Professional Documents
Culture Documents
PhilHealth FAQs May 2012
PhilHealth FAQs May 2012
What is the role of PhilHealth’s Board of Directors? Who composes it? .................................................................................................. 10
B. MEMBERSHIP .........................................................................................................................................................................11
What are the fundamental processes that each member should know? ................................................................................................. 13
C. REGISTRATION/ENROLLMENT ............................................................................................................................................13
How do members enrol into the program? Where can they enrol?........................................................................................................... 13
What are the documents required for the registration of employers (and their employees) in the Government Sector and
Private Sector? ................................................................................................................................................................................................................... 16
How can LGUs enrol their underprivileged constituents into the Sponsored Program? ................................................................... 16
Page 2 of 44
Page 3 of 44
Is it true that retiring employees can now be automatically enrolled by the employer in the Lifetime Member
Program? ................................................................................................................................................................................................................. 17
If both parents are members, can they both declare their children as dependents? ............................................................. 18
How can a member declare his spouse whose membership is inactive as a dependent? ................................................... 18
If all siblings are active members, can each of them declare their parents as dependents? .............................................. 18
Can disabled parents (physically or mentally incapacitated) who are below 60 years old be declared as
dependents? .......................................................................................................................................................................................................... 18
Can my live in partner be declared as a legal dependent? How about our children? ........................................................... 18
My daughter who’s still my dependent (under 21) is about to give birth. Will my membership be able to cover
her? ............................................................................................................................................................................................................................ 18
Do I need to personally submit my registration documents or can I ask my representative to do so? ......................... 18
Are we going to use the same PhilHealth Identification Number (PIN) if we are shifting to another membership
category?.............................................................................................................................................................................................................................. 19
I was given a PhilHealth card by our LGU, but my name was misspelled and data provided were also erroneous.
How do I correct this information? .............................................................................................................................................................. 19
Are overtime pay, commissions, and allowances included in the computation of premium contributions of employees?
.................................................................................................................................................................................................................................................. 20
Aside from paying through service offices and collecting agents, is there another way for me to pay my premiums
easily? .................................................................................................................................................................................................................................... 21
What are the requirements for eligibility? When is a member eligible to claim? ................................................................................. 23
What is the tolerable delay for paying premiums for a member to still be able to use his/her benefits? ................................. 24
Can contributions be refunded by the member who was not able to use it? ........................................................................... 24
If I stopped paying my premium for a considerable amount of time, can I still use my benefits? Do I need to pay
the missed contributions to be able to avail of the benefits again? ............................................................................................. 24
If an employed member who was separated from service last October 2011 wants to continue his membership as
an Individually Paying Member in March 2012, can he retroactively pay the premiums for Nov-Dec 2011 and first
quarter 2012, in March 2012? ........................................................................................................................................................................ 25
A new governor/mayor was elected in our area. Am I still considered a member under the Sponsored Program
even with this change in leadership? .......................................................................................................................................................... 25
What if I have multiple jobs? Can I just pay my contributions once? ........................................................................................... 25
I am an employed member, but I recently found out that my employer stopped paying our contributions even
though he continues to deduct the premiums from our salaries. How do we go about this? .......................................... 25
What if the member passes away? Can the dependents still use their benefits? .................................................................... 25
If a member has paid his premium for one year and he died during the first half of the year, can his dependents
refund his premium? .......................................................................................................................................................................................... 26
I already have a lifetime member card, but my current employer still continues to pay for my premiums. Can these
premium contributions be credited to my son/daughter’s membership when I retire? ...................................................... 26
What if a Lifetime Member is re-hired, must he resume contributing to PhilHealth through salary deduction? ...... 26
Are the payments for OWWA Contributions and PhilHealth premiums different?................................................................. 26
If I stopped paying my premium for a considerable amount of time, how will I reactivate my membership? Do I
need to apply for a new membership/PIN? ............................................................................................................................................. 26
How can a SP member continue PhilHealth membership when his/her PhilHealth ID expires? ....................................... 26
I used to be employed, but am now self-employed. Can I still continue paying for my premiums? How do I go
about this? .............................................................................................................................................................................................................. 26
I am a PhilHealth member sponsored by an LGU; is it still necessary for me to pay my membership as an OFW? . 27
Why do I have to renew my PhilHealth membership every time I leave the country and work as an OFW? .............. 27
I am currently abroad and my coverage is about to expire. How do I continue paying for my PhilHealth in case
there are no available payment centers where I am? .......................................................................................................................... 27
If a member has dual citizenship, can he/she still renew his/her membership and avail of the benefits whenever
he/she is in the Philippines? ........................................................................................................................................................................... 27
I am already an immigrant here in the US. Can I still continue my membership with PhilHealth? .................................. 27
Why is there a need to increase the annual premium of OFW members? .............................................................................................. 27
What was the basis for pegging the new premium rate at P2,400 per year? ......................................................................................... 28
Page 4 of 44
Page 5 of 44
Were OFW members consulted by PhilHealth before the increase was approved? ........................................................................... 28
When was the last time that premium contributions of OFW members increased? ........................................................................... 28
Can OFW members whose families were affected by Typhoon Sendong be exempted from paying the new premium
rate? ....................................................................................................................................................................................................................................... 28
Where can they pay their premium contributions in the Philippines? How about abroad? ............................................................ 28
If an OFW’s membership coverage expires while he is still abroad, will he be required to pay, through his kin in the
Philippines, the new rate when he renews his coverage? ............................................................................................................................... 28
What additional benefits can an OFW member expect from PhilHealth? ............................................................................................... 29
Will the increase in premium mean additional benefits for OFWs and their dependents as well? ............................................... 29
Are these benefits available to the OFW member even while he is abroad? ......................................................................................... 29
How do you plan to inform OFWs about the new premium rate in less than two weeks’ time? ................................................... 29
Is PhilHealth making any representation with Philippine Embassies and consulates overseas to inform OFWs about the
increased premium? ........................................................................................................................................................................................................ 30
Since PhilHealth has no physical presence overseas, how do you plan to discuss the new premium rates with OFWs and
OFW organizations at this time? ................................................................................................................................................................................ 30
Where can OFW-members refer their inquiries pertaining to the new premium rates? ................................................................... 30
If I missed the schedule of biometric capture in our office premises, can I proceed to any PhilHealth Branch for this? .... 31
Are there forms I need to fill out before biometric capture day? ................................................................................................................ 31
Will the biometric capture process eat up a lot of my time from work? .................................................................................................. 31
Are there things I must ensure before I proceed with biometric capture? .............................................................................................. 31
Can I update my MDR on the day of biometric capture through the UMID Mobile Team? ............................................................ 31
Once my biometric data have been captured, what are the next steps? ................................................................................................. 31
Where can I call if I have further questions regarding the biometric capture?...................................................................................... 31
What are the requirements to activate my UMID card with PhilHealth? ..................................................................................... 32
If I missed the schedule of card activation in our office premises, can I proceed to any PhilHealth Branch to have
my UMID card activated? ................................................................................................................................................................................. 32
Can I update my MDR on the day of card activation through the UMID Mobile Team? ..................................................... 33
What are the contact numbers if I have further questions regarding the UMID card activation?.................................... 33
What benefits can a member avail himself of under the NHIP? .................................................................................................................. 33
What documents must a member submit to be able to avail of the benefits? ..................................................................................... 36
How can the member avail himself of PhilHealth benefits if he has an existing coverage with a health maintenance
organization? ...................................................................................................................................................................................................................... 37
Can a senior citizen avail himself of both the PhilHealth benefits and his senior citizen privilege when confined? ............. 37
Can overseas Filipino worker-members reimburse their hospitalization expenses with PhilHealth? ........................................... 37
I’ve been paying my premiums regularly, but I still haven’t availed of any benefits. When will I be able to benefit from
my membership? .............................................................................................................................................................................................................. 37
How will the member know if the PhilHealth benefit deducted from his total hospital bill is correct? ......................... 38
What if the amount deducted as PhilHealth benefit is less than what PhilHealth actually paid to the provider for
the member’s confinement? ........................................................................................................................................................................... 38
If siblings are all active members, can each of them file a claim for the confinement of their parents? ....................... 38
If both spouses are members, can each of them file a claim for the confinement of their children? ............................. 38
If the spouse’s, child’s or parent’s name is not listed in the member’s MDR at the time of confinement, how can
the member avail himself of the benefits? ............................................................................................................................................... 38
How can members separated or resigned from employment avail themselves of maternity benefits? ........................ 38
I. SPECIAL SECTION: CASE RATES FOR 23 MEDICAL AND SURGICAL PROCEDURES ........................................................39
Page 6 of 44
Page 7 of 44
Why shift to case rate payments? What advantages will this form of benefit payment bring, especially to the members?
