Social Health Insurance

in the Philippines

Jane M.N. Sta. Ana, R.N.

Member, Board of Directors
Philippine Health Insurance Corporation
 History of NHIP
Started from the government’s desire to provide its people with
access to effective medical care services
at an affordable price

1972 – Medical Care Act - the country’s first attempt at

universal social health insurance

1995 – National Health Insurance Act - mandate of PhilHealth is

to provide universal social health insurance coverage

The law has been subsequently amended in 2004 through

Republic Act 9241 and in 2013 through Republic Act 10606.

Draws inspiration from the Filipino trait of

“bayanihan” or social solidarity

*Artwork by Filipino National Artist

Carlos "Botong" Francisco
Vision and Mission

Every Filipino is a member,

Every member is financially-risk protected,
Everyone’s health is assured.

Value-added benefits for every member,

Quality service for all.
Covered Members and Dependents
(as of June 2015)
Sector Members Dependents Beneficiaries
Members in the
Formal Economy 13,368,671 14,204,553 27,573,224

Private 11,326,505 10,377,566 21,704,071

Government 1,982,042 3,782,546 5,764,588

Household Help/Kasambahay 59,482 43,421 102,903

88% of 2015
projected population
Enterprise Owner & Family Drivers 642 1,020 1,662
Members in the
Informal Economy 3,602,640 4,163,236 7,765,876

Migrant Worker 1,086,439 976,336 2,062,775

Informal Sector 2,107,443 2,702,689 4,810,132

Self-Earning Individual 396,898 471,890 868,788

Organized Group and Others 11,860 12,321 24,181

Indigents
Note:
15,288,583 30,118,509 45,407,092
- Indigent count of members and dependents was based on DSWD Listahan database and are subject for further validation.
Sponsored Members
- 2015 Projected 489,730
Population is 101,449,681 based on May 2010 Census by NSO. 647,921 1,137,651

Senior Citizens 4,813,460 1,068,411 5,881,871

Contributions
Premium Contribution
o Formal Sector – income base (2.5% of the salary, equally
shared by the employer and employee, subject to a salary cap)
o Indigents - premium of P2,400 per year coming from proceeds
of the Sin Tax
o Informal Sector – premium is set at P2,400 per year; this
sector includes Overseas Filipino Workers (OFWs)
o Lifetime members - entitled to lifetime coverage without having
to pay additional premiums. Automatic coverage for all senior
citizens (but those employed, would still have to continue with
premium payments)
Overseas Workers
Eligible to avail of the benefits on the day of enrollment (no
waiting period)

Member and his / her dependents in the Philippines can avail of

the benefits

After expiry of membership, member has one (1) month grace

period to ensure there is no gap in membership
Senior Citizens
All seniors are automatically covered in PhilHealth

The Office of the Senior Citizens Affairs (OSCA) for each city
and municipality issues an electronic list of senior citizens and
they are automatically enrolled as PhilHealth members. Senior
citizens can also apply directly to PhilHealth with any proof of
their age

Members are immediately eligible to avail of the benefits

17 REGIONAL
O F F I C E S

L O C A L
106
OFFICES

6,400 OFFICERS
S T A F F
We paid P1.5 billion every week in 2014,
now we are paying P2 billion every
week

P 55.46 B
P 78.18 B P 48.6 B

2013 2014 June 2015

Accredited Institutional Providers
(as of June 2015)

Type of Ownership Government Private Total

Accredited Facilities 742 1,105 1,847

99% of DOH-licensed hospitals are accredited by PhilHealth

Primary Care Maternity Care

Benefit Package Package DOTS Package

Number of Accredited 2,253 2,381 1,546

Outpatient Clinics
Spectrum of PhilHealth Benefits

Primary Care Catastrophic

Case Rates
& MDGs (Z benefits)

Primary Care Benefit Inpatient cases Acute Lymphocytic Leukemia

Maternity Care Package Day surgeries Early Breast Cancer
Newborn Care Package Chemotherapy Prostate Cancer
TB-DOTS Package Radiotherapy Kidney Transplantation
Animal Bite Package Hemodialysis Coronary Artery Bypass Graft
Malaria Package Total Correction of TOF
Outpatient HIV-AIDS Package Closure of VSD
Cervical Cancer
Z Morph
Peritoneal Dialysis
Provider Payment Mechanisms of
PhilHealth Then and Now...
Partial Case All Case Rates
Fee-for-Service
Rates (23 cases) (ACR)
Implemented last
Implemented during September 2011
the PMCC era carried
over by PhilHealth 49% of the total
claims
Implemented last
Health care providers January 1, 2014
are paid for every Bundled payment (HCI
unit of service fee and PF)
rendered Uniform rate across
Reimbursement is member category and
dependent on case type type of hospital or
and level of per type of facility
hospitals/ facility
 Sulit ang Benepisyo sa PhilHealth

No balance billing. Indigent members would not be paying extra if

they are confined in service wards in government facilities.

