philippine government institution - philhealth employee contributions and benefits

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PhilHealthwww.philhealth.gov.ph

GROUP4

VISION

BAWAT PILIPINO MIYEMBROBAWAT MIYEMBRO PROTEKTADOKALUSUGAN NATIN SEGURADO

MISSION

"Sulit na Benepisyo sa Bawat Miyembro,Dekalidad na Serbisyo para sa Lahat"

CORE VALUESInnovation

Quality ServiceUtmost Integrity

EquitySocial Solidarity &

Total Care

www.philhealth.gov.ph Outpatient coverage Day surgeries, dialysis and cancer treatment procedures such as chemotheraphy and radiotheraphy.

Special Benefit Packages Case Rates TB Treatment through DOTS SARS and Avian Influenza Novel Influenza A(H1N1)

Inpatient coverageSubsidies for hospital room and board fees, drugs and medicines, x-ray and other laboratory exams, operating room and professional fees for confinements of not less than 24 hours.

BENEFIT PACKAGES

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Benefits

Hospital classifications: Tertiary – (Levels 3 & 4 Hospital)

Secondary – (Level 2 Hospital)

Primary – (Level 1 Hospital)

Inpatient coverageSubsidies for hospital room and board fees, drugs and medicines, x-ray and other laboratory exams, operating room and professional fees for confinements of not less than 24 hours.

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Benefits Inpatient coverageSubsidies for hospital room and board fees, drugs and medicines, x-ray and other laboratory exams, operating room and professional fees for confinements of not less than 24 hours.

Types of Illness:

•A - ordinary case

•B - intensive case

•C - catastrophic case

•D - super catastrophic case

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Benefits

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Benefits

Benefits

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•Outpatient coverage:• Day surgeries, dialysis and cancer treatment

procedures such as chemotheraphy and radiotheraphy in accredited hospitals and free-standing clinics

• outpatient HIV/AIDS treatment package (applicable for HIV/AIDS Treatment Hubs)

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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 • Cataract Package• Bitubal Ligation (BTL) or Vasectomy• Outpatient Blood Transfusion Package

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Benefits •Special benefit packages:

• TB treatment through DOTS • Treatment of new cases of pulmonary and extra-pulmonary

tuberculosis in children and adults are covered through the Directly Observed Treatment Shortcourse or DOTS, the shortest and most effective internationally accepted treatment protocol for TB.

• Amount of coverage Php 4,000 (P2,500 intensive phase & P1,500 maintenance phase)

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Benefits

•Special benefit packages:• SARS and Avian Influenza Package

• Amount of coverage for members and their qualified dependents.• Php 50,000 per case.

• For health care workers or HCW (forefront and high risk)• Php 100,000 per case.

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Benefits •Special benefit packages:

• Influenza A (H1N1) Package • Amount of coverage maximum of Php 75,000 for non-

health worker-members. • Maximum of Php 150,000 for health worker-members.

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Benefits

•Special benefit packages:• Bitubal Ligation (BTL) or Vasectomy

• P3,000 – facility (room & board, OR Fee, meds, lab, supplies)

• P1,000 – Professional Fee• Total amount: P4,000

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Benefits Special benefit packages:

Outpatient Blood Transfusion Package

Case type B package

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Since September 1, 2011, the following medical cases and surgical procedures are being paid through case rate:

Case Rates

Cases Rates

1 Dengue I (Dengue Fever and DHF Grades I & II) 8,000

2 Dengue II (DHF Grades III & IV) 16,000

3 Pneumonia I (Moderate Risk) 15,000

4 Pneumonia II (High Risk) 32,000

5 Essential Hypertension 9,000

6 Cerebral Infarction (CVA I) 28,000

7 Cerebral Hemorrhage (CVA II) 38,000

8 Acute Gastroenteritis (AGE) 6,000

9 Asthma 9,000

10 Typhoid Fever 14,000

11Newborn Care Package in Hospitals and Lying-in Clinics

1,750

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Since September 1, 2011, the following medical cases and surgical procedures are being paid through case rate:

Case Rates

Cases Rates

1 Radiotherapy 3,000

2 Hemodialysis 4,000

3 Maternity Care Package (MCP) 8,000

NSD Package in Level 1 Hospitals 8,000

NSD Package in Levels 2 to 4 Hospitals 6,500

4 Cesarean Section 19,000

5 Appendectomy 24,000

6 Cholecystectomy 31,000

7 Dilatation & Curettage 11,000

8 Thyroidectomy 31,000

9 Herniorrhapy 21,000

10 Mastectomy 22,000

11 Hysterectomy 30,000

12 Cataract Surgery 16,000

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Membership

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These are self-practicing professionals who voluntarily contribute to the program

