed Sector, the premium contribution is dependent upon ones salaryand is as follows:MonthlySalary

Bracket

Monthly SalaryRange

SalaryBase (SB)

TotalMonthly

Contribution

EmployeeShare (EeS)(Ees = 0.5 x

TMC)

Employer Share(ErS)

(Ers = 0.5 xTMC)

1 4,999.99 and Below 4,000.00 100.00 50.00 50.002 5,000.00 to

5,999.995,000.00 125.00 62.50 62.50

3 6,000.00 to6,999.99

6,000.00 150.00 75.00 75.00

4 7,000.00 to7,999.99

7,000.00 175.00 87.50 87.50

5 8,000.00 to8,999.99

8,000.00 200.00 100.00 100.00

6 9,000.00 to9,999.99

9,000.00 225.00 112.50 112.50

7 10,000.00 to10,999.99

10,000.00 250.00 125.00 125.00

8 11,000.00 to11,999.99

11,000.00 275.00 137.50 137.50

9 12,000.00 to12,999.99

12,000.00 300.00 150.00 150.00

10 13,000.00 to13,999.99

13,000.00 325.00 162.50 162.50

11 14,000.00 to14,999.99

14,000.00 350.00 175.00 175.00

12 15,000.00 to15,999.99

15,000.00 375.00 187.50 187.50

13 16,000.00 to16,999.99

16,000.00 400.00 200.00 200.00

14 17,000.00 to17,999.99

17,000.00 425.00 212.50 212.50

15 18,000.00 to18,999.99

18,000.00 450.00 225.00 225.00

16 19,999.99 to19,999.99

19,000.00 475.00 237.50 237.50

17 20,000.00 to20,999.99

20,000.00 500.00 250.00 250.00

18 21,000.00 to21,999.99

21,000.00 525.00 262.50 262.50

19 22,000.00 to22,999.99

22,000.00 550.00 275.00 275.00

20 23,000.00 to

23,999.99

23,000.00 575.00 287.50 287.50

21 24,000.00 to24,999.99

24,000.00 600.00 300.00 300.00

22 25,000.00 and up 25,000.00 625.00 312.50 312.50

For the Individually-Paying Members (Volunteers) the premium contribution is fixed atP100/month.

Premium Sharing Schedule for the Indigent Program



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City MunicipalityYear

1 st -6 th Class 1 st -3 rd Class 4 th -6 th Class1st year 90-102nd year 90-103rd year 85-15

4th

year 80-205 th year 75-256 th year 70-307 th year 65-358 th year 60-409 th year 55-4510 th year

50-50 50-50

50-50

XI. PAYMENT OF CLAIMS TO HEALTH CARE PROVIDERS3, 5, 6 Mechanisms:

1. Fee for service2. Capitation payment

3. Case Payment

Notes: All claims by doctors should be filed within 60 days from date of discharge of the

patient. Extension period of 60 days if there are natural calamites/other fortuitousevents.

Health care institutions MAY NOT charge for PhilHealth forms and processing fees PhilHealth would only pay for drugs included in the Philippine National Drug Formulary

(PNDF) Professional fees for services rendered by salaried health care providers may be

retained by the health care institution in which the services are rendered for poolingand distribution among health personnel. The manner of distributing the professionalfees is left to the discretion of the health care institution.

Dr . Banzuela: In charity hospitals like the PGH, the physicians fee is paid by PhilHealth. The feedoesnt go to the resident physician but is pooled into a PhilHealth Trust Fund.

Hospital confinements of less than 24 hours shall be compensated only if: The patient dies Patient is transferred to another health care institution Emergency cases

Claims in non-accredited health care institutions shall be compensated if it meets thefollowing conditions:

Health care institution has DOH license Emergency case Physical transfer/referral to accredited health care institution is impossible

Physicians must not charge over and above the professional fees provided by the NHIPfor members admitted to PhilHealth bed

XII. OFFENSES 3 Offenses of Institutional Health Care Providers (punishments includes a fine bet P10,000-P50,000, suspension of accreditation for 3 months or more and criminal liability)

