Philhealth circ61_2012

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Transcript of Philhealth circ61_2012

  • 7/28/2019 Philhealth circ61_2012


    Re pub lic of the Philippine sP^t- "@ ,,>'?PHILIPPINE HEALTH INSURANCE CORPORATION** v "

    Citystate Centre, 709 Shaw Boulevard, Pasig CityHealthline 441-7444

    PHILHEALTH CIRCULARNo. D(jI , s. 2012c^T O :A L L I N D IV I D U A L L Y P A Y I N G M E M B E R S , A C C R E D I TE D


    SU BJEC T : N ew Provisions on the Issuance of the Individual Policy

    I.RATIONALEThe Individual Policy Contract (IPC ) is a legal docum ent executed by and betweenPhilHealth and an Individually Paying M ember (IPM ) as evidence of m embership andcoverage in the National Health Insurance Program (NH IP). It is intended to guide andencourage m emb ers lo sustain act ive part icipat ion in the N HIP and gu arantee theentitlement to benefits thereby providing continuous financial risk protection in health carecosts within a specified validity period enunciated under PhilHealth Circular No. 20 s. 2012.In order to ensure utm ost customer satisfaction, the IPC gu arantees more flexible terms inaccessing health care benefits and shall serve as the primary docum ent for IPMs and theirdependen ts to avail of benefits.Effective January 1, 2013, IPC issuance shall form part of the regular registration procedureamong individual mem bers under the Individually Paying Program (IPP).

    I I .EXCLUSIONActive IPM s covered by the Group P olicy Contract sealed between PhilHealth and theOrganized G roup under the iGroup Program shall not be required to sign IPC. Coverageunder the iGroup shall be separate and distinct from that covered under the IPC.

    III.SUPPLEMENTAL IMPLEMENTING GUIDELINESStarting Janua ry 1, 2013, all IPM s shall be issued an enhan ced IPC w hich includeadditional amendatory conditions:

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  • 7/28/2019 Philhealth circ61_2012


    A. IPC VALIDITYAn option to apply for a minimum of twelve (12) months IPC validity, twenty-four (24) or a maximum of thirty-six (36) months with fiscal year application;

    a.A 3-yea r IPC validity shall be required to qualify a me m ber to avail ofCase Type Z Benefits;

    b.Entitlemen t to Case Ty pe Z benefits also requires a minimum of one (1)year advance premium payment.

    To acquire an IPC, an IPM shall be required the following minimum prem iumcontribution according to num ber of years contracted and shall be locked in tothe current premium rate if fully paid upon signing of the IPC :

    a. An IPM who w ould opt for monthly mode of paym ent will still berequired to pay the initial 25% p remium contribution for a 1 year IPC.Succeeding payments may then be made mon thly.

    b. An IPM cannot change the originally set mode of paym ent within thevalidity of the IPC

    B. DEADLINE OF PREMIUM REMITTANCE AND MODE OF PAYMENT1. Premium contributions may be p aid or remitted according to any of the

    following mode:

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  • 7/28/2019 Philhealth circ61_2012


    a.Monthly - one (1) month premium contribution which shall be paid onor before the last working day o f the month prior to the applicable

    month;b.Quarterly - twen ty-five percent (25% ) of the annual prem ium

    contribution which shall be paid on or before the last working day ofthe month prior to the applicable three-month period;

    c.Semi-annual @ fifty percent (50%) of the annual premium contributionwhich shall be paid on or before the last working day of the m onth

    prior to the applicable six-month period;d.Annual - one hundred percent (100% ) of the annual premium

    contribution which shall be paid on or before the last working day ofthe month prior to the applicable twelve-month period;

    2. A ll premium contributions shall have prospective application. Exceptions tothis rule are:

    1. IPMs who shifted from a different paying mem bership category in order toavoid gaps in entitlement to benefits and premium remittance. Thus, IPPpremium payment for the current period may be accepted provided thatthe member is a shifter with previous active contribution immediately prior

    to applicable period.Example: Emploved to IPP

    JAN 2013FEB 2013IPC Validity (1 year/semi-annual moae;

    EmployedIPMFeb 2013 - January 20141.Require 50% advance premium

    PremiumAccept IPPcomputed at Php 1,800 annualPaidpremiumpremium rate for CY 2013 OR PhP

    900.00 to cover Feb - July 2013;2.Remaining 50% should be paid on

    or before the last working day ofJuly 2013 to cover August 2013 to

    January 2014.3.Any increase in CY 2014 shall be

    effective upon renewal of the IPC.

