PhilHealth

Vision A premier government corporation that ensures sustainable, affordable and progressive social health insurance which endeavors to influence the delivery of an accessible quality health care for all Filipinos Mission As a financial intermediary, PhilHealth shall continuously evolve a sustainable National Health Insurance Program that shall: y y y y Lead towards universal coverage Ensure better benefits for its members at affordable premiums; Establish close coordination with its clients through a strong partnership with all stakeholders; and, Provide effective internal information and management systems to influence the delivery of quality health care services.

Our History THE call to serve the rural indigents echoed since the early '60s when the Philippine Medical Association introduced the MARIA Project which prioritized aid to communities in need of medical assistance. The Project would then be considered a valuable precursor to the Medicare program, from which a medical care plan for the entire Philippines was created. On August 4, 1969, Republic Act 6111 or the Philippine Medical Care Act of 1969 was signed by President Ferdinand E. Marcos which was eventually implemented in August 1971. The Philippine Medical Care Commission (PMCC) was tasked to oversee the implementation of the program which went for almost a quarter of a century. In the 1990s, a vision for a better, more responsive government health care program was prompted by the passage of several bills that had significant implications on health financing. The public's clamor for a health insurance that is more comprehensive in terms of covered population and benefits led to the development of House Bill 14225 and Senate Bill 01738 which became "The National Health Insurance Act of 1995" or Republic Act 7875, signed by President Fidel V. Ramos on February 14, 1995. The law paved the way for the creation of the Philippine Health Insurance Corporation (PhilHealth), mandated to provide social health insurance coverage to all Filipinos in 15 years' time. PhilHealth assumed the responsibility of administering the former Medicare program for government and private sector employees from the Government Service Insurance System in October 1997, from the Social Security System in April 1998, and from the Overseas Workers Welfare Administration in March 2005.

PHILHEALTH Members
Qualified Dependents The following also enjoy PhilHealth coverage without additional premiums for each qualified dependent: y y Legal spouse (non-member or membership is inactive) Child/ren - legitimate, legitimated, acknowledged and illegitimate (as appearing in birth certificate) adopted or step below 21 years of age, unmarried and unemployed. Also covered are child/ren 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, including stepparents (biological parents already deceased) and adoptive parents (with adoption papers).

y

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All of your qualified dependents shall be entitled to a separate coverage for up to 45 days per calendar year. However, their 45 days allowance will be shared among them. Important: Your dependents need to be declared and/or updated with PhilHealth to include them in your Member Data Record or MDR, your official membership profile with PhilHealth. Your updated MDR will make your benefit availments easier and convenient. Amending your membership data Data amendment procedures Submit duly accomplished Member Data Amendment Form or (M2) with the following supporting documents as applicable: Correction or change of name: Original or Certified True Copy (CTC) of the Birth Certificate, or in its absence, any two (2) of the following secondary documents: y y y y y y y y y Marriage Contract/Certificate, if married Passport NBI Clearance PRC ID SSS/GSIS ID Postal ID Driver's License Alien 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 Certified True Copy (CTC) of Birth Certificate, or in its absence, any two (2) of the applicable supporting documents mentioned above, except for PRC ID and the joint affidavit. Change of civil status: y y Single to Married Married to Widowed Marriage Annulled - Original or CTC of Marriage Contract / Certificate - Original or CTC of Death Certificate of spouse or Judicial Declaration of Presumptive Death - Original or CTC of annulment papers

y

New / additional dependents: y Legal spouse - CTC of Marriage Contract / Certificate

2

y

Legitimate or illegitimate - CTC of the Birth Certificate children Stepchild/ren - CTC of Marriage Contract / Certificate between the natural parent and the stepfather/mother and Birth Certificate/s of the dependent stepchild/ren - CTC of Birth Certificate and Certification from attending physician stating dependent is disabled - Court Decree of Adoption - CTC of Birth Certificate of member and any proof attesting the date of birth of the parents

y

y

Disabled child/ren 21 years old and above Adopted child/ren Parents

y y

1.

OVERSEAS WORKERS PROGRAM

In March 1, 2005, PhilHealth assumed the administration of the Medicare Program for Overseas Filipino Workers from the Overseas Workers Welfare Administration by virtue of Executive Order No. 182 as amended. The said transfer of program completed the consolidation of different Medicare programs separately administered by the Government Service Insurance System for public sector workers and the Social Security System for those in the private sector. It also paved the way for the creation of the Overseas Workers Program or OWP, to which you proudly belong, as a regular membership category in PhilHealth. The OWP covers all land-based overseas Filipino workers whose jobs are covered by appropriate job contracts with overseas-based employers. Under PhilHealth, your coverage assures you and your family of expanded and more responsive health care benefits. You are assured too of lifetime coverage as soon as you reach the age of retirement and have paid at least 120 month's worth of premiums to PhilHealth!