.................................................................................................................................................................................................................................................. 39
What are the surgical cases under Case Rate that can be reimbursed in particular facilities? ....................................................... 39
How will hospitals be paid for 2 or more surgical case rates performed in a single confinement? ............................................. 40
How will the procedures be reimbursed if a procedure performed has laterality (e.g., cataract)? ................................................ 40
What will happen to major surgical procedures done in Level 1 hospitals? ........................................................................................... 40
Is Case Rate covered by the rule on single period of confinement? Will the 45 days allowance apply for case rates? ....... 40
If a member’s total hospital fees for dengue I is beyond the case rate amount listed by PhilHealth, will the member
shoulder the balance? .................................................................................................................................................................................................... 40
A member is admitted for dengue I for three days, and another member is admitted for dengue I for five days, will they
be entitled to the same case rate amount for dengue I of P8,000.00? ..................................................................................................... 40
What medical cases under Case Rate can be reimbursed in Level 1 hospital? Level 2 hospitals?................................................. 40
For medical case rate, how will PhilHealth pay for a patient admitted for several conditions? ..................................................... 41
In case the member was transferred to another hospital, will PhilHealth pay for both facilities? ................................................. 41
For cases not included in the Case Rates table, how will PhilHealth reimburse those cases? ......................................................... 41
What is “No Balance Billing” (NBB) and to whom it will be applicable? ................................................................................................... 41
Why is this being introduced only for Sponsored Program members? .................................................................................................... 41
What are the conditions for availment of benefits of SP members under the NBB policy? ............................................................. 41
Is the NBB policy also applicable to other PhilHealth membership types? ............................................................................................. 41
If the Sponsored member under NBB bought drugs and medicines or other supplies, will he be able to reimburse then?
How? ...................................................................................................................................................................................................................................... 42
In case a sponsored member/dependent was admitted in a government hospital where the only available room that
time for the patient is a private room, can the sponsored member be admitted in any room or private room of a
government hospital? Will the NBB policy still apply? ..................................................................................................................................... 42
What if a sponsored member is admitted in a private hospital? Will the NBB policy still be applicable? ................................. 42
Kailan dapat magpabakuna? Hihintayin pa bang mamatay ang aso bago magpabakuna? ............................................... 43
Kailangan pa ba akong mabakunahan kung kumpleto naman sa bakuna ang asong kumagat? .................................... 43
Mga Paalala............................................................................................................................................................................................................ 43
Saan ba pwedeng maka-avail ng package? Saan ako pwedeng pumunta para magpabakuna kung nakagat ng
aso? ........................................................................................................................................................................................................................... 44
Kailangan ba akong bumili ng bakuna sa labas? Meron pa ba akong dapat bayaran kung may PhilHealth na?...... 44
Paano kung nakagat ako ulit? Ilang beses ako pwedeng makagamit ng PhilHealth para sa ganitong benepisyo?44
Paano kung hindi aso ang nakakagat? Kasama pa rin po ba ito sa benepisyo? ..................................................................... 44
Page 8 of 44
Page 9 of 44
A. THE ORGANIZATION
What is PhilHealth?
The Philippine Health Insurance Corporation (PhilHealth) is a Government-Owned and Controlled Corporation
that was established to administer the National Health Insurance Program nationwide.
This battle cry captures PhilHealth’s primary purpose of being, which is to ensure that all Filipinos, especially
those who cannot afford the cost of health care, are given real financial risk protection. For PhilHealth, real
financial risk protection means that:
1. All Filipinos are enrolled into the NHIP (100% coverage)
2. Members are empowered to enjoy their enhanced benefits
3. Each member will be assigned to a primary care provider who shall address his/her health needs
4. Members have access to accredited facilities that are of superior quality
5. Every Filipino who desires to avail of the No Balance Billing (zero-copayment) policy will always have an
opportunity to do so anywhere in the country. This reduces, if not totally eliminates, debilitating out-of-
pocket health expenses that drive families deeper into poverty.
Page 10 of 44
Page 11 of 44
B. MEMBERSHIP
Sponsored Program
Under the Sponsored Program, indigents belonging to the lowest 40% (Quintiles 1 and 2) of the Philippine
population in terms of income may enrol, including:
1. Families listed under the National Household Targeting System for Poverty Reduction (NHTS – PR) of
the Department of Social Welfare and Development (DSWD)
2. Families identified poor by the sponsoring Local Government Units (LGUs).
Individuals are encouraged to check whether they belong to the DSWD/LGU lists. Identified members and their
dependents shall be considered part of the NHIP.
1. 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,
and retirees under Presidential Decree 408
2. GSIS disability pensioners prior to March 4, 1995
3. SSS pensioners prior to March 4, 1995
4. SSS permanent total disability pensioners
5. SSS death/survivorship pensioners
6. SSS old-age retirees/pensioners
7. Uniformed members of the AFP, PNP, BFP and BJMP who have reached the compulsory age of
retirement on or after June 24, 1997, being the effectivity date of RA 8291 which excluded them in the
compulsory membership to the GSIS
8. Retirees and pensioners who are members of the judiciary
9. Retirees who are members of Constitutional Commissions and other constitutional offices
10. Former employees of the government and/or private sectors who have accumulated/paid at least 120
monthly premium contributions as provided for by law but separated from employment before reaching
the age of 60 years old and thereafter have reached 60 years old
11. Former employees of the government and/or private sectors who were separated from employment
without completing 120 monthly premium contributions but continued to pay their premiums as
Individually Paying Members until completion of the required 120 monthly premium contributions and
have reached 60 years old as provided for by law
12. Individually Paying Members, including SSS self-employed and voluntary members, who continued
paying premiums to PhilHealth, have reached 60 years old and have met the required 120 monthly
premiums as provided for by law
13. Retired underground mine workers who have reached the age of retirement as provided for by law and
have met the required premium contributions
Page 12 of 44
Page 13 of 44
What are the fundamental processes that each member should know?
Each member ought to be familiar with the following fundamental processes:
1. Enrolling or registering into the NHIP
2. Updating their records regularly
3. Paying for their premiums on-time
4. Getting their claims from PhilHealth
5. Knowing their benefits
C. REGISTRATION/ENROLLMENT
How do members enrol into the program? Where can they enrol?
