2011 revised dialysis benefit schedule
TRANSCRIPT
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Benefits Development and Research Department
Philippine Health Insurance Corporation
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OUTLINE
1 • General
2 • Peritoneal Dialysis
3 • Hemodialysis
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Payroll contribution
Taxes Payment
Providers
Indigents
Employed Self-employed Pensioners
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Formally Employed
Compulsory enrollment for those employed in the government and private sectors
Premiums are paid thru payroll deductions equally shared by the employer and the employee
(2.5% of the total salary per law or 1.25% each paid by employee and employer ); subject to a salary cap
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Overseas Workers
PhilHealth assumed Medicare
functions for OFWs on March 1,
2005
Previously administered by the
Overseas Workers Welfare
Administration (OWWA)
Premium is P900 (around US$19)
per member per year
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Sponsored Program
For families belonging to the lowest income quartile of the population. P1,200 (about US$25) per family per year shared by the National Government (NG) and Local Government Units (LGUs). The proportion of the sharing depends on the income classification of the LGU.
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Lifetime
Members who have reached the age
of retirement (generally 60 years
old) and have paid at least 120
monthly contributions become
lifetime members of PhilHealth
without contributing additional
premiums to the Program
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Individually Paying
Covers the: informal sector (street vendors, drivers, etc) professionals (free-lance lawyers, doctors, etc) individuals who could not be covered by any other programs of PhilHealth
Premium is P1,200 (about US$25) per member per year
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Coverage extends to immediate family…
Legitimate spouse (non-member)
Children* below 21 y.o., unmarried and unemployed
Parents (biological, step or adoptive) 60 y.o. and above & not covered by NPP
*legitimate, illegitimate, legitimated adopted or stepchildren
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Eligibility Requirements
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9/12 Guidelines:
1. Hemodialysis and peritoneal dialysis
2. Chemotherapy administration
3. Radiation oncology services
4. Selected surgeries listed in Annex of Circulars (please refer to www.philhealth.gov.ph)
Exempted from this rule members undergoing emergency dialysis services during hospital confinements.
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Requirements for Filing
PhilHealth Form 1
• (member & employer)
PhilHealth Form 2
• (doctor & hospital)
Member Data Record (MDR)
• Primary document for all members
Other supporting documents
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L4
L3
L2
L1
Tertiary
Level 4
Level 3
Ambulatory surgical clinics (ASC) Freestanding dialysis centers (FDC)
Secondary (Level 2)
Primary (Level 1)
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CASETYPE
Case type is an assessment of complexity of illness assigned to a case after discharge.
It is measured on a four (4) scale system
Fixed on ICD, with exceptions
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Case Types
Medical Surgical
A Simple 0- 80
B Moderate 81- 200
C Severe 201- 500
D Extreme 501- 600
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Case-type A B C D
PD, HD, KT
Level 3 & 4 Hospitals (Tertiary)
Room & Board* P500/day P500/day P800/day P1,100/day
Drugs and Medicines** P4,200 P14,000 P28,000 P40,000
X-ray, Lab & Others P3,200 P10,500 P21,000 P30,000
Level 2 Hospital (Secondary)
Room & Board* P400/day P400/day P600/day N/A
Drugs and Medicines** P3,360 P11,200 P22,400 N/A
X-ray, Lab & Others P2,240 P7,350 P14,000 N/A
Level 1 Hospital (Primary)
Room & Board* P300/day P300/day N/A N/A
Drugs and Medicines** P2,700 P9,000 N/A N/A
X-ray, Lab & Others P1,600 P5,000 N/A N/A
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1/5/2012 Free Template from www.brainybetty.com 21
Peritoneal Dialysis Any modalities of PD may be claimed from
PhilHealth by patients registered at accredited PD centers and hospitals
Modalities:
Automated
Continuous ambulatory PD (CAPD)
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Peritoneal Dialysis 1. All PD exchanges per day = 1 day
2. Claims for PD (Per Single Period of Confinement)
Dialysis solution
Supplies
Laboratory
Facility
3. Maximum 20 liters PD solution per day
4. PF based on RVU
10 RVU x 56 PCF = 560 pesos
To be paid to AP; kidney disease-related management
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Single Period of Confinement
Re-admissions due to same illness within a 90-day period shall only be compensated within one (1) maximum benefit:
Availment for the same illness or condition which is not separated from each other by more than 90 days will not be provided with a new benefit
Only the remaining benefit from the previous confinements may be availed
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Expenses Prior to Admission Claims for drugs and medicines; and supplies,
radiology, laboratory and other ancillary procedures purchased prior to admission may be reimbursed only for:
peritoneal dialysis,
hemodialysis,
chemotherapy and
other elective surgeries
Must be supported by official receipts (with TIN) Official receipts must be dated 30 days prior to admission
Official receipts issued by doctors will not be reimbursed
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BENEFITS LEVEL 4 HOSPITAL
Case Type C PD
Room & Board @ 800/day 0
Drugs & Medicines 28,000
Lab, X-ray, Supplies 21,000
OR Fee @ 20/RVU 0
PF Surgeon @ 10 RVU 560
PF Anesthesiologist @ 40% surgeon’s fee 0
PF Medical Management @ 700/day 0
TOTAL 49,560
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BENEFITS LEVEL 4 HOSPITAL
Case Type C KT HD
Room & Board @ 800/day 8,000 0
Drugs & Medicines 28,000 28,000
Lab, X-ray, Supplies 21,000 21,000
OR Fee @ 20/RVU 9,600 1,200
PF Surgeon @ 480 RVU 26,800 560
PF Anesthesiologist @ 40% surgeon’s fee
10,752 0
PF Medical Management @ 700/day
5,600 0
TOTAL 109,752 50,600
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1/5/2012 Free Template from www.brainybetty.com 27
Tip to maximize your benefit!