y

Benefits

Inpatient coverage: PhilHealth provides subsidy for room and board, drugs and medicines, laboratories, operating room and professional fees for confinements of not less than 24 hours. Please refer to the table of rate ceilings/maximum allowances for inpatient coverage. Outpatient coverage: Day surgeries, dialysis and cancer treatment procedures such as chemotheraphy and radiotheraphy in accredited hospitals and free-standing clinics. Special benefit packages: o o o o o Enhanced Outpatient Benefit Package Coverage for up to the fourth normal delivery! Newborn Care Package TB treatment through DOTS SARS and Avian Influenza Package

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o

Influenza A (H1N1) Package

****Special Packages Enhanced Outpatient Benefit Package Enjoy a comprehensive package of benefits designed to ensure the health of our new heroes and their families. Available in the Philippines only. A. Consultation B. Diagnostic services y y y y y y y y y y y y y y y y Complete blood count (CBC) Routine urinalysis Fecalysis Fasting blood sugar Blood typing Hemoglobin/Hematocrit Electrocardiogram (ECG) Anti-streptolysin O (ASO-Titer) Hepatitis B Screening Test Treponema pallidum hemaglutination assay (TPHA) Potassium hydroxide (KOH) Erythrocyte sedimentation rate (ESR) Pregnancy test X-ray (Skull, Chest, Lower and Upper Extremities) Sputum Microscopy Pap Smear

C. Visual acuity examination D. Psychological evaluation and debriefing E. Promotive/preventive health services: y y y y y y y Visual acetic acid screening for cervical cancer Periodic digital rectal examination Periodic clinical breast examination (CBE) Counseling for cessation on smoking Lifestyle modification (regular blood pressure measurement and nutritional or dietary counseling) Counseling for reproductive health particularly breastfeeding Nutritional or dietary counseling

F. Auditory evaluation G. Treatment of the following diseases based on PhilHealth-adopted clinical practice guidelines: y y y Urinary tract infection (UTI) Upper respiratory tract infection (URTI) Acute gastroenteritis (AGE)

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Availment procedures Here are two simple steps for you and your families to avail of the enhanced outpatient benefit package: 1. Present clear copy of Member Data Record or MDR to the receiving clerk of the hospital.

o o

If qualified dependent is not listed in the MDR - submit valid ID and proof of dependency If MDR is not available - present also valid official receipt of premium payment

2.

After verification, you may now proceed to the doctor for consultation!

Note: Availment of this package shall not be deducted from your 45-days allowance for room and board and from the separate 45-days allowance of your dependents. Coverage for normal spontaneous deliveries PhilHealth provides compensation for uncomplicated normal spontaneous delivery or NSD of the first four births done either in hospital or non-hospital settings. For deliveries in hospital facilities - subsidy shall be broken down as follows: Services Hospital charges which includes room and board; drugs and medicines; laboratory, supplies and other ancillary procedures; labor room, delivery room and recovery rooms; other medically-necessary charges for delivery and postpartum care. Professional fees for delivery services, immediate post-partum care and counseling for reproductive health, breastfeeding and newborn care. Prenatal services for reimbursement of member¶s prenatal expenses prior to confinement which may include drugs and medicines, laboratory tests and ancillary procedures, tetanus immunization, and consultations supported by official receipts. Total Coverage

Php 2,500

Php 2,500

Php 1,500

Php 6,500

For deliveries in non-hospital facilities a comprehensive package consisting of maternal and childcare services are offered under theMaternity Care Package.

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Details of coverage: Services Facility and professional fees which cover charges for PF (delivery, postpartum care, and counseling for reproductive health, breast feeding and newborn screening); room and board; drugs and medicines; laboratory, supplies and other ancillary procedures; labor, delivery and recovery rooms; and other medically necessary charges for delivery and postpartum care. Prenatal services to be reimbursed to the member for prenatal expenses prior to confinement. May cover essential drugs and medicines, laboratory tests and ancillary procedures, tetanus immunization, and PF for consultations supported by official receipts. Total Additional information: Providers Eligibility Exclusions Duly accredited lying-in clinics, birthing homes or midwife-managed clinics. Confinement within validity period as stated in the Member Data Record ‡ NSD of the fifth and subsequent births. ‡ Maternal age of less than 19 years. ‡ First pregnancy of patients aged 35 years and older. ‡ Multiple pregnancies ‡ Ovarian abnormalities (ovarian cyst) ‡ Uterine abnormalities (myoma uteri) ‡ Placental abnormalities (placenta previa) ‡ Abnormal fetal presentations (breech) ‡ History of three or more miscarriages/abortions ‡ History of one stillbirth ‡ History of major obstetric and/or gynecologic operation (cesarian section, uterine myomectomy). ‡ History of medical conditions such as hypertension, pre-eclampsia, eclampsia, heart disease, diabetes, thyroid disorder, morbid obesity, moderate to severe asthma, epilepsy, renal disease, bleeding disorders. ‡ Other risk factors that may arise during present pregnancy (e.g. premature contractions and vaginal bleeding) that warrants a referral for further management. Pregnancies resulting to abortion are not covered by the limitation of coverage of vaginal deliveries of the first four births. Coverage