Sponsored Program
Members whose names appear in the NHTS-PR list or LGU’s list of priority families are automatically enrolled
into the program. Their IDs may be claimed from the Local Social Welfare and Development Office. To date, the
NHTS list has been distributed to providers and has been made available online through PhilHealth’s website:
http://www.philhealth.gov.ph/members/sponsored/nhts-pr_list.html.
If members feel like they should be part of the SP, he/she can approach their local DSWD office, which in turn,
will evaluate and determine if he/she is qualified to join the program. The DSWD shall then endorse the list of
possible beneficiaries to the Local Government Unit (LGU) or any Sponsor.
1. Fill out two copies of the PhilHealth Member Registration Form (PMRF).
2. Attach a clear copy of the following supporting documents to this form (for the applying member and
his/her qualified dependents):
a. Member – Birth/baptismal certificate or any ID card issued by a government official authority
b. Dependents
i. Spouse: Marriage certificate/contract
ii. Children below 21: Birth certificate; court decree of adoption (for adopted children)
iii. Parents 60 and above: Birth certificate
3. Submit these documents to the nearest PhilHealth Service Office for processing.
4. Upon submission of documents, the registrant will be issued his/her PhilHealth Identification Number
(PIN) and a Member Data Record (MDR).
5. He/she shall then be asked to pay the required premium through the PhilHealth Cashier or any
accredited collecting agent (banks, local government units, etc.)
Online Registration
1. Members also have an option to register online. Simply visit http://eregister.philhealth.gov.ph and go
through the procedures indicated in the site.
2. Newly hired employees with PIN need only to report their PIN to their employers for them to be
specified in their ER2 (and subsequently updated in PhilHealth’s database).
Page 14 of 44
Page 15 of 44
When abroad:
1. Submit the following documents to any PhilHealth office:
a. PhilHealth Premium Payment Slip (PPPS)
b. Duplicate copies of the PhilHealth Member Registration Form (for initial registration)
c. Supporting documents (birth certificate, baptismal certificate, POEA ECARD/SSS/Company ID,
Passport or any valid ID)
2. Pay the one-year premium of PhP 1,200. If you have already paid PhP900 during your last transaction,
please expect a notice from PhilHealth charging the additional PhP300 to complete your annual premium.
For AFP, PNP, BFP and BJMP Retirees/Pensioners - those who are in active military service until they
retire at age 56 and those separated by retirement or other reasons prior to the said age but have
reached the age of 60, shall submit any of the following:
1. Statement of Services issued by previous employer indicating not less than 120 months of
service excluding leave of absences without pay;
2. Certification/Letter of Approval of Retirement from the GSIS indicating not less than 120
months of service;
3. General, Bureau or Special Order indicating the effectivity date of retirement.
d. Certified true copy (CTC) of Birth Certificate or any two of the following:
1. CTC of Baptismal Certificate
2. CTC of Marriage Contract/Certificate
3. Passport
4. Driver's License
5. SSS Members ID
6. Alien Certificate of Registration (ACR)
7. Service Record/s
8. Employee ID
9. School records
10. Voter's ID
11. Senior Citizens ID
12. Duly notarized joint affidavit of two disinterested persons attesting to the fact of birth of the
registrant
2. After submission and processing, member will be issued his/her PhilHealth Lifetime Member Card,
which shall serve as a valid ID to be used in all PhilHealth transactions.
What are the documents required for the registration of employers (and their employees) in
the Government Sector and Private Sector?
For Government Employers:
1. Employer Data Record or ER1 (in duplicate)
2. PMRF for each employee (in duplicate)
How can LGUs enrol their underprivileged constituents into the Sponsored Program?
LGUs that wish to enrol their constituents through the Partial Subsidy Scheme must go through the following
steps:
1. Submission of letter of intent
2. Submission of certified list of enrolees and accomplished PMRF
3. Payment of premium contribution
Page 16 of 44
Page 17 of 44
Meanwhile, if he/she is self-employed or merely residing in the country, he may enrol as an Individually Paying
Member. He/she only needs to accomplish the following documents and submit these to any PhilHealth office:
1. PhilHealth Member Registration Form (PMRF)
2. Photocopy of his/her Alien Certificate of Registration (ACR) issued by the Bureau of Immigration (BI)
to prove his/her residency in the country.
Hence, if you retired for instance, at the age of 50, you must continue paying premiums as an Individually Paying
Member until you reach the age of 60 and have made the required number of premium contributions.
Is it true that retiring employees can now be automatically enrolled by the employer in the
Lifetime Member Program?
Yes. As per PhilHealth Circular No. 28, s-2010, retiring employees in the government and private sectors must be
enrolled into the Lifetime Member Program and their enrolment must be facilitated by their employers at least
three (3) months prior to the date of retirement.
The application for Lifetime Member Program shall be filed with PhilHealth as soon as the employee's retirement
application has been approved by the employer. The employer's Human Resource Management Office, through
its authorized representative, shall ensure that the documentary requirements for registration are forwarded to
PhilHealth for processing.
If both parents are members, can they both declare their children as dependents?
PhilHealth does NOT allow multiple declaration and application of PhilHealth entitlements of both spouses. We
advise you to decide who among you will declare and provide for the PhilHealth coverage of your only
child/children as dependents.
How can a member declare his spouse whose membership is inactive as a dependent?
The active member-spouse must submit the following at any PhilHealth Office:
1. 2 copies of duly accomplished PhilHealth Member Registration Form
2. Clear copy of Marriage Certificate/Contract with registry number (original copy to be presented for
validation)
3. Request letter to be declared as legal dependent signed by the inactive/unemployed spouse
After processing, PhilHealth will issue a new (updated) Member Data Record which indicates the name of the
spouse (inactive) as legal dependent.
If all siblings are active members, can each of them declare their parents as dependents?
Multiple declarations of dependents are not allowed. Members are advised to decide who among them will declare
their parents as dependents.
Can disabled parents (physically or mentally incapacitated) who are below 60 years old be
declared as dependents?
No; only parents who are 60 years old and above are qualified as dependents.
Can my live in partner be declared as a legal dependent? How about our children?
While the live in partner cannot be declared as a legal dependent (one of the supporting documents required is the
marriage certificate), your children can still qualify as dependents. Simply update your MDR and submit the
necessary supporting documents (i.e., birth certificate) for your children.
My daughter who’s still my dependent (under 21) is about to give birth. Will my
membership be able to cover her?
Page 18 of 44
Page 19 of 44
To update your MDR, simply submit an updated PMRF to the nearest PhilHealth Office, along with the necessary
supporting documents (marriage certificate, birth certificate, etc.).
Are we going to use the same PhilHealth Identification Number (PIN) if we are shifting to
another membership category?
Your PhilHealth Identification Number (PIN) is your PhilHealth number for life. Hence, if you are shifting to
another membership category, you will be using the same PIN.
I was given a PhilHealth card by our LGU, but my name was misspelled and data provided
were also erroneous. How do I correct this information?
If there’s incorrect information in your ID/MDR, you will have to update your MDR by going through the
following steps:
1. Submit two (2) copies of the PMRF with the corrected information to the nearest PhilHealth Office,
along with the necessary supporting documents (birth certificate of any valid ID)
2. Wait for your updated MDR and ensure that the information has been corrected
Effective January 2012, premium contributions will increase to a minimum of P2400, depending on the
membership category (with OFWs as an exception). Different arrangements are being crafted to give payers ample
time to prepare for this increase. Here are the updates for the different programs:
1. Sponsored Program
a. Premiums of NHTS-PR poor amounting to P2400 by January 2012 will be fully subsidized by the
National Government.
b. Through the partial subsidy scheme, LGUs and other donors may provide the full/partial subsidy to
finance the premiums of identified families within their jurisdiction. Premiums will increase to P2400
by July 2012. Prior to this increase, LGUs are given an option to avail of the two-year lock in deal
(P1200/year for two years).
