phil health
TRANSCRIPT
PhilHealthPhilHealthPresented by:Presented by:
Flolet C. AguirreFlolet C. AguirreLeana M. DizonLeana M. Dizon
Jeadverl F. GuintoJeadverl F. GuintoMaria Louise M. MunarMaria Louise M. Munar
Rochelle Ann S. PanganRochelle Ann S. PanganDominick D. CanlasDominick D. Canlas
Rashid Paul P. GeronaRashid Paul P. GeronaKevin Ashley L. YapKevin Ashley L. Yap
MARIA Project
August 4, 1969
PMCC
House Bill 14225 and Senate Bill 01738
Philippine Health Insurance Corporation (PhilHealth)
HistoryHistory
Vision
Mission
Core Values
People and PartnershipHarmonyInnovationLeadershipHonor, Accountability and TransparencyExcellence and Lifetime LearningHealth for All
Vision, Mission and Core Values
Vision, Mission and Core Values
Know the Rules!Know the Rules!• PhilHealth does not pay for all your
health care costs.
• PhilHealth pays only for covered items and services when its rules are met.
• Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth
• PhilHealth does not pay for all your health care costs.
• PhilHealth pays only for covered items and services when its rules are met.
• Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth
PhilHealthPhilHealth• Govt owned and controlled corporation
• Created by Republic Act 7875
• National Health Insurance Program (NHIP)
• Amended by Republic Act 9241
• Access to health care is a basic right of citizens – “Universal coverage”
• Govt owned and controlled corporation
• Created by Republic Act 7875
• National Health Insurance Program (NHIP)
• Amended by Republic Act 9241
• Access to health care is a basic right of citizens – “Universal coverage”
Members andDependents
Members andDependents
Our MembersOur Members
1. Employees (govt and private)
– monthly payment (3% salary)
2. Individually Paying Program (voluntary)
- quarterly payment (1,200/year)
3. Overseas Workers Program
- Annual payment (900/year)
1. Employees (govt and private)
– monthly payment (3% salary)
2. Individually Paying Program (voluntary)
- quarterly payment (1,200/year)
3. Overseas Workers Program
- Annual payment (900/year)
Our MembersOur Members4. Non-paying (pensioner)
- no payment for life
• 60 years old
• With total 120 monthly contributions
5. Sponsored (thru partnership with LGUs)
- annual payment, eligibility for 1 year
4. Non-paying (pensioner)
- no payment for life
• 60 years old
• With total 120 monthly contributions
5. Sponsored (thru partnership with LGUs)
- annual payment, eligibility for 1 year
Your DependentsYour Dependents
• Spouse
• Children < 21 years old
• Parents > 60 years old
• Spouse
• Children < 21 years old
• Parents > 60 years old
BenefitsBenefits
45 Days Annual Allowance45 Days Annual Allowance
• 45 days allowance per year for the principal (member)
• Another 45 days shared among dependents
• 45 days allowance per year for the principal (member)
• Another 45 days shared among dependents
Your benefitsYour benefits• Illness requiring hospitalisation
• Outpatient:– Surgical procedures
• Cataract surgery• BTL• Vasectomy• Endoscopy• Excision• Suturing
• Illness requiring hospitalisation
• Outpatient:– Surgical procedures
• Cataract surgery• BTL• Vasectomy• Endoscopy• Excision• Suturing
Drugs and MedicinesDrugs and Medicines
• Only drugs used during confinement will be paid
• Drugs must be written in generic name
• Closed formulary – only drugs listed in the preferred list* will be covered by PhilHealth
*6th edition of the Philippine National Drug Formulary (PNDF)
• Only drugs used during confinement will be paid
• Drugs must be written in generic name
• Closed formulary – only drugs listed in the preferred list* will be covered by PhilHealth
*6th edition of the Philippine National Drug Formulary (PNDF)
Drugs and MedicinesDrugs and Medicines
• Only drugs, supplies, and lab
used on confinement shall be
paid
– Must be supported by official
receipts
• Only drugs, supplies, and lab
used on confinement shall be
paid
– Must be supported by official
receipts
• physician charges separately for each patient encounter or service rendered
• expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one
• Needs itemization
• physician charges separately for each patient encounter or service rendered
• expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one
• Needs itemization
Fee for Service Scheme:Fee for Service Scheme:
Benefit Periods
• PhilHealth benefits are divided into benefit
periods
• A benefit period is essentially a single
hospital stay, including re-hospitalisation of
up to 90 days
• In each benefit period, PhilHealth will only
pay 1 benefit
• PhilHealth benefits are divided into benefit
periods
• A benefit period is essentially a single
hospital stay, including re-hospitalisation of
up to 90 days
• In each benefit period, PhilHealth will only
pay 1 benefit
ProfessionalFeeProfessionalFee
PAY TO DOCTOR
Private Patient, Government Hospital
NO Stamp: PF is made to the Chief
PAY TO CHIEF
Service Patient, Pay Hospital
Name of Surgeon
NO Stamp: PF is made to the MD who signed Form 2
Eligibility RulesEligibility Rules
• For employed, at least 3 monthly contributions within the immediate 6 months prior to admission
• the 45-days allowance for room and board has not been consumed yet
• confinement in an accredited hospital of not less than 24 hours
• For employed, at least 3 monthly contributions within the immediate 6 months prior to admission
• the 45-days allowance for room and board has not been consumed yet
• confinement in an accredited hospital of not less than 24 hours
Are you eligible?Are you eligible?
Additional Tips for Better Payment
1. Eliminate down coding by providing complete descriptions
2. Rank procedures by order of importance
3. Don’t send documents not required
4. Submit claims promptly and frequently
5. Complete forms ASAP
6. Fill in all blanks. Type NA
7. Make it a practice to follow up with Claims Dept.
