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Dr.

Banzuelas PhilHealth HandOut


for the Med Boards 2014
by Enrico Paolo Chiong Banzuela, MD
UP College of Medicine Class 2005
Program Director, Topnotch Medical Board Prep
Course Coordinator for Physiology, San Beda College of Medicine
Year Level I Coordinator, San Beda College of Medicine
Faculty, Physiology and Biochemistry, San Beda College of Medicine
Faculty, Biochemistry, Ateneo School of Medicine and Public Health
Faculty, Physiology and Pathology, Topnotch Medical Board Prep
Co-Author, IM Platinum
Former Associate Researcher, UP-National Insitutues of Health, PhilHealth Research Study Group
Dr.Banzuela: This is a compilation of pertinent facts and figures regarding PhilHealth that every physician
needs to know. Its sources are listed (numbers in superscript) in the heading of each section. After 4 years,
it has been updated. Its now updated as of Aug 29,2014. RA 10606, and IRR 2013 have been included. Take
note that rules governing PhilHealth change all the time, so if there are any inconsistencies, please give us
feedback at loroteyang@yahoo.com. It would be highly appreciated. =)

I. PERTINENT LAWS 1, 2
Republic Act 7875
Known as the National Health Insurance Act of 1995 or "An Act Instituting a National Health
Insurance Program For All Filipinos and Establishing the Philippine Health Insurance Corporation
For the Purpose"
Approved on February 14, 1995 by Pres. Fidel Ramos
Republic Act 9241
An Act amending RA 7875
Republic Act 10606
An Act further 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 social services available to all the people at
affordable cost. Priority for the needs of the underprivileged, 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, 9241, 10606. The NHI Act of 1995 is one of the most important laws Congress
has ever passed no kidding.

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II. HISTORY OF PHILHEALTH 4

In 1963, DOH secretary Francisco Quimson Duque, the father of the current DOH secretary, proposed
the National Health Service of the Philippines under the administration of President Diosdado
Macapagal
RA 6111 or the Philippine Medical Care Act was signed into law by President Ferdinand Marcos in
1969
Medicare Program Phase I was started in 1972. Target beneficiaries were SSS/GSIS members
Medicare Program Phase II was started in 1983. Target beneficiaries were low-income and nonsalary based populations not covered by Phase I. Tie-ups with LGUs and HMOs was done
In the early 1990s, The Health Finance Development Project (HFDP) a DOH project funded by USAIDMSH conducted several studies regarding social health insurance and was 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
Decentralization of claims processing starts in Region VI, March 1999
Launching of the Individually Paying Program for the Informal Sector, October 1, 1999
Launching of the first OPD Package in Laguna and Capitation as provider payment scheme, July 2000
Introduction of Dialysis Package and OPD AntiTB/DOTS Benefits Package, April 1, 2003
Maternity Care Package for SVD and SARS package, May 1, 2003
For 2014, 14.7 million families are being enrolled through full National Government subsidy. The
provision of full National Government subsidy was made possible by an amendment introduced in
RA 10606 enacted into law in 2013.
PhilHealth and Kasambahay Law (Philhealth IRR 2013) based on RA 10361 passed Jan 18, 2013:
SECTION 21. Obligations of the Employer of Household Help or Kasambahay
To ensure that PhilHealth membership of the household help or kasambahay is sustained, employers
are required to:
a. Register their kasambahay with the Corporation and the kasambahays qualified dependents
under their PIN;
b. Report to the Corporation their kasambahay within thirty (30) calendar days upon
employment; and,
c. Give notice to the Corporation upon separation of the kasambahay and pay the corresponding
PhilHealth Premium contributions for the rendered services until the date of separation.
Employers of household-help who have registered with the SSS prior to July 1, 1999, are considered
automatically registered. They shall be required to update their records with the Corporation.
SECTION 22. Premium Payment of Household Help
The annual premium contributions of household helps shall be fully paid in accordance with the
provisions of Republic Act No. 10361 or the Kasambahay Law.