    2. Acceptance of retroactive paymen ts for overdue prem ium/s w ith interestcharges.

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    c. GRACE PERIODGrace period shall be allowed for delayed remittance once w itnm a twelvemonth period. Succeeding delay/s in premium remittance w ithin a twelvemonth validity period shall be subject to corresponding interest charge/s thatmay be imposed by the Corporation as penalty;Grace period may van/ according the elected m ode of paym ent;

    Mode ofPaymentAnnualSemi-annualQuarterly

    Grace period Interest charge forPaym ent made afterthe Grace Period

    30 days (renewal)15 days10 days5 days

    Subject to applicableinterest rates and


    D. PAYMENT OF OVERDUE PREMIUMS1.Interest charges shall be applicable to the validity period w ith unpaid or

    incorrect premium contribution.2.Paym ent of overdue premium /s plus charges, // applicable, may be allowed

    within 60 days from date of discharge from hospital confinement to allow theprocessing of benefit claim/s;

    Example: IPM w ith 1 year IPC/quarterly mode of payment


    RemarksPayment on the 4r" qtr w ill require:

    -2"" Qtr plus interest charge-3r" Qtr plus interest charge, and-4lh Qtr contribution w ithout interest charge if m ade

    within the 10 days grace period; or-4m Qtr contribution plus interest charge if paid

    Benefit claim m ay be processed if payment for the junpaid period 0 " Q tr), with interest charges, were jmade before the end of the 60 days prescribed period :(in this case, before Nov 15) to file a benefit claim

    No benefit claim wilh retroactive pay men t/s shall be processed unlessarrearage s are paid in full .

    Filing of claim s for those covered by premium arrearages paid shall be theresponsibility of the member and shall be submitted to the nearest PhilHealth

    CEIm w ^


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    Local Health Insurance Office. The LH IO shall assist the IPM on theprocedures; involved in direct filing.

    5.The PhilHe alth Official Receipt shall reflect paym ents made for prem iumarrears and interest charges.

    6.The Fund M anagement Sector shall guide the PRO Fund M anagementSections on proper recording of advance payments as premium collection for

    applicable year/s.

    E. IPC RENEW ALRenew al is the process of applying for a subsequent IPC covering a new validity period orthe process of ex tending the go od status of a co ntract prior to its expiration to effectcontinuity or resump tion of benefit entitlemen t. IPC ren ew al for purposes of this Circularmay also apply to an expired and /or terminated IPC.

    1.The IPM shall request for the renew al of his/her an IPC within the quarterprior to its expiration to avoid gaps in benefits availment. Regular IPCapplication procedure shall apply.

    2.Non-com pliance to the payment terms of the IPC or any form ofmisrepresentation shall cause the suspension or termination of the contract.However, renewal pre-conditions shall be made available for members

    subject to Ihe approval of PhilHealth.3.Renew al far a suspended or terminated IPC m ay be requested by the

    member subject to compliance with specific requirements, such as:a.Full premium payment covering the unpaid period up to the end

    validity of the contract with interest charges, as applicable;b.Completion of ihe suspension period, if applicable.

    c.Any other documentary p re-requisites that the Corporation m ayimpose as it may deem fit and necessary to effect renewal of the contract.

    4.Premium requirement for the payment of the unpaid period shall be based onthe applicable rate for the missed period.

    F. BENEFITS ENTITLEMENT1. Ent i tlemen t to avai l of benef i ts shal l be based on the 3 /6 m inimum

    requirement regardless of type of illness.a. Exception to this rule are Case Type Z illnesses which require

    advance full payment of at least one year premium contribution and

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    other future benefits specifically requiring more m an j m ontnscontribution after the effective date of this Circu lar;

    b.The 9/12 prerequisite for maternity and other procedures enum eratedunder PhilHealth Circular No 36, s. of 200 6 is superseded by this

    guarantee;c.Counting of the three months requirement shall be reckoned from the

    immediate 6 months prior to confinement.d.Reckoning of th