Php 5,000

Php 1,500

Php 6,500

Other conditions

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Newborn Care Package Part of PhilHealth's commitment to bringing healthy babies who will be tomorrow's nation builders is the Newborn Care Package. Details of coverage: Amount coverage Services included of Php 1,000 ‡ Eye prophylaxis, umbilical cord care, Vitamin K, thermal care, administration of BCG vaccine and resuscitation of the newborn - Php 250. ‡ First dose of Hepatitis B immunization - Php 250. ‡ Newborn screening tests - Php 500. Duly accredited hospitals and non-hospital facilities (such as lying-in clinics, midwife-managed clinics, birthing homes, rural health units, ambulatory surgical clinics and other analogous health facilities) with DOH or NSRC certified newborn screening facility. Newborn-dependent/s even if delivery is not covered by PhilHealth (i.e., fifth and subsequent normal deliveries) Only claims with Newborn Screening Test done between 24-36 hours from complete delivery of the newborn shall be compensated. However, for newborns placed in intensive care to ensure survival, premature and sick newborns may be exempted from the 3-day requirement but should be tested within seven days of age. Room and board not compensated but one day shall be charged against the 45-days allowance for room and board for dependents. Newborns/neonates admitted/confined due to other conditions or illnesses may avail of other benefits (including room and board) based on case/type of illness. Claims for said confinement should also include applicable newborn care services provided for in the package and shall not be considered a separate benefit.

Providers

Eligibility Other conditions

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. Details of coverage:

Amount coverage Services included

of Php 4,000 Diagnostic work-up, consultation services and anti-TB drugs required in an outpatient set-up.

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Providers Eligibility

Duly accredited TB-DOTS Centers (available in the Philippines only) New cases only, i.e., patient has never had treatment for TB or who has taken anti-TB drugs for less than one month. Enrolment with TB-DOTS center falls within the validity period as stated in the Member Data Record.

Exclusions

Failure cases - a patient who, on previous treatment, is sputum smear positive at five months or later during the course of treatment. Relapse case - a patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB. Return after default (RAD) cases - a patient who returns to treatment with positive bacteriology (smear of culture) following interruption of treatment for two months or more.

Other conditions

Additional services rendered or extension of treatment shall not be covered.

SARS and Avian Influenza (Influenza Pandemic or Bird Flu) Package Details of coverage:

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.

Services included y y y Providers Professional fees (Php 2,500 - pay to doctor) Hospital charges (Php 42,500 - pay to hospital) Official receipts amounting to Php 12,000 (Php 5,000 - pay to member)

Patients must be admitted only in accredited DOH-designated SARS or AI/IP hospitals. Confinements abroad shall be paid compensated provided a certification from the attending physician is submitted.

Eligibility

Must be certified by the DOH as SARS or avian influenza/influenza pandemic patient. Confinement within the validity period as stated in the Member Data Record.

Exclusions

SARS suspect cases. Cases of acute respiratory illness where an alternative diagnosis can fully explain such illness.

Other conditions

Rule on single period of confinement and 45-days allowance for room and board per year applies.

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Other conditions(for afflicted HCWs) y y y y Must also be active PhilHealth members. Contracted the disease while caring for a SARS or AI/IP patient (person to person transmission). Renders service in DOH-designated hospital. DOH attests that HCW contracted the disease while on official duty.

y

Availment conditions and procedures

Availment conditions The following must first be met to avail of your PhilHealth benefits: y y Availment must be within the validity period as stated in your Member data record or MDR or in the payment receipt. The 45 days allowance for room and board of the member and the separate 45 days allowance shared among the dependents have not been consumed yet.

Benefit availment procedures For outright/automatic deduction of benefits: Submit to the billing section the following prior to discharge from the hospital: o Duly accomplished PhilHealth Claim Form 1 (original) o Clear copy of 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 Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit. Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill.

y

y y

For direct filing/reimbursement: Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge: y y y PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians) Official receipts or hospital and doctor's waiver Operative record for surgical procedures performed

For confinements abroad: Submit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates. y PhilHealth Claim Form 1

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y y y y

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.

