PhilHealth Programs and Benefits - Employers Confederation of the
Transcription
PhilHealth Programs and Benefits - Employers Confederation of the
PhilHealth Programs and Benefits Alexander A. Padilla President and CEO Philippine Health Insurance Corporation 13 August 2015 Employers Confederation of the Philippines (ECOP) Outline of Presentation 1. 2. 3. 4. 5. 6. Creation of NHIP/PhilHealth PhilHealth’s Vision and Mission Membership Premium Contribution Benefits PhilHealth Organization PHILHEALTH @ 20 Created through Republic Act 7875 on Feb. 14, 1995 As amended by R.A. 9241 and R.A. 10606 MANDATE To provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for ALL FILIPINOS About PHILHEALTH § Single Fund/Single Payor § Draws inspiration from concept of ‘bayanihan’ § Coverage of about 88 percent of population § GOCC § Offshoot of Medicare Vision and Mission Bawat Pilipino MIYEMBRO Formal Economy Informal Economy Sponsored Indigent Members Members Lifetime Members Senior Citizens Legal Dependents Dependent: Children Dependent: Legal Spouse • 20 years old and below • unmarried & unemployed • legitimate, illegitimate • adopted, stepchildren • foster child • Who is not yet a member Dependent: Parents parents with permanent disability thus fully dependent on member Dependent: Disabled Child • 21 years old and above with total disability (congenital/acquired) Covered Members and Dependents as of June 30, 2015 Sector Members in the Formal Economy Private Government Household Help/Kasambahay Enterprise Owner & Family Drivers Members in the Informal Economy Migrant Worker Informal Sector Workers Self-Earning Individual Organized Group and Others Indigents Sponsored Members Senior Citizens Lifetime Members TOTAL Members Dependents Beneficiaries 13,368,671 14,204,553 27,573,224 11,326,505 1,982,042 10,377,566 3,782,546 21,704,071 5,764,588 59,482 43,421 102,903 642 1,020 1,662 3,602,640 4,163,236 7,765,876 1,086,439 2,107,443 396,898 11,860 976,336 2,702,689 471,890 12,321 2,062,775 4,810,132 868,788 24,181 15,288,583 489,730 4,813,460 955,850 30,118,509 647,921 1,068,411 696,157 45,407,092 1,137,651 5,881,871 1,652,007 38,518,934 50,898,786 89,417,720 88% of 2015 projected population Note: - Indigent count of members and dependents was based on DSWD Listahan database and are subject for further validation. - 2015 Projected Population is 101, 449, 681 based on May 2010 Census by NSO. Registration Members and Dependents (as of end of April 2013; in millions) A person intending to register as member should only submit a properly accomplished Member Registration Form (PMRF) The member to certify the truthfulness and accuracy of the information provided including the list of qualified dependents As a general rule, the Corporation will not require documentary requirements unless warranted Premium Contribution Rates Member Type Formal Economy: Employed Premium Rate Not to exceed 5% of employee’s monthly salary (Current rate is 2.5%) Remarks Shared equally by employee and employer * Remitted every month 2014 Collection for Formal Economy (Private) *Data in Billion Peso *Against the potential collection of P40B § Implementation of the adjusted rates across all membership categories with Php2,400 as the lowest premium rate, in order to ensure financial sustainability and viability; § To sustain and further enhance the NHIP benefits of members; § Transitory provisions were established to provide members enough time to adjust to the new premium adjustments. Two (2) dates as deadlines for employers to pay the premium contributions of their employees with a 5-day window to: § § § § Avoid long queues during the deadline Reduce need for overtime of personnel Lessen instances of late/delayed payments Lessen the instances of IT-related technical issues during high-volume transactions days (System slowdown, hanging, etc.) Updates on remittance and reporting procedures* For all small to extra-large enterprises starting applicable month of June 2015 : •Mandatory use of the EPRS in the preparation and submission of remittance reports •Mandatory payment in accredited collecting agents or through e-Payment facilities *Circulars 04-2015 and 09-2015 Exemptions •Micro-firms •Employers of Kasambahay and family drivers •Employers in geographically isolated and disadvantaged areas (GIDA) •Areas without internet service (for EPRS) – soft copy reporting can still be filed with PhilHealth offices More support to Employers Computer terminals in PhilHealth offices to register with EPRS Continuous EPRS orientation and provision of technical support Interests and surcharges soon to be integrated in EPRS Ease of Doing Business •Lessened journeys and waiting time for new businesses registering with SEC, PhilHealth, SSS and Pag-IBIG! •PhilHealth