2. Individually Paying
a. For high income members (monthly salary > P25000), premiums will be pegged at P300/month or
P3600/year.
b. For low income members (monthly salary < P25000), premiums will be pegged at P200/month or
P2400/year.
3. Employed. The premium contribution of each employed member is up to 3% of their basic monthly
salary (with P50000 cap). For this category, the employer and employee split the premium, which is
directly deducted from the members’ salaries and remitted to PhilHealth by the employer.
4. Overseas Workers. By January 2012, premiums of overseas workers will increase from P900 to P1200.
By January 2013, premiums for this segment will further increase to P2400. This has to be settled before
the member leaves the country.
5. Lifetime Members. Members under this category no longer have to pay their premiums, since they have
already completed their 120 monthly contributions.
Are overtime pay, commissions, and allowances included in the computation of premium
contributions of employees?
No, they are not included. The amount of monthly premium contribution of members shall be based on the
employee’s salary or wage which is the basic monthly compensation received for services rendered.
Page 20 of 44
Page 21 of 44
Aside from paying through service offices and collecting agents, is there another way for me
to pay my premiums easily?
Yes. Currently, PhilHealth in collaboration with Smart, Inc. has come up with Text 7442, an easy-to-use service
that will allow Smart/Talk N’ Text pre-paid subscribers to pay for their premiums through SMS. To avail of this
service; just remember the following steps:
1. Type “PHIC (space) <PIN>” and send to 7442. (Example: PHIC 123456789012)
2. After this, you will receive a text message containing your PIN, and name (Last Name, First Name,
Middle Name) as it appears in the PhilHealth database. (Example: PIN 12345679012 Lapuz, Harold,
Chan)
3. If the name and PIN are correct, type “PHIC (space) YES” to confirm your premium payment for the
current month. Each transaction is worth one-month of premium plus a transaction fee.
4. After sending, you will receive a confirmation message, which contains your PIN and Reference Number
for the transaction. Keep this reference number, as you’ll need it to download your proof of payment.
2. Second Payment
2012
First Quarter Second Quarter Third Quarter Fourth Quarter
Jan Feb March April May June July Aug Sept Oct Nov Dec
June
30
3. Third Payment
2012
First Quarter Second Quarter Third Quarter Fourth Quarter
Jan Feb March April May June July Aug Sept Oct Nov Dec
Sep 30
4. Fourth Payment
2012
First Quarter Second Quarter Third Quarter Fourth Quarter
Jan Feb March April May June July Aug Sept Oct Nov Dec
Dec. 31
Semi-Annually
2012 2013
First Quarter Second Quarter Third Quarter Fourth Quarter First Quarter
Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March
Mar 31 Sep30
- First Payment - - Second Payment -
2012 2013
First Quarter Second Quarter Third Quarter Fourth Quarter First Quarter
Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March
June Dec.
30 31
- First Payment - - Second Payment -
2012 2013
First Quarter Second Quarter Third Quarter Fourth Quarter First Quarter
Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March
Sept. Mar
30 31
- First Payment - - Second Payment -
2012 2013
First Quarter Second Quarter Third Quarter Fourth Quarter First Quarter
Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March
Dec.
31
- First Payment -
Annually
2011 2012
J F M A M J J A S O N D J F M A M J J A S O N D
31
2011 2012
J F M A M J J A S O N D J F M A M J J A S O N D
30
2011 2012
J F M A M J J A S O N D J F M A M J J A S O N D
31
Page 22 of 44
Page 23 of 44
2011 2012
J F M A M J J A S O N D J F M A M J J A S O N D
31
What are the requirements for eligibility? When is a member eligible to claim?
In order to become eligible to claim benefits, a member must pay premium contributions regularly. If the member
missed paying for a certain period, he/she and his/her dependents may not be able to use the benefits. The table
below summarizes the eligibility requirements:
Just remember the 3/6, 9/12, and effectivity period requirements and you’re good to go.
1. Sponsored Members
If the member’s card is about to expire already, the member must proactively inquire
whether the Sponsor will renew his/her membership.
If not, the member may opt to register as an Individually Paying Member.
2. Individually Paying Member
Ensure that each calendar quarter has been paid.
If possible, pay your premiums yearly for your own convenience.
3. Overseas Workers Program Member
Premiums must be remitted prior to your membership’s expiration.
If your contract abroad has already terminated, make sure that you shift member category
from OWP to IPM (or other applicable categories) to be able to pay premiums again.
4. Employed Members
For seasonal employment or if you’re going to take a leave without pay, just head to the
nearest PhilHealth Service Office to pay your contributions during those months wherein
you will not be compensated. You may continue paying your premiums as an Individually
Paying Member (IPM).
To pay your premiums as an IPM, visit any PhilHealth office and present a copy of the RF-1
from your employer indicating that you are on leave without pay or a Certification from your
employer indicating the same.
Once you get separated from employment, make sure that you shift category to IPM.
If I missed paying in the past quarters, can I still pay for this now to become eligible again?
This is an example of a retroactive payment. Unfortunately, PhilHealth does not accept retroactive payments to
avoid abuse of benefits. This policy has to be in place to avoid those instances when members only choose to pay
when they get sick or need to avail of benefits (and conversely stop paying when they don’t need it), which will be
unfair for those who pay their premium contributions regularly.
What is the tolerable delay for paying premiums for a member to still be able to use his/her
benefits?
None. PhilHealth strictly follows its policies on premium payment and benefit availment.
Can contributions be refunded by the member who was not able to use it?
No. PhilHealth is a social health insurance program, wherein members’ premiums are pooled into a single fund
used to pay for the benefits of sick members. Even if a member is not able to use benefits or does not get sick
within a particular enrolment year, funds are kept in the pool.
If I stopped paying my premium for a considerable amount of time, can I still use my
benefits? Do I need to pay the missed contributions to be able to avail of the benefits
again?
No. Only active members are eligible to avail of PhilHealth benefits. Member should have paid at least three
months premium contributions within the immediate six month period prior to medical confinement. However,
payment of at least nine months within the last 12 months shall be asked of Individually Paying Members availing
of the following procedures/packages:
• Pregnancy-related cases
• Dialysis (except those undergoing emergency dialysis service during confinement)
• Chemotherapy
• Cataract Extraction
• Radiotherapy
• Selected surgical procedures
Individually Paying Members and Employed Members will now be required to have at least nine (9) months
contributions within twelve (12) months prior to the month of availment for all confinements including availment
of outpatient benefits).
On retroactive payments:
As per PhilHealth Circular No. 06, series of 2001, retroactive payments are not allowed except when a member
can show proof of sufficient regularity of premium contributions or payment of nine (9) consecutive months or
three consecutive quarters within the last 12 months prior to the missed quarter. If you meet this condition, you
Page 24 of 44
Page 25 of 44
shall be given a grace period of one month immediately after the missed quarter to pay retroactively including the
current calendar quarter.
For newly enrolled members (with less than 12 months totalled from date of enrolment), retroactive payment for
the missed quarter including the current calendar quarter shall also be allowed within the month immediately
following the missed period.