Primary Care Benefit (PCB) Package. For Sponsored Members,

they receive a primary care package for basic laboratories and
consultations and would soon include medicines for select chronic
conditions.
TSEKAP Preventive &
Diagnostic Services

• Consultation
• CBC
• BP and Body Measurements
• Breast Exam and Breastfeeding • Urinalysis
Education • Chest x-ray
• Prostatic CA Screening • FBS
• Counselling for Smoking • Lipid Profile
Cessation and lifestyle
• Creatinine
modification
• Risk profiling for Hypertension • ECG
and Diabetes • Blood glucose monitoring
TSEKAP Medicines

• Asthma: Salbutamol, Fluticasone,

• URTI: Amoxicillin, Erythromycin, Paracetamol, Lagundi
• Pneumonia: Amoxicillin, Erythromycin, Co-amoxyclav
• UTI: Ofloxacin, Cotrimoxazole, Co-amoxyclav
• Ischemic Heart Disease: Atenolol, Isosorbide Mononitrate
• Diabetes: Gliclazide
• Hypertension: Enalapril Amlodipine
• Dyslipidemia: Simvastatin
• Gout: Colchicine, Allopurinol

P1,000 cap per family

Top Surgical Case Rates
Surgical Procedures
1 Radiotherapy Linac ₱3,000.00

2 Radiotherapy Cobalt ₱2,000.00

Maternity Care Package (PCF, Birthing Homes) ₱8,000.00
3 Normal Spontaneous Delivery Package ₱6,500.00
(Levels 1-3 Hospitals)

4 Cesarean Section ₱19,000.00

5 Appendectomy ₱24,000.00

Newborn Care Package

6 (Birthing Homes, PCF, Levels 1-3 ₱1,750.00

7 Dilatation & Curettage ₱11,000.00

8 Hemodialysis ₱4,000.00

9 Hysterectomy ₱30,000.00

10 Cataract Package ₱16,000.00

Top Medical Case Rates

Medical Conditions

1 Dengue Fever ₱10,000.00

2 Dengue, Severe ₱16,000.00

3 Pneumonia Moderate Risk ₱15,000.00

4 Pneumonia High Risk ₱32,000.00

5 Hypertensive Emergency / Urgency ₱9,000.00

6 Stroke - Infarction ₱28,000.00

7 Stroke - Hemorrhagic ₱38,000.00

8 Acute Gastroenteritis ₱6,000.00

9 Asthma in Acute Exacerbation ₱9,000.00

10 Typhoid Fever ₱10,000.00

 Type Z Benefits
Type Z Benefits. PhilHealth provides substantial support for
conditions which normally are very expensive.

Coronary Artery
Pediatric P550,000
P210,000 Bypass
Leukemia
Tetralogy of Fallot P320,000
Breast Cancer P100,000
Closure of
Prostate Cancer P100,000
Ventricular Septal P250,000
End Stage Renal Defect
Requiring Kidney P600,000
Cervical Cancer
Transplant P175,000
Chemoradiation
Z Morph (lower limb
P15,000
prostheses)
 Working with Nurses

PhilHealth
Customer Assistance,
Empowerment and Relations Staff
 Working with Nurses

A Circular is currently being finalised that

would provide for the accreditation of nurses
as maternity care providers, antenatal care
and newborn packages
 Key Priorities

 Sustained coverage of the population in the

program;
 Increased financial risk protection that
contributes to poverty reduction; and
 Improved health outcomes through wider
access to health services and better benefits.
Challenges
1. Health expenditure remains low – the Philippines
remain as a low spender on health compared to other regional
and middle income economies.

2. Out of pocket spending is still high – the rising cost of health

care services largely contributes to the growing OOP spending.

3. Poverty incidence has not caught up with overall

improvements – the country’s poverty rate remained one of the
highest in the region despite the decent economic growth.

4. Recurrent shocks from climate change are highly expected –

climate hazards are becoming a constant threat to the social and
environmental determinants of health.
www.philhealth.gov.ph