First
of all, is PhilHealth coverage mandatory for all Filipinos?
Yes, PhilHealth membership is
compulsory. According to Republic Act 7875 Art. III, Sec. 6. Coverage - All
citizens of the Philippines shall be covered by the National Health Insurance
Program. In accordance with the principles of universality and compulsory
coverage enunciated in Section 2 (b) and 2 (1) hereof, implementation of
the Program shall, furthermore, be gradual and phased in over a period of not
more than fifteen (15) years: Provided, That the Program shall not be made
compulsory in certain provinces and cities until the Corporation shall be able
to ensure that members in such localities shall have reasonable access to
adequate and acceptable health care services.
Philhealth
Main Objectives:
Provide all citizens of the
Philippines with the mechanism to gain financial access to health services;
Create the National Health Insurance
Program, hereinafter referred to as the Program, to serve as the means to help
the people pay for health care services;
Prioritize and accelerate the
provision of health services to all Filipinos, especially that segment of the
population who cannot afford such services; and
Establish the Philippine Health
Insurance Corporation, hereinafter referred to as the Corporation, that will
administer the Program at central and local levels.
Philhealth
Member Category
Overseas
Worker/ OFW
·
Who are
qualified member
Active land-based Overseas Filipino Workers (OFWs) who
underwent the normal process of registration as an OFW at Philippine Overseas
Employment Administration (POEA) Offices.
OFWs who are currently abroad but are not yet registered
with PhilHealth may also register under this category.
Note: Sea-based OFWs such as seafarers are considered
locally Employed Members.
·
Member
registration procedures
Submit duly accomplished PhilHealth Member Registration Form
together with applicable for each qualified dependent declared.
Submit any of the following documents as proof of being an
active OFW:
ü Valid Overseas Employment Certificate (OEC) or
E-receipt
ü Valid overseas employment contract or certificate of
employment
ü Valid re-entry visa
ü Valid job contract
Pay the annual premium amounting to P1,200.00. Premium
payments covering the entire duration of contract (equivalent to the number of
years provided for in your contract) is highly encouraged.
Individually
Paying
·
Who are
qualified member
Self-employed individuals - those who work for him/herself
and is therefore both the employer and employee, including but not limited to
the following:
ü Self-earning professionals like doctors and lawyers
ü Business partners and single proprietors /
proprietresses
ü Actors, actresses, directors, scriptwriters and news
reporters who are not under an employer-employee relationship
ü Professional athletes, coaches, trainers and jockeys
ü Farmers and fisher folks
ü Workers in the informal sector such as ambulant vendors,
watch-your-car boys, hospitality girls, tricycle drivers, etc.
ü Separated from employment - those who were previously
formally employed (with employer-employee relationship) and are separated from
employment.
ü Employees of international organizations and foreign
governments based in the Philippines without agreement with PhilHealth for the
coverage of their Filipino employees in the program.
All other individuals not covered under the previous categories
mentioned, including but are not limited to the following:
ü Parents who are not qualified as legal dependents, indigents
or retireess/pensioners
ü Retirees who did not meet the minimum of 120 monthly premium
contributions to qualify as non-paying members
ü Children who are not qualified as legal dependents
ü Unemployed individuals who are not qualified as
indigents
·
Member
registration procedures
ü Attach clear copy of supporting documents for qualified
dependents to be declared
ü Registrant will be issued his/her PhilHealth Identification
Number or PIN and the PhilHealth Member
ü Registration Form or PMRF and shall be asked to pay the
required premiums to the PhilHealth Cashier.
ü Succeeding premium payments may be made at any of
PhilHealth’s accredited collecting banks.
Employed
Sector
·
Who are
qualified member
ü Government sector
ü Private sector
ü Foreign business organizations based abroad with agreement
with PhilHealth to cover their Filipino employees
ü Sea-based OFWs
ü Household employees
·
Member
registration procedures
ü Attach clear copy of supporting documents for qualified
dependents declared
ü Submit to the HR Department for them to forward the above
documents to PhilHealth together with ER2 Form (Report of Employee-Members).
ü PhilHealth will send the PhilHealth Identification Card or
PIC and a copy of the Member Data Record to the member, through the
employer
Lifetime
Sector
·
Who are
qualified member
Old-age retirees and pensioners of the GSIS, including
uniformed and non-uniformed personnel of the AFP, PNP, BJMP and BFP who have
reached the compulsory age of retirement before June 24, 1997.