If an employed member who was separated from service last October 2011 wants to
continue his membership as an Individually Paying Member in March 2012, can he
retroactively pay the premiums for Nov-Dec 2011 and first quarter 2012, in March 2012?
Yes, for the employed member who wants to continue his membership as IPM but failed to immediately pay
his/her premium within the quarter of separation, he/she shall be given a grace period of one calendar quarter
immediately after the unpaid quarterly period to retroactively settle his obligation.
A new governor/mayor was elected in our area. Am I still considered a member under the
Sponsored Program even with this change in leadership?
It is the validity period that determines your membership status. Yes, you are still considered a member even if a
new governor/mayor was elected, so long as your membership has not yet expired.
To ensure the renewal of your membership post-validity date, you can go to the local office of the DSWD that is
in charge of evaluating and determining if you are qualified to join the program. The DSWD shall then endorse
your name to the Local Government Unit (LGU) or any Sponsor for enrolment.
I am an employed member, but I recently found out that my employer stopped paying our
contributions even though he continues to deduct the premiums from our salaries. How do
we go about this?
If the employer failed to remit their employees’ contributions, the employer will have to reimburse PhilHealth’s
payment for claims filed by concerned employees or his/ her qualified dependent/s.
Employees should report through writing if they suspect that their employers are not remitting contributions to
the Corporation so that appropriate action will be taken against them.
What if the member passes away? Can the dependents still use their benefits?
In case the member dies, his/her membership privileges also terminate. However, his/ her dependents may still
avail of the PhilHealth benefits for the unexpired portion of the member’s contribution.
If a member has paid his premium for one year and he died during the first half of the year,
can his dependents refund his premium?
If the member has dependents, they can avail of PhilHealth benefits for the unexpired portion of the member’s
contributions. However, similar to other members, they are not allowed to refund his premium that has already
been channeled to the health insurance pool.
I already have a lifetime member card, but my current employer still continues to pay for my
premiums. Can these premium contributions be credited to my son/daughter’s membership
when I retire?
Since you are considered to formally employed, your employer is really mandated to continue paying for your
premiums. However, payments made are non-transferrable and cannot be credited to your son/daughter’s
membership when you retire.
Is membership transferrable?
No, membership is non-transferrable.
Are the payments for OWWA Contributions and PhilHealth premiums different?
Yes, they are different. OWWA contributions serve as a life insurance of the OFW abroad while PhilHealth
premiums ensure the health benefits of the OFW and his/her dependents in case of illness or injury requiring
hospitalization.
If I stopped paying my premium for a considerable amount of time, how will I reactivate my
membership? Do I need to apply for a new membership/PIN?
There is no need to apply for a new PIN. Using your old PIN, simply carry out the following steps:
1. Fill out two (2) copies of the PhilHealth Member Registration Form indicating the new membership
category and submit these to any PhilHealth office
2. Await a copy of the member’s updated MDR, and proceed to any of PhilHealth’s accredited collecting
agent to pay for the applicable premium using the same PhilHealth identification number (PIN).
How can a SP member continue PhilHealth membership when his/her PhilHealth ID expires?
To continue his/her PhilHealth membership once his/her ID expires and granting that it has not been 'renewed',
a Sponsored Member should enroll as an Individually Paying Member and pay his/her premiums within the
calendar quarter or before the expiry date as reflected in the PhilHealth Identification Card.
I used to be employed, but am now self-employed. Can I still continue paying for my
premiums? How do I go about this?
In case you get separated from employment, you may continue your PhilHealth membership by becoming an
Individually Paying Member and paying the applicable premium. Simply accomplish the PhilHealth Member
Registration Form (PMRF) and tick the box "For Updating" and the appropriate box of the membership category
to which you are shifting. Make sure you continuously and religiously pay your premiums so as to avoid
suspension of benefits.
Page 26 of 44
Page 27 of 44
If in case the member already paid his/her membership as an OFW while his/her sponsored membership is still
active, the member is advised to go to any PhilHealth office to make necessary adjustments on his/her
membership coverage.
Why do I have to renew my PhilHealth membership every time I leave the country and work
as an OFW?
It's not actually renewal of membership but an updating of your premiums, which shall be equivalent to the length
(in years) of your fresh contract. It will also ensure your continuous eligibility to PhilHealth benefits.
I am currently abroad and my coverage is about to expire. How do I continue paying for my
PhilHealth in case there are no available payment centers where I am?
You may ask your relatives in the Philippines to pay your premiums on your behalf to avoid any lapses or delays.
They only need to present a valid ID and an authorization letter from you as the member and any document that
would attest that you are still an active OFW.
If a member has dual citizenship, can he/she still renew his/her membership and avail of the
benefits whenever he/she is in the Philippines?
Yes. Those with dual citizenship still have the option to continue paying for their PhilHealth coverage also as
individually paying members. Entitlement to benefits if confined in the Philippines will depend on such factors as
the member’s qualifying contributions and the accreditation of the health care providers.
I am already an immigrant here in the US. Can I still continue my membership with
PhilHealth?
Yes. You can still continue paying for your PhilHealth coverage as an Individually Paying Member and not as an
Overseas Worker Member.
Were OFW members consulted by PhilHealth before the increase was approved?
The planned increase had been extensively discussed and debated on within our Board of Directors where the
OFW sector is adequately represented. We have commenced our media guestings and tapped print materials
(newspapers, etc.) informing the public about the new rates and we shall continue organizing round-table
discussions with our key stakeholders to address whatever other issues they may have on the matter.
When was the last time that premium contributions of OFW members increased?
As far as OFWs are concerned, the annual rate of P 900.00 has been in place since PhilHealth took over the
Medicare Program from the OWWA in 2005 and no adjustments have been introduced since then, despite the
series of increases in benefit packages that we have implemented across all member-types over the years.
Can OFW members whose families were affected by Typhoon Sendong be exempted from
paying the new premium rate?
No. However, PhilHealth Advisory No. 01-03-2012, extended the deadline of premium payment of members
affected by Typhoon Sendong up to March 31, 2012.
Where can they pay their premium contributions in the Philippines? How about abroad?
Overseas Worker-members may pay at the POEA, or at any of our Service Offices nationwide or through any of
our accredited collecting agencies locally or overseas.
If an OFW’s membership coverage expires while he is still abroad, will he be required to pay,
through his kin in the Philippines, the new rate when he renews his coverage?
An OFW-member may ask his kin in the Philippines to pay for his membership renewal provided he sends his kin
the following:
1. Copies of the required documents such as:
a. Valid overseas employment certificate
b. Valid working visa/re-entry permit
c. Valid job employment contract
d. Certificate of employment from employer abroad
e. Valid company ID issued by employer abroad
Page 28 of 44
Page 29 of 44
2. Cash remittance from member abroad at least 2 months prior to the date of renewal or payment. If the
membership expired last December 31, 2011, the OFW, through his kin, will be required to pay the new
rate of P1,200.00, if he pays anytime between January 1 and June 30, 2012.
Will the increase in premium mean additional benefits for OFWs and their dependents as
well?
Yes. Not only will there be an increase in benefits, but also an improvement in frontline services and access to
these benefits.
Are these benefits available to the OFW member even while he is abroad?
Only some of the upcoming hospitalization benefits and other selected services will be available to the OFW
while he is abroad since some packages are and will be offered by local health facilities. However, all qualified legal
dependents of OFW-members can avail themselves of these benefits locally.
How do you plan to inform OFWs about the new premium rate in less than two weeks’
time?
