PhilHealth PPT Show

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PhilHealth RA 7875, amending PD 1519 and RA 6111 and amended by RA 9241 and RA 10606

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PhilHealth PPT Show

Transcript of PhilHealth PPT Show

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PhilHealth RA 7875, amending PD 1519 and RA 6111 and amended by RA 9241 and RA 10606

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History • RA 6111 enacted on 04 Aug. 1969 was repealed by PD 1519, issued on 11 June

1978

• Article 209 (Labor Code of the Philippines)

– “The Philippine Medical Care Plan shall be implemented as provided under RA 6111, as amended.”

• PD 1519 was further amended by:

– E.O. 105 issued on 24 Dec. 1986

– E.O. 106 issued on 24 Dec. 1986, and

– E.O. 269 issued on 25 Jul. 1987

• RA 7875, The National Health Insurance Act of 1995, approved on 14 Feb. 1995

• Amended by RA 9241

• Amended by RA 10606 (approved: June 19, 2013)

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Disclaimer

• Philhealth doesn’t pay for all your health care costs

• Philhealth pays only for covered items and services when its rules are met

• Members usually give a co-payment for the portion of the actual cost that is not covered by Philhealth

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Guiding Principle

• Universality

• Social Solidarity

• Care for the Indigents

• Quality Assurance for Health Services

• LGU/ Community Participation

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Members

• Employed

– Government Sector

– Private Sector

• Individually Paying Members

• OFWs

• Sponsored Members

• Lifetime Members (Retirees and Pensioners)

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Members

Employed

• Government Sector

• Private Sector

Salary

BracketSalary Range Salary Base

Total

Monthly

Premium

Employee

Share

Employer

Share

1 7,999.99 and below 7,000.00 175.00 87.50 87.50

2 8,000.00 - 8,999.99 8,000.00 200.00 100.00 100.00

3 9,000.00 - 9,999.99 9,000.00 225.00 112.50 112.50

4 10,000.00 - 10,999.99 10,000.00 250.00 125.00 125.00

5 11,000.00 - 11,999.99 11,000.00 275.00 137.50 137.50

6 12,000.00 - 12,999.99 12,000.00 300.00 150.00 150.00

7 13,000.00 - 13,999.99 13,000.00 325.00 162.50 162.50

8 14,000.00 - 14,999.99 14,000.00 350.00 175.00 175.00

9 15,000.00 - 15,999.99 15,000.00 375.00 187.50 187.50

10 16,000.00 - 16,999.99 16,000.00 400.00 200.00 200.00

11 17,000.00 - 17,999.99 17,000.00 425.00 212.50 212.50

12 18,000.00 - 18,999.99 18,000.00 450.00 225.00 225.00

13 19,000.00 - 19,999.99 19,000.00 475.00 237.50 237.50

14 20,000.00 - 20,999.99 20,000.00 500.00 250.00 250.00

15 21,000.00 - 21,999.99 21,000.00 525.00 262.50 262.50

16 22,000.00 - 22,999.99 22,000.00 550.00 275.00 275.00

17 23,000.00 - 23,999.99 23,000.00 575.00 287.50 287.50

18 24,000.00 - 24,999.99 24,000.00 600.00 300.00 300.00

19 25,000.00 - 25,999.99 25,000.00 625.00 312.50 312.50

20 26,000.00 - 26,999.99 26,000.00 650.00 325.00 325.00

21 27,000.00 - 27,999.99 27,000.00 675.00 337.50 337.50

22 28,000.00 - 28,999.99 28,000.00 700.00 350.00 350.00

23 29,000.00 - 29,999.99 29,000.00 725.00 362.50 362.50

24 30,000.00 - 30,999.99 30,000.00 750.00 375.00 375.00

25 31,000.00 - 31,999.99 31,000.00 775.00 387.50 387.50

26 32,000.00 - 32,999.99 32,000.00 800.00 400.00 400.00

27 33,000.00 - 33,999.99 33,000.00 825.00 412.50 412.50

28 34,000.00 - 34,999.99 34,000.00 850.00 425.00 425.00

29 35,000.00 and up 35,000.00 875.00 437.50 437.50

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Members

Individually Paying Member

Average Monthly Income Quarterly Annually

25,000.00 and below 450.00 1,800.00

above 25,000.00 900.00 3,600.00

Quarterly Semi-annual Annual

Pay until the last working day

of the quarter being paid for.

Pay until the last working day

of the first quarter of the

semester being paid for.

Pay until the last working day of

the first quarter of the year being

paid for.

Example: Example: Example:

Period: January to March Period: January to June Period: January to December

Deadline: March 31 Deadline: March 31 Deadline: March 31

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Members

OFW

• Pay the annual premium amounting to P1,200.00.