Post availment reminders: After the automatic deduction or reimbursement of your benefits, PhilHealth will send you (to the address you have indicated in your claim form) a benefit payment notice or BPN. The BPN is a report of actual payments made by PhilHealth relative to your confinement/availment. Should there be discrepancies or if you have other concerns pertaining to your benefit availments, you may contact PhilHealth or your health care providers and bring the BPN as reference document. Continuing your Coverage The following are some of the options available to you if you wish to continue your PhilHealth coverage. Use the M2 Form to update PhilHealth of changes in your membership status. Just be sure to have the form duly acknowledged by PhilHealth. y If no longer an active OFW or is currently in the Philippines waiting for another overseas contract: Register as an Individually Paying Member and continue paying your premiums for only Php 300/quarter at any PhilHealth Offices or accredited payment centers. Payment can be made quarterly, semi-annually or annually. y If gaining formal employment in the Philippines: Provide your employer with your PhilHealth Identification Number or PIN for their use in remitting your premiums as an Employed Member. y If already reached 60 years old and have contributed at least 120 monthly premiums and is not gainfully employed: You may now register under as a Lifetime Member to enjoy lifetime coverage together with your qualified dependents. EMPLOYED SECTOR PROGRAM This program is for all employees in the government sector(regardless of their status of appointment) and in the private sector under which household helps and sea-based overseas Filipino workers belong. Under this program, monthly premiums are shared between the employee and the employer and are remitted to PhilHealth by the employer through accredited payment centers nationwide. y Premium Contribution Schedule for the Employed Sector

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Salary Bracket

Salary Range

Salary Base

Total Monthly Premium

Employee Share

Employer Share

1

4,999.99 and below

4,000.00

100.00

50.00

50.00

2

5,000.00 - 5,999.99

5,000.00

125.00

62.50

62.50

3

6,000.00 - 6,999.99

6,000.00

150.00

75.00

75.00

4

7,000.00 - 7,999.99

7,000.00

175.00

87.50

87.50

5

8,000.00 - 8,999.99

8,000.00

200.00

100.00

100.00

6

9,000.00 - 9,999.99

9,000.00

225.00

112.50

112.50

7

10,000.00 - 10,999.99

10,000.00

250.00

125.00

125.00

8

11,000.00 - 11,999.99

11,000.00

275.00

137.50

137.50

9

12,000.00 - 12,999.99

12,000.00

300.00

150.00

150.00

10

13,000.00 - 13,999.99

13,000.00

325.00

162.50

162.50

11

14,000.00 - 14,999.99

14,000.00

350.00

175.00

175.00

12

15,000.00 - 15,999.99

15,000.00

375.00

187.50

187.50

13

16,000.00 - 16,999.99

16,000.00

400.00

200.00

200.00

14

17,000.00 - 17,999.99

17,000.00

425.00

212.50

212.50

15

18,000.00 - 18,999.99

18,000.00

450.00

225.00

225.00

16

19,000.00 - 19,999.99

19,000.00

475.00

237.50

237.50

17

20,000.00 - 20,999.99

20,000.00

500.00

250.00

250.00

18

21,000.00 - 21,999.99

21,000.00

525.00

262.50

262.50

19

22,000.00 - 22,999.99

22,000.00

550.00

275.00

275.00

20

23,000.00 - 23,999.99

23,000.00

575.00

287.50

287.50

21

24,000.00 - 24,999.99

24,000.00

600.00

300.00

300.00

22

25,000.00 - 25,999.99

25,000.00

625.00

312.50

312.50

23

26,000.00 - 26,999.99

26,000.00

650.00

325.00

325.00

11

24

27,000.00 - 27,999.99

27,000.00

675.00

337.50

337.50

25

28,000.00 - 28,999.99

28,000.00

700.00

350.00

350.00

26

29,000.00 - 29,999.99

29,000.00

725.00

362.50

362.50

27

30,000.00 and up

30,000.00

750.00

375.00

375.00

*Employee share represents half of the total monthly premium while the other half is shouldered by the employer. y Benefits

Inpatient coverage: PhilHealth provides subsidy for room and board, drugs and medicines, laboratories, operating room and professional fees for confinements of not less than 24 hours. Please refer to the table of rate ceilings/maximum allowances for inpatient coverage. Outpatient coverage: Day surgeries, dialysis and cancer treatment procedures such as chemotheraphy and radiotheraphy in accredited hospitals and free-standing clinics. 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

y y y y y

Availment conditions and procedures

Availment conditions The following must first be met to avail of your PhilHealth benefits: y y Payment of at least three monthly premiums within the immediate six months prior to confinement. Confinement in an accredited hospital for at least 24 hours (except when availing of outpatient care and special packages) due to an illness or disease requiring hospitalization. Attending physicians must also be PhilHealth-accredited. Availment is within the 45 days allowance for room and board.

y

Benefit availment procedures For outright/automatic deduction of benefits: 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).

y

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y y

If dependent - patient is not listed yet in the MDR, submit applicable proof of dependency Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit. Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill. y

For direct filing/reimbursement: Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge: y y y PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians) Official receipts or hospital and doctor's waiver Operative record for surgical procedures performed

For confinements abroad: Submit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates. y y y y PhilHealth Claim Form 1 MDR or supporting documents 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.