·
Member
registration procedures
ü Submit the following to any PhilHealth Local Health
Insurance Office (LHIO) nearest you:
ü Duly accomplished PhilHealth Membership Registration Form
(PMRF)
ü Two (2) pieces of latest "1X1" ID picture
ü Photocopy of Birth Certificate or ANY two (2) valid IDs
issued by a government official authority with birth date
Note: Please
present original copy
- Senior Citizen ID
- Passport
- Driver’s License
- Professional Regulation Commission (PRC) ID
- National Bureau of Investigation (NBI) Clearance
- Police Clearance
- Postal ID
- Voter's ID
- Barangay Certification
- Government Service Insurance System (GSIS) e-Card
- Social Security System (SSS) Card
- OFW ID
- Seaman's Book
- Overseas Workers Welfare Administration (OWWA) ID
- Alien certification of Registration/ Immigrant
Certification of Registration
- Government Office and Government Owned and Controlled
Corporation (GOCC) ID
- Certificate from the National Council for the Welfare
of the Disabled Persons (NCWDP)
- Department of Social Welfare and Development (DSWD)
Certification
- Integrated Bar of the Philippines ID
- Company ID issued by private entities or institutions
registered with or supervised or regulated either by the Bangko Sentral ng
Pilipinas (BSP), Securities and Exchange Commission (SEC) or Insurance
Commission (IC).
Benefit
coverage
Inpatient coverage
Outpatient coverage
Day surgeries, dialysis and cancer treatment procedures such
as chemotherapy and radiotherapy.
Special Benefit Packages
Exclusions
- Fifth and subsequent normal obstetrical
deliveries
- Non-prescription drugs and devices
- Alcohol abuse or dependency treatment
- Cosmetic surgery
- Optometric services
- Other cost-ineffective procedures as defined by
PhilHealth
Benefit availment conditions
- Eligibility Requirements
- Payment of at least three (3) monthly premiums within
six (6) months prior to the month of confinement.
- Confinement in an accredited hospital for at least 24
hours (except when availing of outpatient care and special packages) due
to illness or injury requiring hospitalization.
- Attending physicians must also be
PhilHealth-accredited.
- The 45 days allowance for hospital room and board is
not consumed yet.
Post Availment Reminders
After the automatic deduction or reimbursement of your
benefits, PhilHealth will send the Benefit Payment Notice or BPN to the address
indicated in the member’s claim form. The BPN is a report of actual payments
made by PhilHealth relative to member’s the confinement/availment.
Should there be discrepancies between the amounts reflected
in the BPN and in the member’s final billing statement issued by the hospital,
or if the member has other concerns pertaining to benefit availment, he may
contact PhilHealth or the health care provider. The member must bring the BPN
as reference document.
Availment
procedures
Outright/automatic
deduction of benefits
Submit
the following to the billing section prior to hospital discharge:
·
Duly accomplished PhilHealth Claim
Form 1
·
Clear copy of Member Data Record
(MDR)
For qualified dependent not listed in the MDR, submit clear
copy of 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.
Direct
Filing/reimbursement
Submit the following to PhilHealth or through the hospital
in addition to the documents mentioned earlier within 60 calendar days from the
date of discharge:
1.
PhilHealth Claim Form 2 (to be
filled up by the hospital and attending physicians)
2.
Official receipts of payments made
to the hospital and to the doctor's waiver
3.
Operative record, if surgical
procedures was performed
Confinement
abroad
Submit the following within180 days from the date of
discharge. Overseas confinements shall be paid based on Level 3 hospital
benefit rates and in the Philippine peso equivalent. Overseas confinements shall
be paid based on Level 3 hospital benefit rates.
1.
PhilHealth Claim Form 1
2.
MDR or supporting documents
3.
Original official receipt or
detailed statement of account (written in English)
4.
Medical certificate (written in
English) indicating the final diagnosis, confinement period and services
rendered.
Disclaimer: This
blog is not in any way authorized, commissioned, endorsed or sanctioned by the
Philippine Health Insurance Corporation. The authors make no guarantees about
the accuracy of the information presented in this blog, though every effort is
exerted to ensure the correctness and accuracy of all explanations and
procedures described in the posts.