Why Medicare was Replaced by PhilHealth


to accelerate universal coverage (health insurance for ALL Filipinos)
to enhance and expand a unified benefit package that can be used by ALL members, regardless of
category
consolidate separate Medicare programs given by the SSS, GSIS and OWWA
Dr.Banzuela: Before PhilHealth was created, there used to be different premium contributions and different benefit
packages for those mandated to have social health insurance. PhilHealth changed all that by requiring EVERYONE to
procure social health insurance. Also, there would be A SINGLE UNIFIED BENEFIT PACKAGE although premium
contributions are still based on salaries/wages in the case of formal sector employees and on household earnings & assets in
the case of the self-employed. The rich would subsidize the poor and the healthy would subsidize the sick. (social solidarity
concept)

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III. TERMS AND DEFINITIONS 1,2,3


1.

2.

Capitation - a payment mechanism where a fixed rate, whether per person, family, household or
group is negotiated with the health care provider who shall be responsible for delivering or
arranging the delivery of health services required by the covered person under the conditions of a
health provider contract.
Fee-for-Service a fee pre-determined by Philhealth for each service delivered by a health care
proverider based on the bill. The payment ystem shall be based on a pre-negotiated schedule
promulgated by the Corporation.

3.

Case payment a health care payment system in which health care providers are given a fixed
amount for every specific case diagnosed. E.g. in PhilHealths DOTS package, a physician is given
P4,000/patient to cover for the patients drugs, his consultation fee and additional laboratory exams
needed.

4.

Coverage - the entitlement of an individual, as a member or as a dependent to the benefits of the


program

5.

Premium Contribution the amount paid by or in behalf of a member to the PhilHealth program for
coverage, based on salaries/wages in the case of formal sector employees, and on household
earnings and assets in the case of self-employed, or on other criteria as maybe defined by PhilHealth
in accordance with the guiding principles of Act I of RA 7875

6.

Dependents - legal dependents are


a. Legitimate spouse who is not a member;
b. Unmarried and unemployed legitimate, legitimated, acknowledged, illegitimate children and
legally adopted or stepchildren below twenty-one (21) years of age;
c. Children who are twenty-one (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, as determined by the Corporation;
d. Foster child as defined in Republic Act 10165 otherwise known as the Foster Care Act of 2012 ;
e. Parents who are sixty (60) years old or above, not otherwise an enrolled member, whose
monthly income is below an amount to be determined by the Corporation in accordance with the
guiding principles set forth in the Act; and,
f. Parents with permanent disability regardless of age as determined by the Corporation, that
renders them totally dependent on the member for subsistence.

Dr.Banzuela: memorize who the legal dependents are. Remember that queridas are not covered by PhilHealth, but mga
anak sa labas are as long as they are below 21 years of age. If the children are physically/mentally handicapped, they are
still considered dependents even if they are more than 21 years of age. Note that parents greater than 60 years old or with
permanent disabilities are considered dependents also.

7. Emergency an unforeseen combination of circumstances which calls for immediate action to


preserve the life of a person or to preserve the sight of one or both eyes; the hearing of one or both
ears; or one or two limbs at or above the ankle or wrist.
Dr.Banzuela: Its important to know PhilHealths definition of emergency. There are a lot of unsavory hospitals that do not
reimburse PhilHealth claims in the emergency room; they rationalize their actions by saying that these cases are considered
more appropriate for the OPD.

8.

Health Care Provider - refers to:

a.

A health care institution, which is duly licensed and/or accredited, devoted primarily to the
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maintenance and operation of facilities for health promotion, prevention, diagnosis, treatment and
care of individuals suffering from illness, disease, injury, disability or deformity, drug addiction or in
need of obstetrical or other medical and nursing care. It shall also be construed as any institution,
building or place where there are installed beds, cribs or bassinets for twenty-four (24) hour use or
longer by patients in the treatment of disease, injuries, deformities or abnormal physical and mental
states, maternity cases or sanitarial care; or infirmaries, nurseries, dispensaries, rehabilitation
centers and such other similar names by which they may be designated; or,
b.

A health care professional, who is any doctor of medicine, nurse, midwife, dentist, pharmacist or
other health care professional or practitioner duly licensed to practice in the Philippines and
accredited by the Corporation; or,

c.

A health maintenance organization (HMO), which is an entity that provides, offers or arranges for
coverage of designated health services needed by plan members for a fixed pre-paid premium; or,

d.

A community-based health care organization (CBHCO), which is an association of members of the


community organized for the purpose of improving the health status of that community through
preventive, promotive and curative health services.

9.

Indigent - a person who has no visible means of income, or whose income is insufficient for family
subsistence, as identified by the DSWD based on specific criteria set for this purpose in accordance
with the guiding principles set forth in Article I of the Act.