Post availment reminders: After the automatic deduction or reimbursement of your benefits, PhilHealth will send you (to the address you have indicated in your claim form) a benefit payment notice or BPN. The BPN is a report of actual payments made by PhilHealth relative to your confinement/availment. Should there be discrepancies or if you have other concerns pertaining to your benefit availments, you may contact PhilHealth or your health care providers and bring the BPN as reference document. Continuing your Coverage Be guided by the following in continuing your PhilHealth coverage. Use the M2 Form in shifting member categories. y If leaving formal employment to venture into self-employment: Register as an Individually Paying Member and continue paying your premiums for only Php 300/quarter at any PhilHealth Offices or accredited payment centers. Payment can be made quarterly, semi-annually or annually. y If seeking employment as land-based Overseas Filipino Worker:

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Indicate your existing PhilHealth Identification Number or PIN when processing your registration and payment to PhilHealth as an OFW. y If already reached 60 years old and have contributed at least 120 monthly premiums and is not gainfully employed: You may now register as a Lifetime Member to enjoy lifetime coverage. INDIVIDUALLY PAYING PROGRAM Established in 1999, the Individually Paying Program is open to self-practicing professionals, freelance writers and photographers, artists, employees of religious and civic organizations and Philippine-based international organizations. The program also welcomes self-employed individuals, farmers and fisherfolks, and even daily wage earners such as vendors and transport drivers and operators. Your health insurance premiums are remitted voluntarily at any accredited payments centers on a quarterly, semiannual or annual basis. Benefits Inpatient coverage: PhilHealth provides subsidy for room and board, drugs and medicines, laboratories, operating room and professional fees for confinements of not less than 24 hours. Please refer to the table of rate ceilings/maximum allowances for inpatient coverage. Outpatient coverage: Day surgeries, dialysis and cancer treatment procedures such as chemotheraphy and radiotheraphy in accredited hospitals and free-standing clinics. 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

y y y y y

Availment conditions and procedures Availment conditions The following must first be met to avail of your PhilHealth benefits: y Payment of at least three monthly premiums within the immediate six months prior to confinement. For pregnancy-related cases and availment of the new born care package, dialysis (except those undergoing emergency dialysis service during confinement), chemotherapy, radiotherapy and selected surgical

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procedures, payment of nine (9) monthly premium contributions within the last 12 months shall be required except for those enrolled under the KASAPI program. y Confinement in an accredited hospital for at least 24 hours (except when availing of outpatient care and special packages) due to an illness or disease requiring hospitalization. Attending physicians must also be PhilHealth-accredited. Availment is within the 45 days allowance for room and board.

y

Benefit availment procedures For outright/automatic deduction of benefits: Submit to the billing section the following prior to discharge from the hospital: y Duly accomplished PhilHealth Claim Form 1 (original) y Proof of applicable premium payments. y Clear copy of Member Data Record (MDR). y If patient is a qualified dependent but not listed in the MDR, submit applicable proof of dependency. y Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit. y Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill.

y

For direct filing/reimbursement: Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge: y y y PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians) Official receipts or hospital and doctor's waiver Operative record for surgical procedures performed

For confinements abroad: Submit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates. y y y y y 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.

Post availment reminders: After the automatic deduction or reimbursement of your benefits, PhilHealth will send you (to the address you have indicated in your claim form) a benefit payment notice or BPN. The BPN is a report of actual payments made by PhilHealth relative to your confinement/availment.

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Should there be discrepancies or if you have other concerns pertaining to your benefit availments, you may contact PhilHealth or your health care providers and bring the BPN as reference document. Continuity of Coverage The following are some of the options available to you if you wish to continue your PhilHealth coverage. Use the M2 Form to update PhilHealth of changes in your membership status. Just be sure to have the form duly acknowledged by PhilHealth. y If gaining formal employment in the Philippines: Provide your employer with your PhilHealth Identification Number or PIN for their use in remitting your premiums as an Employed Member. y If seeking employment as land-based Overseas Filipino Worker: Indicate your existing PhilHealth Identification Number or PIN when processing your registration and payment to PhilHealth as an OFW. y If already reached 60 years old and have contributed at least 120 monthly premiums and is not gainfully employed:

