PhilHealth Programs and Benefits - Employers Confederation of the

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
PhilHealth’s 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
employee’s 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 -Php14,500–25,700
• 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
₱9,000.00
10
Typhoid Fever
₱10,000.00
Inpatient Benefits – Surgical (partial list only)
Surgical Procedures
1
Radiotherapy Linac
₱3,000.00
2
Radiotherapy Cobalt
₱2,000.00
Maternity Care Package (PCF, Birthing Homes)
₱8,000.00
Normal Spontaneous Delivery Package
₱5,000.00
4
Cesarean Section
₱19,000.00
5
Appendectomy
Newborn Care Package
₱24,000.00
3
(Levels 1-3 Hospitals)
6
7
Dilatation & Curettage
₱1,750.00
₱11,000.00
8
Hemodialysis
₱4,000.00
9
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 Mayor’s 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!
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