10. Philippine National Formulary - the essential drugs list of the Philippines which is prepared by the
Department of Health (DOH) in consultation with experts and specialists from organized professional
medical societies, the academe and the pharmaceutical industry and which is updated regularly.
Dr.Banzuela: Remember that only the drugs in the PNF are PhilHealth reimbursable drugs.

8. Preferred Health Care Institution - is a recognition conferred to a health facility that has been granted
advanced participation for beyond compliance with PhilHealth policies, demonstrated higher
financial risk protection, excellent quality of care and better service satisfaction to its
clients/patients.
9. Public Health Services the Government shall be responsible for providing public health services for
all groups such as women, children, indigenous, people, displaced communities and communities in
environmentally endangered areas, while the NHIP shall focus on the provision of personal health
services. Preventive and promotive health services are essential for reducing the need and spending
for personal health service.
10. Means Test A protocol administered at the barangay level to determine the ability of individuals
or households to pay varying levels of contributions to the Program, ranging from the indigent in the
community whose contributions should be totally subsidized by government, to those who can afford
to subsidize part but not all the required contributions for the Program.
11. Single Period of Confinement a series or successive confinements for the SAME illness/injuries not
separated from each other by more than 90 days. PhilHealth gives a member/dependent a 45-day
allowance, after which it would not pay anymore.

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IV. FACTS ABOUT PHILHEALTH 1,2,3

The purpose of PhilHealth is to ensure the provision of affordable, available and accessible health
care services for ALL citizens of the Philippines.
PhilHealths goal is universal coverage or KALUSUGAN PANGKAHALATAAN (defined as 85% of the
Philippine population)

Dr.Banzuela: Its impossible to cover 100% of the Philippine population; so PhilHealth has defined universal coverage at
85%. In 2004, PhilHealth claims the coverage is 81% already due to extensive enrolment of people in the Indigent program
using the giveaway PhilHealth cards. (though these PhilHealth cards expired after one year their premium contributions
have to be shouldered by the Local Government Units or they must enroll in the Individually-Paying Program to continue
receiving PhilHealth benefits) As of 2013, coverage was pegged at 79%.

end goal of Bawat Pilipino, Miyembro, Bawat Miyembro, Protektado, Kalusugan Natin Segurado
all families in the DSWDs National Household Targeting System for Poverty Reduction (NHTS-PR)
are covered by PhilHealth (Philhealth IRR 2013)
Limited to paying for the utilization of health services by the covered beneficiaries or to purchasing
health services in behalf of the beneficiaries
Prohibited from:
1. Providing health care directly
2. Buying and dispensing drugs and pharmaceuticals
3. Employing physicians and other professionals for the purpose of directly rendering care
4. Owning or investing in health care facilities

Dr Banzuela: 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 and controlled corporation
(GOCC)
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 receipt from the health care
institution and certification of the attending physician as to the final diagnosis, period of confinement
and services rendered.
Sec.54 of RA 9241 Oversight Provision Congress shall conduct a regular review of the National
Health Insurance Program which shall entail a systematic evaluation of the Programs performance,
impact or accomplishments with respect to its objectives or goals. Such review shall be undertaken
by the Committees of the Senate and the House of Representatives which have legislative jurisdiction
over the Program. The National Economic and Development Authority, in coordination with the
National Statistics Office and the National Institutes of Health of the University of the Philippines
shall undertake studies to validate the accomplishments of the program. The budget required to
undertake such study shall come from the income of PhilHealth.

Dr Banzuela: The PhilHealth Research Study Group, with Dr.Jimmy Galvez-Tan and Dr. Ramon Paterno as its leaders, was
created at the National Institutes of Health to fulfill this Oversight Provision, in partnership with NEDA and NSO. NEDA is the
head agency. The validation framework, performance indicators and research agenda have been identified by the
interagency body and research is currently being conducted to validate PhilHealths performance.