SPONSORED PROGRAM Considered the heart of the National Health Insurance Program, this program provides health insurance coverage to less privileged families through a partnership where health insurance premiums for a year's coverage are paid in behalf of deserving members. (Ang Sponsored Program ang itinuturing na puso ng National Health Insurance Program dahil sa pamamagitan nito ay nabibigyan ng health insurance ang mga mahihirap na pamilya.) The annual premiums of enrolled families are jointly shouldered by the National Government through PhilHealth and sponsors such as local governments, private individuals with philanthropic hearts and private corporations whose thrusts include poverty alleviation as an agenda in their corporate social responsibility (CSR) programs. Members of Congress also join the program as sponsors through their Priority Development Assistance Fund or PDAF. (Ang kanilang taunang premiums ay binabalikat ng PhilHealth at ng mga sponsors gaya ng nga lokal na pamahalaan, mga pilantropo, mga pribadong kumpanya at maging mga miyembro ng Kongreso sa pamamagitan ng kanilang Priority Development Assistance Fund o PDAF.) Benefits Inpatient coverage: PhilHealth provides subsidy for room and board, drugs and medicines, laboratories, operating room and professional fees for confinements of not less than 24 hours. Please refer to the table of rate ceilings/maximum allowances for inpatient coverage.

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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. Special benefit packages: Outpatient Benefit Package Coverage for up to the fourth normal delivery! Newborn Care Package TB treatment through DOTS SARS and Avian Influenza Package Influenza A (H1N1) Package

y y y y y y

Availment conditions and procedures Availment conditions The following must first be met to avail of your PhilHealth benefits: y y y y Availment/confinement is within the validity period as stated in the Family Health Card or Member Data Record. Must be admitted in an accredited hospital and attended to by accredited physicians. Confinement of at least 24 hours (except when availing of outpatient care and special packages) due to an illness or disease requiring hospitalization. Availment is within the 45 days allowance for room and board.

Benefit availment procedures For outright/automatic deduction of benefits: Present your valid Family Health Card to the admitting/billing section. Submit the following prior to discharge from the hospital:  Duly accomplished PhilHealth Claim Form 1 (original)  Copy of valid Family Health Card  Copy of MDR. y If patient is a qualified dependent but not listed in the MDR, submit applicable proof of dependency or PhilHealth Form CE-1. Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit. Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill. For confinements in DOH-retained hospitals, Sponsored Members will no longer have to pay anything.

y y

y y y

For direct filing/reimbursement: Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge: y PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians)

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y y

Official receipts or hospital and doctor's waiver Operative record for surgical procedures performed

For confinements abroad: Submit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates. y y y y y PhilHealth Claim Form 1 Valid Family Health Card MDR/supporting documents/PhilHealth Form CE1 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.

Post availment reminders: After the automatic deduction or reimbursement of your benefits, PhilHealth will send you (to the address you have indicated in your claim form) a benefit payment notice or BPN. The BPN is a report of actual payments made by PhilHealth relative to your confinement/availment. Should there be discrepancies or if you have other concerns pertaining to your benefit availments, you may contact PhilHealth or your health care providers and bring the BPN as reference document. Continuity of Coverage The following are some of the options available to you if you wish to continue your PhilHealth coverage after your Family Health Card expires. Use the M2 Form to update PhilHealth of changes in your membership status. Just be sure to have the form duly acknowledged by PhilHealth. y If venturing into self-employment: Register as an Individually Paying Member and continue paying your premiums for only Php300/quarter at any PhilHealth Offices or accredited payment centers. Payment can be made quarterly, semi-annually or annually. y If gaining formal employment in the Philippines: Provide your employer with your PhilHealth Identification Number or PIN for their use in remitting your premiums as an Employed Member. y If seeking employment as land-based Overseas Filipino Worker: Indicate your existing PhilHealth Identification Number or PIN when processing your registration and payment to PhilHealth as an OFW. y If already reached 60 years old and have contributed at least 120 monthly premiums and is not gainfully employed:

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You may now register as a Lifetime Member to enjoy lifetime coverage.

HEALTH CARE PROVIDERS
Accreditation is a privilege given only to health care providers who are at par with the exacting standards of PhilHealth. Through accreditation, we forge partnerships with only the best in the industry to fulfill our mandate of providing all Filipinos with accessible, available, acceptable and affordable health care services that will lead to better health outcomes and improved quality of life. Institutional Health Care Providers Accreditation Process What is Accreditation? It is a process whereby the qualifications and capabilities of health care providers are verified in accordance with the guidelines, standards and procedures set by the Corporation. Why the need for accreditation? To participate in the National Health Insurance To assure that health care services rendered by them are of the desired and expected quality. Who may apply? Hospitals Ambulatory Surgical Clinics (ASCs) Free Standing Dialysis Clinics (FSDCs) Rural Health Units/Health Centers (RHUs/HCs) as providers of the Out Patient Benefit Package for sponsored members of PHIC Maternity Care Clinics - for low risk, normal spontaneous deliveries Anti-TB/DOTS Clinics Program.