Employer Number (PEN) now issued quickly and with great ease through the Securities and Exchange Commission – Integrated Business Registration System Post-registration musts* Employer to receive e-mail advise to bring the following to nearest PhilHealth office: - Unified Registration Record (URR) - Accomplished ER-1 and ER2 To get the following in return: - Certificate of Registration - Employer Data Record Kasambahay payments* Premium sharing: - Salary below P5,000 - premium of P200 to be solely borne by employer -P5,000 and up - subject to current contribution schedule; equally shared by employer and employee •Should be made at PhilHealth offices only •Payment through collecting partners to be made available soon! *Circular 16-2015 Bawat MIYEMBRO, Protektado Range of PhilHealth Benefits: 1. Outpatient Benefits 2. Inpatient Benefits 3. Catastrophic & Other Special Benefits 1. Outpatient Benefits (Partial list only) • TB Treatment through DOTS - Php4,000 • Voluntary Surgical Contraception Procedures -Php4,000 • OPB Malaria Package -Php600 • Outpatient Blood Transfusion -Php14,500–25,700 • Outpatient HIV/AIDS Treatment - Php30,000 • Animal Bite Treatment Package -Php3,000 • Moderate Leptospirosis Package -Php11,000 2. Inpatient Benefits - Medical Case (partial list only) Medical Conditions 1 Dengue Fever ₱10,000.00 2 Dengue, Severe ₱16,000.00 3 Pneumonia Moderate Risk ₱15,000.00 4 Pneumonia High Risk ₱32,000.00 5 Hypertensive Emergency / Urgency ₱9,000.00 6 Stroke - Infarction ₱28,000.00 7 Stroke - Hemorrhagic ₱38,000.00 8 Acute Gastroenteritis ₱6,000.00 9 Asthma in Acute Exacerbation ₱9,000.00 10 Typhoid Fever ₱10,000.00 Inpatient Benefits – Surgical (partial list only) Surgical Procedures 1 Radiotherapy Linac ₱3,000.00 2 Radiotherapy Cobalt ₱2,000.00 Maternity Care Package (PCF, Birthing Homes) ₱8,000.00 Normal Spontaneous Delivery Package ₱5,000.00 4 Cesarean Section ₱19,000.00 5 Appendectomy Newborn Care Package ₱24,000.00 3 (Levels 1-3 Hospitals) 6 7 Dilatation & Curettage ₱1,750.00 ₱11,000.00 8 Hemodialysis ₱4,000.00 9 Hysterectomy ₱30,000.00 10 Cataract Package ₱16,000.00 (Birthing Homes, PCF, Levels 1-3 Hospitals) 3. Catastrophic Benefits (Z Benefits) 1. Acute Lymphocytic / Lymphoblastic Leukemia (standard risk) ₱210,000 2. Breast Cancer (stage 0 to IIIA) ₱100,000 3. Prostate Cancer (low to intermediate risk) ₱100,000 4. End-state renal disease eligible for requiring kidney transplantation (low risk) 5. Coronary Artery Bypass Graft Surgery (standard ₱550,000 risk) 6. Surgery for Tetralogy of Fallot in Children (Blue Baby Syndrome) ₱600,000 ₱320,000 Catastrophic Benefits (Z Benefits) 7. Surgery for Ventricular Septal Defect in Children 8. Cervical Cancer: Chemoradiation with Cobalt and Brachytherapy (low dose) or Primary surgery for Stage IA1, IA2 – IIA1 Chemoradiation with Linear Accelerator and Brachytherapy (high dose) 9. Z MORPH (Mobility, Orthosis, Rehabilitation, Prosthesis Help) - first right and/or left below the knee - both limbs 10. Selected Orthopedic Implants (See next slide) 11. End-Stage Renal Disease Requiring Peritoneal Dialysis ₱250,000 ₱120,000 ₱175,000 ₱15,000 ₱30,000 ₱270,000 Selected Orthopedic Implants IMPLANTS Rates per side (left or right) Total Hip Prosthesis , cemented* ₱ 105,000 Total Hip Prosthesis , cementless** ₱ 175,000 Partial Hip Prosthesis, bipolar ₱ 85,000 Multiple screw fixation (MSF)* ** ₱ 65,000 Compression Hip Screw Set (CHS) ₱ 80,000 Proximal Femoral Locked Plate (PFLP) ₱ 80,000 Intramedullary Nail with Interlocking Screws ₱ 55,000 Locked Compression Plate (LCP) Broad/Metaphyseal/ Distal Femoral LC ₱ 55,000 Other Benefits PhilHealth members and their qualified dependents who are 50 years old and above may avail of pneumococcal vaccine at a discounted rate of P600.00 through any of the Vaccine Access Points (VAPs) NCR : Caloocan / Makati / Mandaluyong / Manila / Pasay / Quezon City / San Juan City / Muntinlupa Luzon : Cavite / Laguna / Bataan / Batangas / Quezon / Bicol / Ilocos / Cagayan Valley / CAR Visayas : Bacolod / Iloilo/ Roxas / Leyte / Samar / Cebu Mindanao: CARAGA / Central, Northern and Western Mindanao Availment Conditions: Members and their dependents are entitled to avail of the benefits if: Employed, Self-employed, Professionals, Sea-based OFWs, Voluntary Land-based OFWs Paid at least 3 months premium contributions within immediate 6 months prior to the first day of confinement Within the validity period of premium payments Within validity period of membership Sponsored/Indigent Automatic PhilHealth coverage Senior Citizens (not gainfully employed) Lifetime coverage Lifetime NBB No Balance Billing (NBB) Policy PhilHealth Circular No. 3 s-2014 For members and dependents of the following categories of membership: a) b) c) d) Indigent