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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 the filed of health
care financing and corporate management
o Must NOT be involved in any health care institution as owner or member of its board
Composition:
1. The DOH Secretary Ex Officio Chairperson of the Board (Dr.Enrique Ona)
2. The President and Chief Executive Officer (CEO) of the Corporation Vice-Chairperson (Alexander
Padilla)
3. DOLE Secretary or permanent representative (Rosalinda Baldoz)
4. DILG Secretary or a permanent representative (Mar Roxas)
5. DSWD Secretary or a permanent representative (Corazon Soliman)
6. DOF Secretary or a permanent representative (Cesar Purisima)
7. The SSS Administrator (President & Chief Executive Officer) or a permanent representative
8. The GSIS General Manager (President and General Manager) or a permanent representative
9. The Vice-Chairperson for the basic sector of the National Anti-Poverty Commission or a permanent
representative
10. The Chairperson of the Civil Service Commission (CSC) or a permanent representative
11. A permanent representative of Filipino Migrant Workers
12. A permanent representative of the members in the Informal Economy
13. A permanent representative of the members in the Formal Economy
14. A representative of employers
15. A representative of health care providers to be endorsed by their national associations of health care
institutions and medical health professionals
16. A permanent representative of the elected Local Chief Executives to be endorsed by the League of
Provinces, League of Cities and League of Municipalities
17. An independent Director to be appointed by the Monetary Board
VI. MONEY, MONEY, MONEY 3

The National Health Insurance Fund, the money PhilHealth is working with, has 3 components:
o Basic benefit funds
o Supplementary benefit funds
o Reserve funds
Basic benefit funds shall finance the basic minimum package to be enjoyed by ALL members. The
National Government and the Local Government Unit pays for the premium contributions of
indigents. For non-indigents, premium prices for specific population shall be actuarially determined
based on a.) Variations in risk b.) Capacity to pay and c.) Projected costs of services utilized
Supplementary benefit funds shall finance the extension and availment of ADDITIONAL BENEFITS
not included in the basic minimum benefit package BUT approved by the Board. However, in
accordance with the principles of equity and social solidarity, after 5 years, such funds shall be
merged into the basic benefit fund.
Reserve funds is a portion of PhilHealths accumulated revenues not intended to meet the cost of the
current years expenditures; it shall not exceed a ceiling equivalent to the amount actuarially
estimated for two years of projected program expenditures. The funds are to be invested in interestbearing bonds, securities, deposits/loans/securities to any domestic bank and stocks of corporations.
Total Annual of PhilHealth shall not exceed SUM TOTAL of 4% of the total premium contributions
during the immediately preceding year, 5% of total reimbursements and 5% of investment earnings
generated during the immediately preceding year.

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Philhealth has the following sources of funds


1. Premiums
2. Grants and Donations
3. Investment Earnings
4. Sin Taxes

VII. MEMBERSHIP 3, 6
Initial members of the program in 1995
1. SSS/GSIS members, retirees, pensioners and their dependents under Medicare Program I
2. Those enrolled in local government unit sponsored health insurance plans (who are mostly indigents
and lowly-paid workers) under the Medicare Program II
3. Members of other government-initiated health insurance programs, community based health care
organizations, cooperatives or private non-profit health insurance plans who are subsequently
accredited by PhilHealth
Current Members are classified as follows:
1. Paying Members
a. Government employee
b. Private Sector employee including househelps and sea-based OFWs
c. Individually-Paying Member including land-based OFWs
2. Indigent Member
3. Privately-Sponsored Member
4. Lifetime Member/Covered Member (those who have reached the age of retirement and has made at
least 120 monthly contributions). This will include but is not limited to retirees of government
sector, private sector and uniformed members of the AFP, PNP, BMJP, BFP
Requirements for Membership Registration (any of the following)
1. Birth Certificate
2. Baptismal Certificate
3. GSIS/SSS Members ID
4. Passport
5. Any other valid ID/document acceptable to the Corporation
Requirements for Declaration of Dependents
1. Marriage Contract/Marriage Certificate
2. Birth/Baptismal Certificate
3. Court Order on Adoption
4. Birth/baptismal certificate of the member and dependent parents
5. Marriage Contract of the parent and stepfather/stepmother and birth certificate of the dependent
stepchildren
6. 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 supposed members except
declaration of spouse
7. Certificate from the DSWD or Punong Barangay attesting to the fact of the relationship of 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 to operate)
1. For single proprietorships DTI registration
2. For partnerships and corporations SEC registration
3. For foundation and other non-profit organizations SEC registration
4. For cooperatives Cooperative Development Authority (CDA) registration
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5.