y y y y y y

When to apply? 1. Initial or Re-accreditation - anytime 2. Renewal o Hospitals, ASCs and FSDCs: January 1 to 31 of the succeeding year o OPB, Maternity Care and Anti-TB/DOTS Package Providers: September 1 - 30 of the current year.

y y

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Status of Accreditation Institutional HCP (as of July 2010) Hospitals Ambulatory Surgical Clinics Free Standing Dialysis Clinics Outpatient Benefit Package Providers (RHUs/HCs) Maternity Care Package Providers Anti-TB/DOTS Centers Total Professional Health Care Providers Accreditation Process What is Accreditation? It is a process whereby the qualifications and capabilities of health care providers are verified in accordance with the guidelines, standards and procedures set by the Corporation. Why the need for accreditation? To participate in the National Health Insurance To assure that health care services rendered by them are of the desired and expected quality. Who may apply? Physicians Dentists Midwives Program. No. of Accredited Facilities 1,549 42 44 1291 603 705 4234

y y y

When to apply? 1. Initial or Re-accreditation - anytime 2. Renewal o 120 - 91 days prior to the expiry of accreditation.

y y

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Status of Accreditation as of December 31, 2009 Professional HCP (as of June 2010) No. of Accredited 10,298 11,095 217 220 21,830

General Practitioners Medical Specialists Dentists Midwives Total

EMPLOYERS
Are you an employer concerned about how best you can protect the company's bottom line? We know that as managers who aim for greater financial sustainability and corporate longevity, you want to equally sustain the productivity of your valued partners in the workforce. Today, more and more companies are investing in health and wellness programs, treating such investments as effective management strategies and not as expenses. One way of ensuring financial sustainability and employee productivity is to make sure that your employees are adequately covered by health insurance that will enable them to manage the rising costs of hospitalization. It is in this area where your PhilHealth can help you get the health insurance cover that will respond to the health care needs of your employees at the most reasonable price. Beyond being a mandatory undertaking for employers, providing PhilHealth coverage is a sure way to lessen the impact of medical costs that can affect your company's finances. The premiums that you religiously contribute to PhilHealth on behalf of every employee under your care are sure investments in their health and productivity - undeniably the keys to keeping a company's bottom line. Employer registration with PhilHealth All government and private sector employers shall be required to register with PhilHealth to enable them to provide social health insurance coverage to their employees. Private sector employers, including those of household helps, who have registered with the SSS prior to July 1, 1999 are considered automatically registered and will only be required to update their records with PhilHealth. Registration procedures and documentary requirements 1. Submit the following at any PhilHealth Office: For Government Sector Employers -

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y y

Employer Data Record or ER1 Form (in duplicate) M1a forms for each employee (in duplicate)

For Private Sector Employers y y Employer Data Record or ER1 Form (in duplicate) Business permit/license to operate and/or any of the following as applicable: Nature of Entity Single proprietorships Additional Documents Required Department of Trade and Industry (DTI) Registration Securities and Exchange Commission (SEC) Registration Securities and Exchange Commission (SEC) Registration Cooperative Development Authority (CDA) Registration Barangay Certification and/or Mayor's Permit

Partnerships and corporations

Foundations and non-profit organizations

Cooperatives

Backyard industries/ventures and micro-business enterprises

2.

After processing, the employer will be issued the following: y y PhilHealth Employer Number (PEN) and the Certificate of Registration PhilHealth Identification Number (PIN) and Member Data Record (MDR) for concerned employees

3.

Employers shall be asked to display the Certificate of Registration in their offices as proof of registration with PhilHealth.

Amending Employer Data An employer may request revision or amendment in data previously furnished by submitting the following: y y Employer data Amendment Form or ER3 Any of the following to substantiate the request for amendment: Nature of Amendment Correction/change of business Additional Documents Required Certificate of filing of business name with DTI or Articles of

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name/legal personality Temporary suspension of operation

Partnership/Incorporation If due to bankruptcy - any of the following: y y y Financial Statement Income Tax Return Board Resolution

Separation of employees - all of the following: y y Latest submitted prescribed PhilHealth form Separation paper of last employee

If due to fire or demolition - all of the following: y y Termination/dissolution Certification from the City/ Municipal Fire Department Certification from the concerned city or municipality

For single proprietorships - all of the following: y y Approved application for business retirement by the City or Municipal Treasurer's Office Death Certificate in case of death of owner

For partnerships or corporations - any of the following: y y Deed of Dissolution approved by SEC Minutes of Meeting certified by the corporate secretary

For Cooperatives: y Certificate/Order of Dissolution/Cancellation issued by the CDA

Under fortuitous events as defined by law - to submit applicable documents as determined by PhilHealth Mergers Submit any of the following: y y Change of ownership Resumption of operation Deed of Merger/Merger Agreement duly certified by SEC Memorandum of Agreement filed with SEC

Deed of Sale/ Transfer/Assignment Prescribed PhilHealth form reporting newly hired or re-hired employees.