File only up to
• 3 claims per month or
• 9 claims per 90 days
(single period of confinement)
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45 days consumed in 1 quarter
(45/Q)
45 days consumed
in 2 quarters (22/Q)
45 days consumed
in 3 quarters (15/Q)
45 days consumed
in 4 quarters (11/Q)
1st Quarter 50,000 50,000 50,000 50,000
2nd Quarter 50,000 50,000 50,000
3rd Quarter X 50,000 50,000
4th Quarter X X 50,000
Maximum benefit
50,000 100,000 150,000 200,000
Dialysis Benefit for Tertiary Drugs; Lab, Supplies & Others
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PhilHealth Circular Nos. 011, 011-A and 011-B, s-2011
Pursuant to Board Resolution No.1441 s.2010
Case payment mechanism for the most common medical and surgical conditions (49% of total claims)
“No Balance Billing Policy” (NBB)
Improve turn-around time for claims processing and payment
Effectivity: September 1, 2011
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NEW PAYMENT MECHANISM Case Payment Scheme
Hospital payment method that reimburses hospitals a predetermined fixed rate for each treated case
also called per-case payment or packages
Single rate regardless of hospital category and length of stay
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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
Surgical Case Rates
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Case rate directly paid to the facility
40% of rate is for PF except for hemodialysis
Allowed only in L2 to L4 facilities, but some may allowed in other facilities: – Completion curettage : L1
– Fractional curettage : L1, ASC
– Herniorraphy : ASC
– Laparoscopic chole : ASC
– Cataract : ASC
– Hemodialysis : FDC
– Radiotherapy : L3 to L4 only
Surgical Case Rates
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General Rules
Shall follow the rule on single period of confinement
Except for hemodialysis and radiotherapy per session
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Hemodialysis 90935
Features: @4,000 per session
Outpatient hemodialysis
Includes payment for PF (Php500), dialyzer and epoetin
Not allowed in L1 and ASC
Excluded (pay under FFS): – Hemodialysis during confinements – Peritoneal dialysis – Treatment of acute renal failure – Creation of fistula
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No Balance Billing Policy
“No Balance Billing” Policy shall mean that no
other fees or expenses shall be charged or paid
for by the patient-member above and beyond
the packaged rates.
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No Balance Billing Policy
Shall be applied to ALL SPONSORED Program members and/or their dependents for the specified cases under the following conditions:
1. When admitted in government facilities/ hospitals.
2. When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in accredited government hospitals and all non-hospital facilities (e.g. FDCs, ASCs)
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No Balance Billing Policy
3. Claims for reimbursement of Sponsored members and/or their dependents availing of the following existing outpatient packages:
a) TB DOTS (Php 4,000)
b) Malaria (Php 600)
c) HIV-AIDS (Php 7,500 /qtr or Php 30,000/yr)
All other existing policies/guidelines covering these packages shall remain in effect.
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No Balance Billing Policy
4. In support of Millennium Development Goals (MDG)
NBB policy shall apply to ALL PhilHealth members and their dependents regardless of membership type in ALL Accredited MCP (non-hospital) providers
This shall cover claims for MCP and NCP
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NBB APPLICATION
Facility/Benefit Sponsored Non Sponsored
Gov’t Hosp NBB X
Private Hosp X X
MCP NBB NBB
DOTS NBB X
Malaria NBB X
HIV AIDS NBB X
FDC NBB X
ASC NBB X
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No Balance Billing Policy
Facility should purchase necessary items/services in advance on behalf of the member if drugs, supplies, or diagnostic procedures are not available.
Out-of-pocket payment (OOP) made by members shall automatically be deducted against claims of the hospitals (charged to case rates) with corresponding sanctions or penalties the Corporation may charge.
Require attachment of official receipt/s (ORs) for any OOP made by member (for hospital and/or professional fee)
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Remember
Number of days allowed per year
45 for the member
Another 45 for all dependents
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Remember
Number of days per single period of confinement
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Remember
Days prior to session official receipts honored
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Remember
Number of days allowed to file claim from date of discharge
Number of days allowed to comply with returned claim
Number of days allowed for PhilHealth to process claims
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