1. Padding of claims2. Making claims for non-admitted patient3. Extending period of confinement



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4. Post-dating of claims5. Misrepresentation by furnishing false/incorrect information6. Filing of multiple claims7. Unjustified admission beyond accredited bed capacity8. Unauthorized operations beyond service capability (performing complex procedures in a

primary hospital)9. Fabrication/Possession of fabricated forms and supporting documents10. Other fraudulent acts

Offenses of Health Care Professionals (punishments includes a fine between P10,000-P50,000,suspension of accreditation for 6 months-3 years and criminal liability)

1. Misrepresentation by false/incorrect information2. Breach of warranties of accreditation3. Other violation whether willful or negligent

Offenses of Employers1. Failure/Refusal to deduct contributions2. Failure/Refusal to remit contributions3. Unlawful deductions4. Offenses committed by an institution(association, partnership, corporation, etc)

XIII. STATISTICS 7,8

Year Collection Benefit Payments Members +Dependents

Percentage ofthe Population

Covered2004 16,515,723,554.00 12,953,288,449.84 69,500,000 81%2003 13,151,720,380.00 10,956,629,035.002002 12,271,040,389.11 8,839,294,863.02 43,564,611 54.30%2001 11,068,892,896.18 7,740,168,979.49 37,460,401 48.10%2000 8,557,124,578.23 6,763,502,012.02 54%1999 5,400,000,000.00 4,217,691,182.25

1998 4,851,566,626.00 2,998,948,511.59 37,100,0001997 4,419,303,494.00 20,637,2781996 4,710,860,000.00 3433.08M 34,510,000 50%1995 4,359,170,000.00 2560395M

In 2004(Latest Stats) LGU participation: 68 out of 79 provinces, 113 out of 118 cities, 1,365 out of 1,492

municipalities 1,579 accredited facilities - 18 dialysis clinics, 71 Maternity Care Clinics, 29 DOTS

Centers Reserve Funds of P35,287,000,000

XIV. SOURCES

1. RA 78752. RA 91413. PhilHealth Implementing Rules and Regulation4. The PhilHealth Chronicles5. You and your Medicare Benefits A Primer on the Most Commonly Asked Questions on

the National Health Insurance Program6. PhilHealth Website7. PhilHealth Annual Reports 1996-20048. PhilHealth Stats and Charts 1996-2004



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XV. GREETINGS

To avoid the bad luck of having a 13-paged primer, I decided to add a greetings partto this primer. =)

Thank you, thank you, thank you very much to the following people : (in no particular order)To the very kind Buching Paterno, MD, MPH, our boss at the PhilHealth Research Study

Group at the UP-NIH.To my friends/co-workers/foodtrip partners at PRSG Dr.Kokoi Domingo, Dr.Valerie

Buenviaje-Cu and Ate Raquel Mijares.To Dr.Anthony Cordero who, despite being a member of a rival fraternity, was so kind

and compassionate as to help me land my first job here at PRSG. Malaki po utang na loob ko sainyo sir.

To my bosses Dr.Noel Guison, Dr.Francis Cid, Dr.Helen Sigua and Dr. Hazel Paragua fortheir all-out support and for giving me an opportunity to work under them.

To my parents, Zeus and Arabella BanzuelaTo Dr.Robert Arias, for the many employment opportunities he has given me and for

the comprehensive exams he has made for San Beda.To all my students and friends at the San Beda College of Medicine, especially members

of SBCM Class 2007 and SBCM Class 2009. To the SBCM tropa salamat sa lahat.To Dr.Jun Logronio, for giving me an opportunity to work under him at the Cebu Review

Medical Center, one of the premier medical board review centers in the Philippines.To Dr.June Ann Rosales, for the invitation to lecture at her medical school.To Mrs.Cherrie Gal Espiritu for giving me an opportunity to lecture to her doctors-to-

be. Her Fairview dormitory exclusive for those taking the medical board exams has topnotchfacilities and excellent service.

To all the brods of the Most Venerable Fraternity of the UP College of Medicine, the PhiKappa Mu.

To God, to country and to our profession.

THIS PRIMER TO PHILHEALTH IS SPONSORED BY:

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