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Closure due to fortuitous events

Submit applicable documents as determined by PhilHealth

Reporting your Employees to PhilHealth Report form to be used

If reporting for:

Grace period

Newly hired employees Within 30 calendar days from assumption to office. ER2 Form Separated employees Within 30 calendar days from separation. Indicate in the RF1

Employers shall also be required to keep true and accurate work records that should contain information as PhilHealth may prescribe. Such records shall be open for inspection by PhilHealth or any of its authorized representatives. PhilHealth Premium Rates The monthly health insurance premium of an employee is pegged at 2.5 percent of the salary base of the range within which their basic monthly salary belongs. Only half of the required monthly premium is shouldered by the employee which are automatically deducted and withheld from their salary, while the other half is paid for by the employer. The employer's counterpart in the payment of contributions shall not in any manner be charged to the employee. Refer to the Table of Premium Contributions for your reference. Payment and Reporting Procedures 1. 2. Deduct from the employee's salary the corresponding amount of premium. Together with the employer's counterpart, the premiums shall be remitted to PhilHealth or at any accredited collecting bank/agent on or before the 10th day of the month following the month being paid for. Use the ME-5 Form in remitting your premiums. To facilitate posting of your premium payments, employers shall be required to report their payments to PhilHealth on a monthly basis using the revised Remittance Report Form (RF-1). Starting with your July 2008 payments, submission of monthly RF-1 must be made on or before the 15th of the month following the applicable month. Your RF-1 shall be filed with your respective PhilHealth Office or you may drop them in drop boxes located in selected accredited banks nearest you. Accredited Collecting Agents Updated July 26, 2010 Local Universal Banks Allied Bank Corporation Banco de Oro Unibank (previous EPCIB branches only) Bank of the Philippine Islands** China Bank Corporation

3.

y y y y

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y y y y y y y y

Citibank N. A. Development Bank of the Phils. Land Bank of the Philippines Metropolitan Bank and Trust Company* Philippine National Bank Rizal Commercial Banking Corp. United Coconut Planters Bank Union Bank of the Phil.(Over-the-Counter & E-Pay)**

Commercial Banks Asia United Bank Bank of Commerce Export & Industry Maybank Philippines Philippine Veterans Bank

y y y y y

Thrift Banks Asia Trust Bank Bank One Savings and Trust Corp. Century Savings Bank Citystate Savings Bank Philippine Business Bank Philippine Postal Bank & Savings, Inc. Planters Development Bank Premiere Development Bank RCBC Savings Bank Robinson's Savings Bank

y y y y y y y y y y

Rural Banks 1st Valley (RB) / RB of Kapatagan Valley Country Rural Bank of Taguig Enterprise Bank, Inc. Gulf Bank One Network Bank, Inc. Peninsula Rural Bank, Inc. People's Bank of CARAGA Producer's Rural Banking Corp. Asian Hills Bank, Inc. Century Rural Bank, Inc. Money Mall Rural Bank, Inc. Progressive Bank, Inc. Rural Bank of Bambang (NV), Inc. Rural Bank of Sta. Catalina (Negros Oriental), Inc. Rural Bank of Jose Panganiban (CN), Inc. Rural Green Bank of Caraga

y y y y y y y y y y y y y y y y

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Cooperative Bank Bukidnon Cooperative Bank

y

Non Bank Philippine Postal Corporation (Regions 2, 4A, 4B, V, VI, VIII, X, XI & XII) E-Soluzione MLhuillier Phils. Inc. (Region VI only) Local Government Units o a. PhRO IV-A  Calauag, Quezon  Catanauan, Quezon  Guinayangan, Quezon  Perez, Quezon  San Narciso, Quezon  Tagkawayan, Quezon  Unisan, Quezon o PhRO IV-B  Taytay, Palawan o PhRO VIII  Bato, Leyte  Laoang, Samar  Leyte, Leyte o PhRO X  Calamba, Misamis Oriental  Initao, Misamis Oriental  Kibawe, Bukidnon o PhRO XII  Banicilan, Cotabato Province

y y y y

Overseas Banks Development Bank of the Philippines » Philippine Veterans Bank »

y y

Non Bank I-Remit, Inc. » (Asia, Pacific, Europe, Middle East and North America)

y

*Selected branches only **E-Pay only and initially available to Employers

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