PhilHealth intends to go full blast in its IEC initiative. The following will be conducted:
Send advisories to all recruitment agencies, PDOS providers and accredited collecting agents abroad
Distribute flyers at POEA
Post tarpaulin at POEA
Conduct orientation meetings with OFWs at POEA
Conduct meeting with OFW organizations
Tri-media exposures
Post advisory at OWP and in the official Facebook and Twitter accounts
Is PhilHealth making any representation with Philippine Embassies and consulates overseas
to inform OFWs about the increased premium?
We will communicate and send advisories to all Philippine Posts abroad to help spread the word about the new
premium rates.
Since PhilHealth has no physical presence overseas, how do you plan to discuss the new
premium rates with OFWs and OFW organizations at this time?
We will seek the assistance of our Embassies and Consulates in discussing this increase together with the leaders
of OFW organizations while we send individual e-mail and text messages to our OFW contacts.
Where can OFW-members refer their inquiries pertaining to the new premium rates?
OFW members can refer their inquiries to the following:
PhilHealth Call Center 4417442
Mobile Numbers 09189635396/09175129149
Page 30 of 44
Page 31 of 44
If I missed the schedule of biometric capture in our office premises, can I proceed to any
PhilHealth Branch for this?
You may call the UMID Project Management Office to ask for the next schedule at your office premises, or if the
UMID Mobile Team has a scheduled biometric capture activity near your office location.
Are there forms I need to fill out before biometric capture day?
It is advisable for you to fill out the UMID Registration Form (URF) before going to the biometric capture
station.
Will the biometric capture process eat up a lot of my time from work?
No, the biometric capture process itself takes only about 6 minutes.
Are there things I must ensure before I proceed with biometric capture?
Make sure that your MDR is updated with PhilHealth prior to biometric capture activity and the UMID
Registration Form properly filled up.
Can I update my MDR on the day of biometric capture through the UMID Mobile Team?
Updating of MDR cannot be made on the day of the biometric capture. It is advised that you update your MDR
before the day of the biometric capture.
Once my biometric data have been captured, what are the next steps?
Your biometric data will be processed then forwarded to Central Verification System (CVS) for CRN generation
and for UMID card issuance later on.
Where can I call if I have further questions regarding the biometric capture?
Further questions on the UMID Biometric Capture may be referred to the UMID Project Management Office at
441-7444 extension 7671 or 7672.
UMID Card Activation
Why must I activate my UMID card with PhilHealth?
Activating your UMID card will prepare you for PhilHealth’s shift to paperless transactions. Your UMID card will
eventually enable you to access health care services at accredited facilities without having to submit documentary
requirements anymore.
Are there forms I need to fill out before card activation day?
None, you will not be required to fill out any forms prior to nor during card activation day.
Are there things I must ensure before I proceed with activating my UMID card?
First, make sure that your UMID card is already activated with the GSIS. There are GSIS kiosks in selected
local government units where your UMID card may be activated. Second, make sure that your MDR is
updated; otherwise, the MDR that is currently posted in our database will be loaded into your UMID card
once card activation takes place.
If I missed the schedule of card activation in our office premises, can I proceed to any
PhilHealth Branch to have my UMID card activated?
You may call the UMID Project Management Office to ask for the next schedule at your office premises, or if the
UMID Mobile Team has a scheduled card activation near your office location so you can activate your card.
Page 32 of 44
Page 33 of 44
Can I update my MDR on the day of card activation through the UMID Mobile Team?
The UMID Mobile Team will be busy handling the card activation process and they will not be able to attend to
your MDR updating requirements. We advise you to do this at least three (3) days before the schedule of card
activation. Your HRD can help you update your PhilHealth records.
What are the contact numbers if I have further questions regarding the UMID card
activation?
Further questions on the UMID card activation may be referred to the UMID Project Management Office at 441-
7444 extension 7671 and 7672.
Medical Cases
Dengue I P 8,000.00
Dengue II P 16,000.00
Pneumonia I P 15,000.00
Pneumonia II P 32,000.00
Essential Hypertension P 9,000.00
Cerebral Infarction P 28,000.00
Cerebro-vascular accident with hemorrhage P 38,000.00
Acute Gastroenteritis P 6,000.00
Typhoid Fever P 14,000.00
Asthma P 9,000.00
Newborn Care Package P 1,750.00
Surgical Procedures
Radiotherapy P 3,000.00
Hemodialysis P 4,000.00
Maternity Care Package P 8,000.00
NSD, Level 1 P 8,000.00
NSD, Levels 2-4 P 6,500.00
Caesarean Section P19,000.00
Appendectomy P 24,000.00
Cholecystectomy P 31,000.00
Dilatation and curettage P 11,000.00
Thyroidectomy P 31,000.00
Herniorrhaphy P 21,000.00
Mastectomy P 22,000.00
Hysterectomy P 30,000.00
Cataract surgery P 16,000.00
In the future, a second component of this package will be rolled out, giving an additional PhP 400 for
outpatient medicines covering diseases like hypertension and diabetes. Moreover, this is coupled with a
performance incentive of PhP100 which rewards data quality, and eventually, the actual quality of care being
given to patients.
MDG Benefits
Benefit Amount Covered Description
Goal 4: Reduce Child Mortality
Newborn Care Package PhP1,750 This package for newborn dependents covers the following:
1. Necessary/essential newborn care – P500
2. Newborn screening test – P550
3. Newborn hearing screening test – P200
4. Professional fee – P500
Goal 5: Improve Maternal Health
Normal Spontaneous PhP6,500 – 8,000 The NSD Package is the benefit provided by PhilHealth for the coverage of normal
Delivery (NSD) Package deliveries of the first four births in accredited government and private hospitals.
Page 34 of 44
Page 35 of 44
Maternity Care Package PhP8,000 The MCP Package is the benefit provided by PhilHealth for the coverage of normal
(MCP) deliveries of the first four births in non-hospital facilities (lying-in clinics, maternity
clinics, birthing homes and RHUs). This covers:
1. Facility fee (including professional fee) – P6,500
2. Member’s prenatal care fee – P1,500
Goal 6: Combat HIV/AIDS, Malaria, and other Diseases
Outpatient HIV/AIDS PhP30,000 This benefit aims to increase the proportion of the population having access to
Treatment Package, effective HIV/AIDS treatment and patient education measures. This covers:
1. All necessary diagnostics – P3,000/year
2. Professional fee – P2,000/year (P400 per single check-up)
3. Retrovirals – P2,500/month
Outpatient Malaria PhP600 The case rate for this package covers the following services that the patient
Package requires:
1. Diagnostic malaria smears and other laboratory procedures
2. Drugs and medicines
3. Consultation services, including patient education and counselling
Outpatient Anti- PhP4,000 This case rate shall be paid to accredited DOTS facilities, and shall cover diagnostic
Tuberculosis/DOTS work-up, consultation services, and anti-TB drugs that the patient requires in an
Benefit Package outpatient set-up. Payment will be split as follows:
1. Intensive Phase of DOTS Treatment – P2,500
2. Maintenance Phase – P1,500
Animal Bite Package PhP3,000 Effective May 3, 2012, this benefit package aims to support the National Rabies
(Rabies Post-exposure Prevention and Control Program by defraying the cost of post-exposure
prophylaxis) prophylaxis (PEP) treatment to animal bite patients who are PhilHealth
beneficiaries. This package covers:
1. Drugs (vaccine, immunoglobulin, and antibiotics) and supplies – P2,700
2. Health staff service fee – P300
SARS and Avian Php50,000 – Amount of coverage:
Influenza Package 100,000 1. For members and their qualified dependents – P50,000 per case
2. For healthcare workers (forefront and high risk) – P100,000 per case
This amount covers room and board; drugs and medicines, x-ray, lab, and others;
and professional fees.