• Premium payments covering the entire duration of contract (equivalent to the number of years provided for in your contract) is highly encouraged.

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Members

Sponsored Member

• DSWD

• Local Government Unit (LGU) or any sponsor

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Members

• Old-age retirees and pensioners of the GSIS, including uniformed and non-uniformed personnel of the AFP, PNP, BJMP and BFP who have reached the compulsory age of retirement before June 24, 1997, and retirees under Presidential Decree 408;

• GSIS disability pensioners prior to March 4, 1995; • SSS pensioners prior to March 4, 1995:

– SSS permanent total disability pensioners;

– SSS death/survivorship pensioners • SSS old-age retirees/pensioners; • Uniformed members of the AFP, PNP, BFP and BJMP who have reached the compulsory age of

retirement on or after June 24, 1997, being the effectivity date of RA 8291 which excluded them in the compulsory membership to the GSIS;

• Retirees and pensioners who are members of the judiciary; • Retirees who are members of Constitutional Commissions and other constitutional offices; • Former employees of the government and/or private sectors who have accumulated/paid at least

120 monthly premium contributions as provided for by law but separated from employment before reaching the age of 60 years old and thereafter have reached 60 years old;

• Former employees of the government and/or private sectors who were separated from employment without completing 120 monthly premium contributions but continued to pay their premiums as Individually Paying Members until completion of the required 120 monthly premium contributions and have reached 60 years old as provided for by law;

• Individually Paying Members, including SSS self-employed and voluntary members, who continued paying premiums to PhilHealth, have reached 60 years old and have met the required 120 monthly premiums as provided for by law;

• Retired underground mine workers who have reached the age of retirement as provided for by law and have met the required premium contributions.

Lifetime Members

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Coverage also includes

• Member Spouse

• Parents who are 60 years old or above

• Children below 21 years old and those with mental and physical disabilities

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Entitlement to Benefits

• At least 3 consecutive monthly contribution within the immediate 6 months prior to admission

• The 45-days allowance for room and board has not been consumed yet

• Confinement in an accredited hospital of not less than 24 hours

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Mandated Benefits

• Inpatient Hospital Care

– Room and Board

– Services of health care professionals

– Diagnostic, laboratory, and other medical examination services

– Use of surgical or medical equipment & facilities

– Prescription drugs and biologicals

– Subj. to the limitation stated in Sec. 37

– Inpatient education packages

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Mandated Benefits

• Outpatient Care

– Diagnostic laboratory, and other medical exam. Services

– Personal preventive services

– Prescription Drugs and Biologicals

– Subj. to the limitation set in Sec. 37

– Services of health care Professionals

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Mandated Benefits

• Emergency and transfer services

• Such other health care services that the Corporation and the DOH shall determine to be appropriate and cost-effective.

These services and packages shall be reviewed annually to determine their financial sustainability and relevance to health innovations, with the end in view of quality assurance, increased benefits and reduced out-of-pocket expenditure.

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Exclusion

• The Corporation shall not cover expenses for health services which the Corporation and the DOH consider cost-ineffective through health technology assessment.

• The Corporation may institute additional exclusions and limitations as it may deem reasonable in keeping with its protection objectives and financial sustainability.

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Exception to the 24 hour confinement

• Emergency cases as defined by PhilHealth

• Patient died

• Patient was transferred to another hospital

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Availment Procedures Step 1:

• Members accomplishes Philhealth Claim Form 1

Step 2:

• Submit the Form together with the following

– Proof of Contribution

– Supporting documents

– Philhealth Number Card

Step 3:

• The hospital will deduct the benefits from the hospital bill prior to the discharge of the patient

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Claims Prescription Period Guidelines

• All claims for payment of services rendered shall be filed within 60 calendar days from the date of discharge of the patient.

• All claims returned for completion of requirements shall be re-filled within 60 calendar days from receipt of notice.

• All request for payment adjustments must be made within 60 days from date of receipt of check payment or of the benefit payment notice

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Confinement in a Non-Accredited Hospital is possible IF:

• The case is Emergency

• The Hospital has a current Dept. of Health (DOH) License

• And transfer/referral to a PhilHealth accredited hospital is physically impossible.