For backyard industries/ventures and micro-business enterprises Barangay Certification and/or


Mayors Permit

VIII. ACCREDITATION 3
Accreditation for Health Care Institutions
1. Health care institution must be operating for at least the past three years. This 3 year requirement is
waved if:
a. Managing health care professional has had working experience in another accredited health
care institution for at least 3 years OR a graduate of hospital adminitration or any related
degree
b. Operates as a tertiary facility
c. Operates in a LGU where the accredited health care provider cannot adequately or fully
service its population
d. Service capability is not currently available in the LGU
2. Adequate quality human resources, equipment and physical structure
3. Licensed/Certified by the DOH as applicable
4. Comply with provisions of perfomance commitment. They must have their own ongoing formal
program of quality assurance that satisfy PhilHealths standards
Accreditation Requirements for Physicians, Dentists, Nurses, Midwives, Pharmacists and other
Licensed Health Care Professionals
1.
2.
3.

They must be duly licensed to practice in the Philippines by the PRC;


They must be members of the Program with qualifying premium contributions;
They must comply with the provisions set forth in the performance commitment for professionals

* No accreditation fee shall be charged; no certificate of good standing is required


IX. BENEFIT PACKAGE 2, 3, 5, 6, 11
The Benefit package to be enjoyed by ALL members includes the following:
1. Inpatient hospital care
a. Room and board
b. Services of health care professionals
c. Diagnostic, laboratory and other medical examination services
d. Use of surgical or medical equipment and facilities
e. Prescription drugs and biologicals; subject to limitations of the act
f. Health Education
2. Outpatient care
a. Services of health care professionals
b. Diagnostic, laboratory and other medical examination services
c. Personal preventive services
d. Prescription drugs and biologicals, subject to limitations stated in Section 37 of RA 7875
e. Health Education
3. Health Education Packages
4. Emergency and transfer services
5. Other health care services that PhilHealth shall determine to be appropriate and cost-effective
Excluded Personal Health Services: those deemed by PhilHealth and DOH to be cost-ineffective through
health technology assessment (A field of science that investigates the value of a health technology such as
procedure, process, products, or devices, specifically on their quality, relative cost-effectiveness and safety. It
usually involves the science of epidemiology and economics. It has implications on policy, decision to adopt
and invest in these technologies, or in health benefit coverage. RA 10606)
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The following are NOT included in the benefit package unless PhilHealth recommends otherwise after
actuarial studies:
1. non-prescription drugs and devices
2. drug/alcohol abuse or dependency treatment
3. cosmetic surgery
4. optometric services
5. fifth and subsequent normal obstetrical delivery
6. cost ineffective procedures which shall be defined by PhilHealth
Note: in RA 7875, normal obstetrical deliveries, out-patient psychotherapy and counseling for mental
disorders and home & rehabilitation services used to be part of excluded personal health services. After RA
9241 amended RA 7875, PhilHealth could now include these services in the minimum basic package.
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 OR paid in full the required premium for the year. He should have a
PhilHealth ID and he should NOT be currently subject to legal penalties by PhilHealth
2. SSS/GSIS retirees and pensioners prior to March 4, 1995
3. PhilHealth Members who have reached the age of retirement and have made at least 120 monthly
contributions.
4. Enrolled indigents
Special Benefit Package
1. Case Rates
2. TB Treatment through DOTS
3. SARS and Avian Influenza
4. Novel Influeza A (H1N1)
Case Rates

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http://www.philhealth.gov.ph/members/special_package/case_rates.htm

TB Treatment through DOTS

http://www.philhealth.gov.ph/members/special_package/tbdots_benefits.htm

No Balance Billing for Indigents in Government Health Care Institutions


No other fee/expense shall be charged to indigents in government health care institutions, subject to
guidelines by PhilHealh
Indigent members have preferential access to HCIs social welfare funds
Health Care Professionals must not charge over and above the professional fees provided by
Philhealth for members admitted to a service bed
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Payment for Health Care Professional in Health Care Institutions


Professional Fees payments in Public HCIs are pooled and distributed among health personnel.
Charges paid to public facilities are retained by the HCI and are to be utilized to defray operating
costs other than salaries
X. PREMIUM CONTRIBUTIONS 3, 6, 10

The amount of premium contribution shall NOT exceed 5% of the members respective monthly
salaries to be shared equally by the employer and employee. The members monthly contribution
shall be automatically deducted by the employer from the formers salary, wage or earnings.

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http://www.philhealth.gov.ph/news/updates/2014/citizens_charter_2013_revised.pdf

http://www.philhealth.gov.ph/news/updates/2014/citizens_charter_2013_revised.pdf

The premium payment for Sponsored Members shall be as follows:


1.