Other Benefits
An Enhanced Outpatient Package for OWP members and dependents is also available in participating DOH-
retained hospitals nationwide. We also cover dialysis, day surgeries and chemotherapy in accredited facilities.
All lifetime members can also take advantage of the 60% discount on the pneumococcal vaccine beginning June
1, 2012 in PhilHealth-accredited hospitals.
PhilHealth will also reimburse overseas confinements and shall be paid based on Level 3 Hospitals benefit rates.
How can these benefits be availed of?
Availment Conditions
Employed and KASAPI Members Payment of at least 3 monthly premiums within the
immediate six months prior to confinement
Individually Paying Members Payment of at least 3 monthly premiums within the
immediate six months prior to confinement (for some
confinement cases). Payment of 9 months premiums
within the immediate 12 month period prior to
confinement (for selected surgical procedures and
pregnancy-related cases.
OWP Members Confinement should be within the effectivity period
stated in the Member Data Record or PhilHealth
Official Receipt (MDR).
Sponsored Program Members Confinement should be within the effectivity period as
stated in the PhilHealth Identification Card and
Member Data Record (MDR)
Lifetime Members The only requirement is the PhilHealth Lifetime
Member Identification Card
1. Prior to discharge from the hospital, submit the following documents to the hospital’s billing section:
a. Duly accomplished PhilHealth Claim From 1(original)
b. Clear Copy of Member Data Record (MDR)
c. If your dependent is the patient, and he/she is not yet listed in the MDR, submit an applicable
proof of dependency
2. Agree with your attending physicians on the professional fee that shall be covered.
3. Upon submission of all documents, the billing section will compute and deduct your benefits from your
total hospital bill.
Direct Filing/Reimbursement
If benefits were not availed of at the hospital, members still have this option to reimburse what they spent during
their last confinement. Simply submit the following documents to the nearest PhilHealth office within sixty (60)
days after discharge:
1. PhilHealth Claim Form 1 filled out by member
2. PhilHealth Claim Form 2 filled out by hospital and attending physician
3. MDR/PhilHealth ID
4. Proof of premium payment
5. Official receipts for hospital services and professional fees
6. Official receipts for medicines and procedures paid for outside the hospital while confined
7. Statement of account
8. Waiver from the hospital and physician stating that benefits were not claimed at the point of service
9. Copy of operative record (for surgical procedures)
10. PhilHealth Claim Form 3
11. Results of laboratory and diagnostic exam for case rates claims
Page 36 of 44
Page 37 of 44
How can the member avail himself of PhilHealth benefits if he has an existing coverage with
a health maintenance organization?
For PhilHealth members who have an existing coverage with a health maintenance organization (HMO),
PhilHealth benefits should be the first peso to be deducted from the hospital bill. The HMO will cover the
expenses after the deduction of PhilHealth benefits.
Can a senior citizen avail himself of both the PhilHealth benefits and his senior citizen
privilege when confined?
Yes. The senior citizen privilege is a separate benefit and the 20% discount must first be deducted from your
hospital bill prior to the application of PhilHealth benefits.
a. PhilHealth Claim Form 1 accomplished and signed by the member or his authorized representatives;
b. Photocopy of MDR or latest receipt;
c. Medical certificate with complete diagnosis, period of confinement and services rendered;
d. Statement of Account and/or Official Receipts with itemized charges; and other supporting documents.
(Items c & d should be translated in ENGLISH)
I’ve been paying my premiums regularly, but I still haven’t availed of any benefits. When will
I be able to benefit from my membership?
Perhaps you have managed to stay healthy, therefore not needing to be admitted in the hospital, which is why you
have not yet availed of any benefits. Depending on your membership type (applicable for Sponsored, OWP,
Lifetime), you may still avail of preventive services and vaccines in the outpatient setting to improve your health.
Situationers: Benefits and Benefits Availment
How will the member know if the PhilHealth benefit deducted from his total hospital bill is
correct?
Members are sent a benefit payment notice or BPN to report the actual payments made by PhilHealth relative to
their confinement/availment. The BPN is sent to the address indicated by the member in their claim form. Should
there be discrepancies in the payments and the actual benefits deducted from your hospital and doctors' bills, you
may present your BPN, your copy of the hospital's Statement of Account/Billing Statement, and Official Receipts
to your health care provider for appropriate action to be taken.
What if the amount deducted as PhilHealth benefit is less than what PhilHealth actually paid
to the provider for the member’s confinement?
Members are sent a benefit payment notice or BPN to report the actual payments made by PhilHealth relative to
their confinement/availment. The BPN is sent to the address indicated by the member in his claim form. Should
there be discrepancies in the payments and the actual benefits deducted from your hospital and doctors' bills, you
may present your BPN, your copy of the hospital's Statement of Account/Billing Statement, and Official Receipts
to your health care provider for appropriate action to be taken.
If siblings are all active members, can each of them file a claim for the confinement of their
parents?
No. PhilHealth does not allow multiple declaration and application of PhilHealth entitlements. The siblings
should decide who will declare and provide for the PhilHealth coverage of their parents.
If both spouses are members, can each of them file a claim for the confinement of their
children?
No. PhilHealth does not allow multiple declaration and application of PhilHealth entitlements of both spouses.
If the spouse’s, child’s or parent’s name is not listed in the member’s MDR at the time of
confinement, how can the member avail himself of the benefits?
If the dependent gets hospitalized and he/she is not listed in the principal member’s MDR yet, the member may
submit a clear copy of the following as proof of dependency:
1. Spouse - marriage contract/certificate
2. Children - birth certificate
3. Parents - birth certificate of member and patient or Senior Citizen's ID
How can members separated or resigned from employment avail themselves of maternity
benefits?
After separation from employment, the member must immediately enrol/shift his/her membership from
employed to Individually Paying Program (IPM) to avoid the gap on his/her PhilHealth contributions. As an IPM
member the following documents must be submitted to the billing section of the hospital:
1. Fully accomplished PhilHealth Claim Form 1 (CF 1)
2. Clear copy of Member Data Record (MDR)
3. Proof of premium payments - nine (9) monthly premium contributions within the immediate twelve
(12) months prior to availment of benefits. If the delivery date may cover the contributions during
employment, secure copy of RF-1 (reflecting the member’s name) with proof of payment from
previous employer or “Certificate of Contribution” from any PhilHealth Office.
Page 38 of 44
Page 39 of 44
Why shift to case rate payments? What advantages will this form of benefit payment bring,
especially to the members?
With case rates, hospital charges are no longer a mystery! Since rates remain the same in all facilities, you will
immediately know how much subsidy you can get from PhilHealth for particular diseases and surgical procedures.
At the same time, this simpler method will help PhilHealth speed up its processes, which means that your claims
will be released faster.
What are the surgical cases under Case Rate that can be reimbursed in particular facilities?
Level-I Hospitals:
a. D & C (Completion and Fractional Curettage)
b. Normal Spontaneous Delivery
Note: The said case shall be reimbursed as NSD package in Level I hospitals (P8,000)
c. Newborn Care Package
How will hospitals be paid for 2 or more surgical case rates performed in a single
confinement?
PhilHealth shall reimburse all packages if two or more different surgical case rates are performed in separate
operative sessions even within a confinement period.
