Benefits Development and Research Department Philippine Health Insurance Corporation

OUTLINE

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General Peritoneal Dialysis Hemodialysis

Payroll contribution Employed Self-employed Pensioners

Taxes

Payment

Indigents Providers

Compulsory enrollment for those employed in the government and private sectors

Premiums are paid thru payroll deductions equally shared by the employer and the employee (2.5% of the total salary per law or 1.25% each paid by employee and employer ); subject to a salary cap

Formally Employed

PhilHealth assumed Medicare functions for OFWs on March 1, 2005

Previously administered by the Overseas Workers Welfare Administration (OWWA)
Premium is P900 (around US$19) per member per year

Overseas Workers

For families belonging to the lowest income quartile of the population.

P1,200 (about US$25) per family per year shared by the National Government (NG) and Local Government Units (LGUs).
The proportion of the sharing depends on the income classification of the LGU.

Sponsored Program

Members who have reached the age

of retirement (generally 60 years

old) and have paid at least 120 monthly contributions become lifetime members of PhilHealth without contributing additional

premiums to the Program

Lifetime

Covers the:

informal sector (street vendors, drivers, etc) professionals (free-lance lawyers, doctors, etc) individuals who could not be covered by any other programs of PhilHealth
Premium is P1,200 (about US$25) per member per year

Individually Paying

Coverage extends to immediate family

Legitimate spouse (nonmember) Children* below 21 y.o., unmarried and unemployed Parents (biological, step or adoptive) 60 y.o. and above & not covered by NPP
*legitimate, illegitimate, legitimated adopted or stepchildren

Eligibility Requirements

9/12
Guidelines: 1. Hemodialysis and peritoneal dialysis 2. Chemotherapy administration 3. Radiation oncology services 4. Selected surgeries listed in Annex of Circulars (please refer to www.philhealth.gov.ph)
Exempted from this rule members undergoing

emergency dialysis services during hospital confinements.

Requirements for Filing

PhilHealth Form 1
(member & employer)

PhilHealth Form 2
(doctor & hospital)

Member Data Record (MDR)

Primary document for all members

Other supporting documents

L4
L3
L2
L1

Tertiary Level 4 Level 3 Secondary (Level 2)

Ambulatory surgical clinics (ASC) Freestanding dialysis centers (FDC)

Primary (Level 1)

CASETYPE
Case type is an assessment of

complexity of illness assigned to a case after discharge. It is measured on a four (4) scale system Fixed on ICD, with exceptions

Case Types
Medical Surgical
0- 80

A B

Simple

Moderate

81- 200

C
D

Severe

201- 500

Extreme

501- 600

Case-type

B
Level 3 & 4 Hospitals (Tertiary)

C
PD, HD, KT

Room & Board* Drugs and Medicines**

P500/day P4,200 P3,200

P500/day

P800/day

P1,100/day

P14,000

P28,000

P40,000

X-ray, Lab & Others

P10,500

P21,000

P30,000

Level 2 Hospital (Secondary)

Room & Board*

P400/day

P400/day

P600/day

N/A

Drugs and Medicines**

P3,360
P2,240

P11,200
P7,350

P22,400
P14,000

N/A
N/A

X-ray, Lab & Others

Level 1 Hospital (Primary)

Room & Board* Drugs and Medicines**

P300/day P2,700 P1,600

P300/day P9,000 P5,000

N/A N/A N/A

N/A N/A N/A

X-ray, Lab & Others

Peritoneal Dialysis
Any modalities of PD may be claimed from PhilHealth by patients registered at accredited PD centers and hospitals

Modalities:
Automated Continuous ambulatory PD (CAPD)

1/5/2012

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Peritoneal Dialysis
1. All PD exchanges per day = 1 day

2.

Claims for PD (Per Single Period of Confinement)

Dialysis solution Supplies Laboratory Facility

3. Maximum 20 liters PD solution per day

4. PF based on RVU

10 RVU x 56 PCF = 560 pesos To be paid to AP; kidney disease-related management

Single Period of Confinement

Re-admissions due to same illness within a 90-day period shall only be compensated within one (1) maximum benefit: Availment for the same illness or condition which is not separated from each other by more than 90 days will not be provided with a new benefit Only the remaining benefit from the previous confinements may be availed

Expenses Prior to Admission

Claims for drugs and medicines; and supplies,

radiology, laboratory and other ancillary procedures purchased prior to admission may be reimbursed only for:
peritoneal dialysis, hemodialysis, chemotherapy and other elective surgeries

Must be supported by official receipts (with TIN)

Official receipts must be dated 30 days prior to admission

Official receipts issued by doctors will not be reimbursed

BENEFITS LEVEL 4 HOSPITAL

Case Type C
Room & Board @ 800/day Drugs & Medicines Lab, X-ray, Supplies OR Fee @ 20/RVU

PD 0 28,000 21,000 0

PF Surgeon @ 10 RVU
PF Anesthesiologist @ 40% surgeons fee PF Medical Management @ 700/day