These are the employees in the government and private sectors, as well as household employees and sea-based OFWs whose premiums are jointly shouldered by the employee and the employer

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These are land-based overseas contract workers whose premiums are paid prior to departure

These are retirees and pensioners who are entitled to lifetime coverage once they reach the age of retirement and have made at least 120 monthly contributions13

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These are the marginalized and less privileged families whose coverage is jointly shouldered by the National Government and the Local Government Units or by private individuals and companies, members of Congress and other philanthropists

The following also enjoy PhilHealth coverage without additional premiumsLegal spouse (non-member or whose membership is inactive)

Child or children - legitimate, legitimated, acknowledged and illegitimate (as appearing in birth certificate) adopted or stepchild or stepchildren below 21 years of age, unmarried and unemployed.

Child or children - 21 years old or above but suffering from congenital disability, either physical or mental, or any disability acquired that renders them totally dependent on the member for support.

Parents (non-members or membership is inactive) who are 60 years old and above, including stepparents (biological parents already deceased) and adoptive parents (with adoption papers).

Qualified dependents shall be entitled to a separate coverage of up to 45 days per calendar year. However, the 45 days allowance shall be shared among them.

Important:Qualified dependents must be declared by the principal member. Their names must

be listed under the principal member's Member Data Record (MDR) to ensure hassle-free benefits availment

WHO ARE QUALIFIED AS DEPENDENTS?

AMENDING YOUR DATASubmit duly accomplished PhilHealth Member Registration Form (PMRF) for the following:

CORRECTION OR CHANGE OF NAME:

Original or Certified True Copy (CTC) of birth certificate or any two of the following:Marriage Contract/Certificate, (if married)PassportNBI ClearancePRC IDSSS/GSIS IDPostal IDDriver's LicenseAlien Certificate of Registration or (ACR)Duly notarized Joint Affidavit of Two (2) Disinterested Persons attesting to the veracity of the

name of the person requesting for amendment

CORRECTION OF DATE OF BIRTH:

Original or CTC of birth certificate, or any two (2) of the supporting documents mentioned above except for PRC ID and joint affidavit.

CONTINUING YOUR COVERAGE

Use the PhilHealth Member Registration Form (PMRF) to shift from one membership category to another.

If currently waiting for another overseas contract or if no longer an active OFW:Register as an Individually Paying Member and pay the required premiums at any accredited payment center.

If gaining formal employment in the Philippines:Provide your employer with your PhilHealth Identification Number (PIN) which they will use when remitting and reporting your premium contributions as an Employed Member.

If already 60 years old, have contributed at least 120 monthly premiums, and not gainfully employed:Register as a Lifetime Member to enjoy continued coverage without having to contribute any premium anymore.

BENEFIT AVAILMENT CONDITIONS

Eligibility RequirementsAvailment must be within the validity period as stated in the OFW's PhilHealth Member

Registration Form (PMRF) or in the payment receipt

The OFW-member's 45 days allowance per year for hospital room and board and the separate 45 days allowance shared among the dependents have not been consumed yet

Post Availment RemindersAfter the automatic deduction or reimbursement of benefits, PhilHealth will send the Benefit

Payment Notice or BPN to the address indicated in the member's claim form. The BPN is a report of actual payments made by PhilHealth relative to the member's the confinement/availment.

Should there be discrepancies between the amounts reflected in the BPN and in the member's final billing statement issued by the hospital, or if the member has other concerns pertaining to benefit availment, he may contact PhilHealth or the health care provider. The member must bring the BPN as reference document.

BENEFIT AVAILMENT PROCEDURES

Outright/Automatic Deduction Of Benefits1. 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 MDR is not available, submit official receipt of applicable premium payment. If qualified dependent is not listed in the MDR, submit applicable proof of dependency.2. Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit.3. Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill.

Direct Filing/ReimbursementSubmit 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 waiverOperative record for surgical procedures performed

Confinements AbroadSubmit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates.

PhilHealth Claim Form 1 MDR or supporting documents Proof of applicable premium payments Original official receipt or detailed statement of account (written in English) Medical certificate (written in English) indicating the final diagnosis, confinement period and

services rendered

PhilHealth Membership Registration FormPMRF

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PhilHealth Membership Registration FormPMRF

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PhilHealth Membership Registration Form

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PhilHealth Membership Registration Form

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PhilHealth Membership Registration Form

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PhilHealth Identification Card (PIC)

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THANK YOU!