How will the procedures be reimbursed if a procedure performed has laterality (e.g.,
cataract)?
The hospital shall be paid once if the procedure performed has laterality (e.g., cataract), whether done in one or
different operative session in a single confinement or different confinement within 90 days.
Is Case Rate covered by the rule on single period of confinement? Will the 45 days
allowance apply for case rates?
Yes, the rule on single period of confinement still applies except for hemodialysis and radiotherapy packages,
where availment is on a per session basis but subject to 45-days allowance in a year.
If a member’s total hospital fees for dengue I is beyond the case rate amount listed by
PhilHealth, will the member shoulder the balance?
Yes. The member shall shoulder the amount in excess of what we will provide under the new case rate packages,
except for those covered under the NBB policy in government accredited facilities.
A member is admitted for dengue I for three days, and another member is admitted for
dengue I for five days, will they be entitled to the same case rate amount for dengue I of
P8,000.00?
Yes. Whether a member uses up three days or ten days for a particular medical condition, they will still be entitled
to the same amount. PhilHealth will reimburse to the health care facility the case rate amount indicated in the list.
What medical cases under Case Rate can be reimbursed in Level 1 hospital? Level 2
hospitals?
a. Dengue I (Dengue Fever and Dengue Hemorrhagic Fever Grades I and II)
b. Dengue II (Dengue Hemorrhagic Fever Grades III and IV)
Note: The said cases managed in Level I hospitals shall only be reimbursed as Dengue I package
c. Pneumonia I (Moderate Risk Pneumonia)
d. Pneumonia II (High Risk Pneumonia)
Note: The said case managed in Level I hospitals shall only be reimbursed as Pneumonia I package
e. Essential Hypertension
f. Cerebral Infarction (CVA I)
g. Cerebro-vascular Accident with Hemorrhage (CVA II)
Page 40 of 44
Page 41 of 44
Note: The said case managed in Level I hospitals shall only be reimbursed as CVA I package
h. Asthma
i. Typhoid Fever
j. Acute Gastroenteritis
k. NSD
Note: In level I hospitals the benefit amount is Php 8000 while in Levels 2-4 hospitals the benefit is Php 6500.
For medical case rate, how will PhilHealth pay for a patient admitted for several conditions?
PhilHealth shall reimburse the medical case rates based on the main condition. Therefore, cases with several co-
morbidities shall have no additional payment.
In case the member was transferred to another hospital, will PhilHealth pay for both
facilities?
The member is entitled to one package and this will be reimbursed to the referral facility. Cost incurred at the
referring facility will be shouldered by the member and the claim filed by the facility will be denied except
MCP.
For cases not included in the Case Rates table, how will PhilHealth reimburse those cases?
PhilHealth will continue to reimburse those cases through the existing benefit table of fee for service scheme.
What are the conditions for availment of benefits of SP members under the NBB policy?
The NBB policy applies only to all PhilHealth Sponsored Program members and their dependents that avail of the
specified cases under the following conditions:
When they are admitted in government facilities/hospitals in defined NBB Beds
When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in
accredited government hospitals and non-hospital facilities
When availing of existing outpatient packages, including Maternity Care Package and Newborn Care
Package, TB-DOTS, Malaria, HIV-AIDS, and Animal Bite Package
What if a sponsored member is admitted in a private hospital? Will the NBB policy still be
applicable?
The NBB policy will not apply, unless the private hospital voluntarily implements it. The sponsored member and
his/her dependents will pay the excess of the hospitalization costs including the PF for the attending physician/s
after deduction of the applicable case rates.
a. Kumuha ng malinis na tela at diinan ang sugat hanggang sa humupa ang pagdurugo.
b. Linisin ang sugat nang sabon at tubig.
c. Lagyan ng alcohol, povidone-iodine (halimbawa: betadine) o kahit anong panlinis ang sugat.
d. Takpan ang sugat nang malinis at tuyong gauze. Maari ring magpahid ng antibiotic ointment
upang maiwasan ang impeksiyon.
e. Matapos linisin ang sugat, magpunta agad sa pinakamalapit na Animal Bite Treatment Center.
Page 42 of 44
Page 43 of 44
Kailan dapat magpabakuna? Hihintayin pa bang mamatay ang aso bago magpabakuna?
Kahit na buhay pa ang asong nakakagat, maiging kumunsulta na agad sa pinakamalapit na Animal Bite Treatment
Center para mabakunahan. Kailangan pa rin ng pasyente ng tatlong dose ng bakuna kahit na nanatiling buhay ang
aso.
Mga Paalala
a. Ipaalam sa baranggay o munisipyo kung may mga asong gala sa inyong lugar na maaaring
mangagat at maging sanhi ng rabies.
b. Pabakunahan ang inyong alagang aso at wag pabayaang pagala-gala sa labas ng bahay o bakuran.
Ito ay maaring ibigay sa mga sumusunod na kasong maituturing na Category III Rabies Exposure na naidulot ng
hayop (aso, pusa, baka, baboy, kabayo, kambing, paniki at unggoy) o pasyenteng napatunayang may rabies.
a. Kagat/kalmot ng hayop na tumagos sa balat at nagdurugo
b. Kagat o pagpasa ng laway/fluids (sa mata, ilong, maseselan na bahagi ng katawan at bukas na
sugat) ng pasyenteng mayroong rabies
c. Paghawak ng bangkay ng hayop na may rabies o pagkain ng laman ng hayop na mayroong rabies
d. Kalmot at sugat (kahit na hindi nagdurugo) na natamo sa ulo at leeg
Saan ba pwedeng maka-avail ng package? Saan ako pwedeng pumunta para magpabakuna
kung nakagat ng aso?
Pumunta lamang sa kahit anong PhilHealth-Accredited na Animal Bite Treatment Center upang makagamit ng
benepisyong ito.
Kailangan ba akong bumili ng bakuna sa labas? Meron pa ba akong dapat bayaran kung
may PhilHealth na?
Kung ikaw ay isang sponsored member, wala nang kailangan pang bilhin na gamot o bakuna. Sagot na dapat ng
Animal Bite Treatment Center ang lahat ng kakailanganin sa paggamot ng kagat.
Para sa ibang miyembro ng PhilHealth, hanggang PhP3,000 lamang na halaga ng bakuna, gamot at gamit ang
kasama sa package. Kapag naubos na ang PhP 3,000, kailangan ng bayaran o bilhin ng miyembro ang natitirang
gamit, gamot o bakuna. Tandaan na kinakailangang makumpleto ang 3 o 4 na dose ng bakuna upang ito ay maging
mabisa.
Paano kung nakagat ako ulit? Ilang beses ako pwedeng makagamit ng PhilHealth para sa
ganitong benepisyo?
Hangga’t ikaw ay lehitimong miyembro ng PhilHealth, maaari kang makagamit ng benepisyong ito kapag ikaw ay
nakagat ng hayop. Para sa mga kailangan para maka-avail ng package, tingnan ang sagot sa question #2.
Paano kung hindi aso ang nakakagat? Kasama pa rin po ba ito sa benepisyo?
Hindi lahat ng kagat ng hayop ay may rabies. Tanging ang kagat ng aso, pusa, baka, baboy, kabayo, kambing,
paniki at unggoy lamang ang kasama sa benepisyo. Ang kagat ng daga, guinea pig o kuneho ay hindi
nangangailangan ng bakuna laban sa rabies kung kaya’t hindi kasama sa benepisyo.
Page 44 of 44