560
0 0 49,560

TOTAL

BENEFITS LEVEL 4 HOSPITAL

Case Type C
Room & Board @ 800/day Drugs & Medicines Lab, X-ray, Supplies OR Fee @ 20/RVU PF Surgeon @ 480 RVU PF Anesthesiologist @ 40% surgeons fee PF Medical Management @ 700/day

KT 8,000 28,000 21,000 9,600 26,800 10,752

HD 0 28,000 21,000 1,200 560 0

5,600
109,752

0
50,600

TOTAL

Tip to maximize your benefit! File only up to 3 claims per month or 9 claims per 90 days (single period of confinement)

1/5/2012

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27

Dialysis Benefit for Tertiary

Drugs; Lab, Supplies & Others
45 days consumed in 1 quarter (45/Q) 45 days 45 days 45 days consumed consumed consumed in 2 quarters in 3 quarters in 4 quarters (22/Q) (15/Q) (11/Q)

1st Quarter
2nd Quarter

50,000

50,000
50,000

50,000
50,000

50,000
50,000

3rd Quarter
4th Quarter Maximum benefit

X
X

50,000
X

50,000
50,000

50,000

100,000

150,000

200,000

PhilHealth Circular Nos. 011, 011-A and 011-B, s-2011

Pursuant to Board Resolution No.1441 s.2010
Case payment mechanism for the most common medical and surgical conditions (49% of total claims) No Balance Billing Policy (NBB) Improve turn-around time for claims processing and payment

Effectivity: September 1, 2011

NEW PAYMENT MECHANISM Case Payment Scheme

Hospital payment method that reimburses hospitals a predetermined fixed rate for each treated case also called per-case payment or packages

Single rate regardless of hospital category and length of stay

Surgical Case Rates

Cases
1 Radiotherapy

Rates
3,000

2
3 4 5 6 7 8 9 10 11 12

Hemodialysis
Maternity Care Package (MCP) NSD Package in Level 1 Hospitals NSD Package in Levels 2 to 4 Hospitals Cesarean Section Appendectomy Cholecystectomy Dilatation & Curettage Thyroidectomy Herniorrhapy Mastectomy Hysterectomy Cataract Surgery

4,000
8,000 8,000 6,500 19,000 24,000 31,000 11,000 31,000 21,000 22,000 30,000 16,000

Surgical Case Rates

Case rate directly paid to the facility 40% of rate is for PF except for hemodialysis Allowed only in L2 to L4 facilities, but some may allowed in other facilities:
Completion curettage Fractional curettage Herniorraphy Laparoscopic chole Cataract Hemodialysis Radiotherapy : L1 : L1, ASC : ASC : ASC : ASC : FDC : L3 to L4 only

General Rules
Shall follow the rule on single period of confinement Except for hemodialysis and radiotherapy per session

Hemodialysis
90935

Features: @4,000 per session Outpatient hemodialysis Includes payment for PF (Php500), dialyzer and epoetin Not allowed in L1 and ASC Excluded (pay under FFS): Hemodialysis during confinements Peritoneal dialysis Treatment of acute renal failure Creation of fistula

No Balance Billing Policy

No Balance Billing Policy shall mean that no

other fees or expenses shall be charged or paid

for by the patient-member above and beyond

the packaged rates.

No Balance Billing Policy

Shall be applied to ALL SPONSORED Program members and/or their dependents for the specified cases under the following conditions: 1. When admitted in government facilities/ hospitals. 2. When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in accredited government hospitals and all non-hospital facilities (e.g. FDCs, ASCs)

No Balance Billing Policy

3. Claims for reimbursement of Sponsored members and/or their dependents availing of the following existing outpatient packages: a) TB DOTS (Php 4,000) b) Malaria (Php 600) c) HIV-AIDS (Php 7,500 /qtr or Php 30,000/yr) All other existing policies/guidelines covering these packages shall remain in effect.

No Balance Billing Policy

4. In support of Millennium Development Goals (MDG) NBB policy shall apply to ALL PhilHealth members and their dependents regardless of membership type in ALL Accredited MCP (non-hospital) providers This shall cover claims for MCP and NCP

NBB APPLICATION
Facility/Benefit Sponsored Non Sponsored

Govt Hosp
Private Hosp MCP DOTS Malaria HIV AIDS

NBB
X NBB NBB NBB NBB

X
X NBB X X X

FDC
ASC

NBB
NBB

X
X

No Balance Billing Policy

Facility should purchase necessary items/services in advance on behalf of the member if drugs, supplies, or diagnostic procedures are not available. Out-of-pocket payment (OOP) made by members shall automatically be deducted against claims of the hospitals (charged to case rates) with corresponding sanctions or penalties the Corporation may charge.

Require attachment of official receipt/s (ORs) for any OOP made by member (for hospital and/or professional fee)

Remember
Number of days allowed

per year 45 for the member Another 45 for all dependents

Remember
Number of days per

single period of confinement

Remember
Days prior to session

official receipts honored

Remember
Number of days allowed

to file claim from date of discharge Number of days allowed to comply with returned claim Number of days allowed for PhilHealth to process claims