Sponsored Household Help iGroup Gold members with existing Group Policy Contract (GPC) * Confined in government health care institutions Benefit Payment January 1 to June 30, 2015 Sector Government Private Amount of PhilHealth Benefit % to Total (in million pesos) 4,041.72 8,823.69 9% 20% Informal Economy OFW NHTS/Sponsored Lifetime Members 9,400.37 659.09 13,192.36 8,325.43 21% 1% 30% 19% Total 44,442.66 100% Source: Financial Statements Kalusugan Natin, SEGURADO Accredited Health Care Institutions (as of June 30, 2015) Hospitals: 1,145 MCP providers: 2,381 Specialized outpatient clinics Animal bite treatment centers: 235 -Primary care facilities: 690 -Ambulatory surgical clinics: 130 Outpatient malaria package -Free-standing dialysis clinics: 176 providers: 135 PCB1 providers: 2,253 Outpatient HIV treatment hubs: 19 TB DOTS providers: 1,546 Vaccine access points: 110 Kalusugan Natin, SEGURADO Accredited Health Care Providers (as of June 30, 2015) Contracted for Z Benefit Packages: -Breast CA: 20 -Prostate CA: 14 -Kidney transplant: 6 -Acute Lymphocytic Leukemia: 13 -Coronary Artery Bypass Graft: 4 -Tetralogy of Fallot: 2 -Ventricular Septal Defect: 2 -Cervical CA: in process Kalusugan Natin, SEGURADO Accredited Health Care Professionals (as of June 30, 2015) General Practitioners: 15,304 Medical Specialists: 16,725 Dentists: 386 Midwives: 2,205 TOTAL: 34,620 The PhilHealth Organization 17 REGIONAL OFFICES LOCAL OFFICES 59 120 PHILHEALTH EXPRESS 6,400 OFFICERS STAFF FILIPINOS 100,000,000 Registration of Employers Employers need not present documents when the register via the Philippine Business Registry (PBR). Should they be unable to register via the PBR, the Corporation shall require documentary requirements. (Section 13) PhilHealth as a Pre-Requisite (Section 34) The law mandates national agencies and LGUs to require proof of PhilHealth membership before doing business or issuing professional or business license or permit. However, before the end of 2014, all employers, owners or operators of business establishments with no record of remittance deficiency shall no longer be required to submit a certificate or proof of payment of PhilHealth premium contributions as a documentary requirement in renewing their business permits/licenses and securing a Mayor’s Permit. (MOA with DILG) Visitorial Powers § Any representative of the Corporation as duly authorized by the President and CEO or by the concerned Regional Vice President shall have the power to visit, enter and inspect facilities of health care providers and employers during office hours, unless there is reason to believe that inspection has to be beyond office hours § And where applicable, secure copies of their medical, financial, and other records and data pertinent to the claims, accreditation, premium contribution and that of their patient or employees, who are members of the Program. § (Section 221) Obligations of the Employer: • Register with PhilHealth • Provide updates as to correction/change of business name, temporary suspension/resumption of operation, termination/dissolution, change of ownership, closure • Register their employees and their qualified dependents Obligations of the Employer: • Report to the Corporation newly-hired and separated employees • Timely and correct payment of premium remittance • Timely/regular submission of reports • Keep true and accurate work records PhilHealth Updates PhilHealth Circulars (Formal Economy) •(PhilHealth Circular No. 010-2015) SEC-IBR PostRegistration Guidelines in PhilHealth •(PhilHealth Circular No. 009-2015 and PhilHealth Advisory 06-02-2015) Mandatory Payment of Premium Contributions of Employers and Employees in PhilHealth Accredited Collecting Agents •(PhilHealth Circular No. 004-2015) Payment and Reporting of Premium Contributions of Employers and Employees •(PhilHealth Circular No. 003-2015) Recovery of Payments for Properly Filed Claims by Employed Members but without Qualifying Contributions PhilHealth Circulars (Formal Economy) •(PhilHealth Circular No. 0005 s.2014) Issuance and Voluntary Availment of the Health Insurance Cards by the Member of the Formal Economy •(PhilHealth Circular No. 0001 s. 2014) New Payment Schedule for Premium Contributions •(PhilHealth Circular No. 027 s. 2013) on the CY 2014 Premium Contribution Issuance and Voluntary Availment of the Health Insurance Cards by the Member of the Formal Economy Online Services http://www.philhealth.gov.ph • Member Inquiry • Search Case Rates Online Services http://www.philhealth.gov.ph/services/ Thank you! ÆWebsite ÆFacebook ÆTwitter ÆE-mail ÆYouTube ÆHealthlines : : : : : : www.philhealth.gov.ph www.facebook.com/PhilHealth @teamphilhealth [email protected] www.youtube.com/teamphilhealth (02) 441-7442