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Benefit Schedule

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A B C D

Level 1 Hospital (Primary)

ROOM AND BOARD * 300/day 300/day N/A N/A

DRUGS AND MEDICINES ** 2,700 9,000 N/A N/A

X-RAY, LABORATORY, ETC. ** 1,600 5,000 N/A N/A

OPERATING ROOM FEE 500 500 N/A N/A

Level 2 Hospital (Secondary)

ROOM AND BOARD * 400 400 600 N/A

DRUGS AND MEDICINES ** 3,360 11,200 22,400 N/A

X-RAY, LABORATORY, ETC. ** 2,240 7,350 14,700 N/A

OPERATING ROOM FEE N/A

Level 3 & 4 Hospital (Tertiary)

ROOM AND BOARD * 500 500 800 1,100

DRUGS AND MEDICINES ** 4,200 14,000 28,000 40,000

X-RAY, LABORATORY, ETC. ** 3,200 10,500 21,000 30,000

OPERATING ROOM FEE

* Not exceeding 45 days for each member & another 45 days to be shared by his dependents per year

For procedures with RVU 30 and below = 1,200

For procedures with RVU 31 to 80 = 1,500

For procedures with RVU 81 to 600: RVU x PCF 20

(minimum = 3,500)

Case Type

** Refers to a confinement or series of confinements of the same illness not separated from each other by 90 days within a calendar year. In this case, a member or

beneficiary is not entitled to another set of benefits until after 90 days. They can only avail of the unused portion of the benefits and the room and board fees until the 45

days allowance is exhausted.

However, a member can avail of new set of benefits if succeeding confinements are of different illness or condition.

For procedures with RVU 30 and below = 750

For procedures with RVU 31 to 80 = 1,200

For procedures with RVU 81 to 600 = RVU x PCF 15

(Minimum = 2,200 and maximum = 7,500

Benefit Items

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Claim Benefits for Confinement Abroad

• Entitlement to Benefits:

– Member or his/her qualified dependents

– Confinement / Surgery or OPD Benefits

• Benefit & Claims Filing

– 180 calendar days from the date of discharge

– Always payable to member

– Based on application benefit schedule, case type for a Tertiary level hospital

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Confinement Abroad

• Documentary Requirement

– PH Form 1

– Photocopy of MDR (Medical Data Record)

– Medical certificate/Abstract (with English translation)

– SOA with itemized charges and/or ORs (proof of hospital bill and PF)

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Reason for Denial

• Late filing

• Less than 45 days of confinement

• Not accredited hospital

• Inconsistent data

• Case not compensable

• Same illness with in 90 days

• No qualifying contribution

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Maternity Care Package

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Maternity Care Package

Normal Birth

• Spontaneous onset of labor

• Low risk at the start of labor, throughout labor, and delivery

• Infant in vertex position

• 37-42 completed weeks of pregnancy

Payment scheme

• Reimbursement utilize a Case Payment Scheme

• Case Rate: Php 4,500

• Limited to NSD of first three (3) births

Providers:

• Non hospital based-facility

• RHUs/HCs

• Lying-in Clinics

• Hospitals based-facility

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Maternity Care Package

4,500

(per patient)

P2,000.00

For the Health Professional

P2,500.00

For the Health Facilities (Room &

board, drugs & meds, diagnostics, OR fee)

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Maternity Care Package

Payment for Non-hospital based facility:

Php 3,650

• Prenatal

• Delivery

• Newborn Care

Php 850

• Postnatal Care

• Family Planning Service

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Maternity Care Package

Claims Filing

• Claims for the first payment must be filed within 60 days from date of discharge

• For the second payment, claim must be filed within 90 days from date of discharge.

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Philippine Health Insurance Corporation

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Corporation

• Tax-exempt corporation

• Follows the guideline of Dept. of Health (DOH)

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Board of Directors

Composition of Board of Directors • The Secretary of Health; • The Secretary of DOLE or his representative; • The Secretary of DILG of his representative; • The Secretary of DSWD or his representative; • The President of the Corporation; • A representative of the labor sector; • A representative of employers; • The SSS Administrator or his representative; • The GSIS General Manager or his representative; • A representative of the Self-employed Sector; and • A representative of health care providers.

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Board of Directors • The Secretary of the Department of Finance (DOF) or a permanent

representative;

• The Vice Chairperson for the basic sector of the National Anti-Poverty Commission or a permanent representative;

• The Chairperson of the Civil Service Commission (CSC) or a permanent representative;

• A permanent representative of Filipino migrant workers;

• A permanent representative of the members in the informal economy;

• A permanent representative of the members in the formal economy;

• A permanent representative of the elected local chief executives to be endorsed by the League of Provinces, League of Cities and League of Municipalities;

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Board of Directors

• An independent director to be appointed by the Monetary Board.

• The Secretary of Health shall be the ex officio Chairperson while the President and CEO of the Corporation shall be the Vice Chairperson of the Board.

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Appointment and Tenure

• Pres. of the Phil. shall appoint the Members of the Board

• Upon Recommendation of the Chairman of the Board

• Each member shall have 4 years of term

• Renewable for a maximum of 2 years.

• Vacancy shall be filled up for the unexpired term of his predecessor.

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Meetings and Quorum

• Shall hold regular meetings at least once a month

• Special meeting may be convened at the call of he chairperson or by a majority of the members of the Board

• The presence of six (6) voting members shall constitute a quorum.