2.

3.
4.

Members of the informal economy from the lower income segment who do not qualify for full
subsidy under the means test rule of the DSWD shall be subsidized by the LGUs or through cost
sharing mechanisms between/among LGUs, and/or legislative sponsors, and/orother sponsors
and/or the member, including the National Government.
The premium contributions of orphans, abandoned and abused minors, out-of-school youths,
street children, persons with disability (PWD), senior citizens and battered women under the
care of the DSWD, or any of its accredited institutions run by NGOs or any nonprofit private
organizations, shall be paid by the DSWD and the funds necessary for their inclusion in the Program
shall be included in the annual budget of the DSWD;
The needed premium contributions of all barangay health workers, nutrition scholars, barangay
tanods, and other barangay workers and volunteers shall be fully borne by the LGUs concerned;
The annual required premium for the coverage of un-enrolled women who are about to give birth
shall be fully borne by the National Government and/or LGUs and/or legislative sponsors or the
DSWD if such woman is an indigent as determined by it through the means test. (PhilHealth IRR)

*the female spouse identified by the DSWD which is considered the primary member for indigent families

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XI. PAYMENT OF CLAIMS TO HEALTH CARE PROVIDERS 3, 5, 6


Mechanisms:
1. Fee for service
2. 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 another 60 days if there natural calamites/other fortuitous events.
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)
Hospital confinements of less than 24 hours shall be compensated only if:
Patient is transferred to another health care institution
Emergency cases
The patient dies
Claims in non-accredited health care institutions shall be compensated if it meets the following
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 NHIP for members
admitted to PhilHealth bed
XII. OFFENSES 3
Offenses of Institutional Health Care Providers
1. Padding of claims
2. Making claims for non-admitted or non-treated patient
3. Extending period of confinement
4. Post-dating of claims
5. Misrepresentation by furnishing false/incorrect information
6. Filing of multiple claims
7. Unjustified admission beyond accredited bed capacity
8. Unauthorized operations beyond service capability (performing complex procedures in a primary
hospital)
9. Fabrication/Possession of fabricated forms and supporting documents
10. Other fraudulent acts
Offenses of Health Care Professionals
1. Misrepresentation by false/incorrect information
2. Breach of warranties of accreditation
3. Other violation whether willful or negligent
Offenses of Employers
1. Failure/Refusal to deduct contributions
2. Failure/Refusal to remit contributions
3. Unlawful deductions
4. Institution as Offenders

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Administrative Penalties

Penalties for PhilHealth member fraudulently claiming benefits: Fine between P5,000-P10,000 and/or
supension for 3-6 months.
Penalties for employer who does not deduct and remit contribution: not less than P5,000 x number of
employees involved
XIII. STATISTICS AS OF DECEMBE 31 20139

http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf

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http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
REGISTERED MEMBERS:
Private: 33%
Sponsored Program - 31%
IPP (Individually Paying Program): 17%
OWP (Overseas Workers Program): 10%
Lifetime: 2%
ACCREDITATION (HOSPITAL TYPE)
Private (1052 Institutional Health Care Providers): 60%
Government (1053 Institutional Health Care Providers): 40%
9 out of 10 DOH-licensed hospitals are accredited by PhilHealth

http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf

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http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf

http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
Sponsored Program (Number of Claims Paids) Jan 1- Dec 31, 2013
Case Rates: 62%
Fee for Service: 38%
No Billing Balance: 30%
Not NBB: 70%
Support Value
Support Value: 54%
Out of Pocket: 46%

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XIV. SOURCES
1.
2.
3.
4.
5.

RA 7875
RA 9241 and 10606
PhilHealth Implementing Rules and Regulation 2013
The PhilHealth Chronicles
You and your Medicare Benefits A Primer on the Most Commonly Asked Questions on the National
Health Insurance Program
6. PhilHealth Website
7. PhilHealth Annual Reports 1996-2004
8. PhilHealth Stats and Charts 1996-2004
9. http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
10. http://www.philhealth.gov.ph/news/updates/2014/citizens_charter_2013_revised.pdf
11. http://www.philhealth.gov.ph/members/special_package/case_rates.htm
To My Dear Students:
You are destined to become Doctors.
Have faith.
See you at the oathtaking!
From Broli, Bogie, and Rocky =)

loroteyang@yahoo.com

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