• In the absence of the Chairperson and Vice-Chairperson, a temporary presiding officer shall be designated by the majority of the quorum.

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Allowance and Per Diems

• The members of the Board shall receive a per diem for every meeting actually attended subject to the pertinent budgetary laws, rules and regulations on compensation, honoraria and allowances.

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President of the Corporation

• The Pres. of the Phil. shall appoint the President and CEO of the Corp. upon recommendation of the board with a tenure of one (1) year in accordance with the provision of RA 10149

• Must be a Filipino citizen with five (5) years experience in the industry

• Salary is being fixed by the Pres. of the Phil., payable from the fund of the corporation

• Must not involved with any health care institution as owner or member of the board

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The National Health Insurance Fund Sec. 24-27 of RA 7875

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Sources of the Fund

• Contribution from Program members

• Other appropriations earmarked by the national and local gov’t purposely for the implementation of the program

• Subsequent appropriation earmarked by the national and local gov’t purposely for the implementation of the Program

• Donations and grants-in-aid

• All accruals thereof

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Components

The Basic Benefit Fund

• The availment of the basic

minimum package by eligible

• All liabilities associated with

the extension of entitlement to

the basic minimum benefit

package to the enrolled

population shall be borne by

the basic benefit fund.

Supplementary Benefit Fund

• It is eligible for use to provide

supplementary coverage

various groups of the

population enjoying the basic

benefit coverage as are

affordable by their respective

funding sources.

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Financial Management • All Funds under the management and control of the Corporation shall

be subject to all rules and regulations applicable to public funds.

• The corporation is authorized to charge the various funds under its control for the costs of administering the program.

• Such cost may include administration, monitoring, marketing, and promotion, research and development, audit and evaluation, information services, and other necessary activities for the effective program management.

• The total annual cost for the shall not exceed twelve percent (12%) of the total contribution, including gov’t contribution to the program

• Not more than three percent (3%) of the investment earning collected during the immediate preceding year.

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Reserve Funds

• The corporation shall set aside a portion of its accumulated revenues not needed to meet the cost of the current year’s expenditures as reserve funds

• Provided that the total amount of reserves shall not exceed a ceiling equivalent to the amount actuarially estimated for 2 years projected program expenditure

• Provided further that whatever actual reserves exceed the required ceiling at the end of the corporation fiscal year, the program’s benefits shall be increased or member-contributions decreased prospectively in order to adjust expenditures or revenues to meet the required ceiling for reserve funds.

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Investment of Reserve Funds

• Interest-Bearing Bonds and Securities

• Interest-Bearing Deposits

• Preferred Stocks

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Administrative Powers

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Quasi-Legislative Powers

• To sue and be sued in court;

• To administer the National Health Insurance Program

• To formulate and promulgate policies for the sound administration of the program

• To set standards, rules and regulations necessary to ensure quality of care appropriate utilization of services fund viability, member satisfaction, and over-all accomplishment of program objectives

• To acquire property, real and personal which may be necessary or expedient for the attainment of the purposes of this act.

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Quasi-Judicial Powers

• Conduct investigation for the determination of a question, controversy, complaint, or unresolved grievance brought to its attention, and render decisions order or resolutions thereon.

• To summon the parties to a controversy, issue subpoenas requiring the attendance and testimony of witnesses or the production of documents and other materials necessary to a just determination of the case under investigation.

• To suspend temporarily, revoke permanently, or restore the accreditation of a health care provider or the right to benefits of a member and/or impose fines after due notice and hearing

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Grounds for Grievances

• Any violation of the rights of the patients

• A willful neglect of duties of program implementors that results in the loss or non-enjoyment of benefits of members or their dependents

• Unjustifiable delay in actions on claims

• Delay in processing of claims that extends beyond the period agreed upon

• Any other act or neglect that tends to undermine or defeat the purposes of this act

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Grievance and Appeal Review Committee

Composition of Grievance Appeal Review Committee:

• Three (3) to five (5) members

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Grievance and Appeal Procedure

• A complaint for grievance must be filed with the Office which shall rule on the complaint within 90 calendar days from receipt thereof.

• Appeals from Office decisions must be filed with the Board within 30 days from receipt of notice of dismissal or disallowance by the office.

• The offices shall have no jurisdiction over any issue involving the suspension or revocation of accreditation, the imposition of fines or the imposition of charges on members or their dependents in case of revocation of their entitlement.

• All decisions by the Board as to entitlement to benefits of members or to payments of health care providers shall be considered final and executory.

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Hearing Procedures

• Action on Complaint

• Defendant’s failure to answer

• Power to administer Oath and issue Subpeona

• Submission of Pleadings

• Clarificatory Hearing

• Finality of Decision