PhilHealth

RA 7875, amending PD 1519 and RA

6111 and amended by RA 9241 and
RA 10606
History
RA 6111 enacted on 04 Aug. 1969 was repealed by PD 1519, issued on 11 June
1978
Article 209 (Labor Code of the Philippines)
The Philippine Medical Care Plan shall be implemented as provided under RA 6111, as
amended.
PD 1519 was further amended by:
E.O. 105 issued on 24 Dec. 1986
E.O. 106 issued on 24 Dec. 1986, and
E.O. 269 issued on 25 Jul. 1987
RA 7875, The National Health Insurance Act of 1995, approved on 14 Feb. 1995
Amended by RA 9241
Amended by RA 10606 (approved: June 19, 2013)
Disclaimer
Philhealth doesnt pay for all your health care costs
Philhealth pays only for covered items and services when its rules
are met
Members usually give a co-payment for the portion of the actual
cost that is not covered by Philhealth
Guiding Principle
Universality
Social Solidarity
Care for the Indigents
Quality Assurance for Health Services
LGU/ Community Participation
Members
Employed
Government Sector
Private Sector
Individually Paying Members
OFWs
Sponsored Members
Lifetime Members (Retirees and Pensioners)

Members
Employed
Government Sector
Private Sector


Salary
Bracket
Salary Range Salary Base
Total
Monthly
Premium
Employee
Share
Employer
Share
1 7,999.99 and below 7,000.00 175.00 87.50 87.50
2 8,000.00 - 8,999.99 8,000.00 200.00 100.00 100.00
3 9,000.00 - 9,999.99 9,000.00 225.00 112.50 112.50
4 10,000.00 - 10,999.99 10,000.00 250.00 125.00 125.00
5 11,000.00 - 11,999.99 11,000.00 275.00 137.50 137.50
6 12,000.00 - 12,999.99 12,000.00 300.00 150.00 150.00
7 13,000.00 - 13,999.99 13,000.00 325.00 162.50 162.50
8 14,000.00 - 14,999.99 14,000.00 350.00 175.00 175.00
9 15,000.00 - 15,999.99 15,000.00 375.00 187.50 187.50
10 16,000.00 - 16,999.99 16,000.00 400.00 200.00 200.00
11 17,000.00 - 17,999.99 17,000.00 425.00 212.50 212.50
12 18,000.00 - 18,999.99 18,000.00 450.00 225.00 225.00
13 19,000.00 - 19,999.99 19,000.00 475.00 237.50 237.50
14 20,000.00 - 20,999.99 20,000.00 500.00 250.00 250.00
15 21,000.00 - 21,999.99 21,000.00 525.00 262.50 262.50
16 22,000.00 - 22,999.99 22,000.00 550.00 275.00 275.00
17 23,000.00 - 23,999.99 23,000.00 575.00 287.50 287.50
18 24,000.00 - 24,999.99 24,000.00 600.00 300.00 300.00
19 25,000.00 - 25,999.99 25,000.00 625.00 312.50 312.50
20 26,000.00 - 26,999.99 26,000.00 650.00 325.00 325.00
21 27,000.00 - 27,999.99 27,000.00 675.00 337.50 337.50
22 28,000.00 - 28,999.99 28,000.00 700.00 350.00 350.00
23 29,000.00 - 29,999.99 29,000.00 725.00 362.50 362.50
24 30,000.00 - 30,999.99 30,000.00 750.00 375.00 375.00
25 31,000.00 - 31,999.99 31,000.00 775.00 387.50 387.50
26 32,000.00 - 32,999.99 32,000.00 800.00 400.00 400.00
27 33,000.00 - 33,999.99 33,000.00 825.00 412.50 412.50
28 34,000.00 - 34,999.99 34,000.00 850.00 425.00 425.00
29 35,000.00 and up 35,000.00 875.00 437.50 437.50
Members
Individually Paying Member

Average Monthly Income Quarterly Annually
25,000.00 and below 450.00 1,800.00
above 25,000.00 900.00 3,600.00
Quarterly Semi-annual Annual
Pay until the last working day
of the quarter being paid for.
Pay until the last working day
of the first quarter of the
semester being paid for.
Pay until the last working day of
the first quarter of the year being
paid for.
Example: Example: Example:
Period: January to March Period: January to June Period: January to December
Deadline: March 31 Deadline: March 31 Deadline: March 31
Members
OFW
Pay the annual premium amounting to P1,200.00.
Premium payments covering the entire duration of contract
(equivalent to the number of years provided for in your contract)
is highly encouraged.
Members
Sponsored Member
DSWD
Local Government Unit (LGU) or any sponsor

Members
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;
GSIS disability pensioners prior to March 4, 1995;
SSS pensioners prior to March 4, 1995:
SSS permanent total disability pensioners;
SSS death/survivorship pensioners
SSS old-age retirees/pensioners;
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;
Retirees and pensioners who are members of the judiciary;
Retirees who are members of Constitutional Commissions and other constitutional offices;
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;
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;
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;
Retired underground mine workers who have reached the age of retirement as provided for by
law and have met the required premium contributions.
Lifetime Members

Coverage also includes
Member Spouse
Parents who are 60 years old or above
Children below 21 years old and those with mental and physical
disabilities

Entitlement to Benefits
At least 3 consecutive monthly contribution within the immediate
6 months prior to admission
The 45-days allowance for room and board has not been
consumed yet
Confinement in an accredited hospital of not less than 24 hours

Mandated Benefits
Inpatient Hospital Care
Room and Board
Services of health care professionals
Diagnostic, laboratory, and other medical examination services
Use of surgical or medical equipment & facilities
Prescription drugs and biologicals
Subj. to the limitation stated in Sec. 37
Inpatient education packages
Mandated Benefits
Outpatient Care
Diagnostic laboratory, and other medical exam. Services
Personal preventive services
Prescription Drugs and Biologicals
Subj. to the limitation set in Sec. 37
Services of health care Professionals
Mandated Benefits
Emergency and transfer services
Such other health care services that the Corporation and the
DOH shall determine to be appropriate and cost-effective.

These services and packages shall be reviewed annually to
determine their financial sustainability and relevance to health
innovations, with the end in view of quality assurance, increased
benefits and reduced out-of-pocket expenditure.
Exclusion
The Corporation shall not cover expenses for health services
which the Corporation and the DOH consider cost-ineffective
through health technology assessment.

The Corporation may institute additional exclusions and
limitations as it may deem reasonable in keeping with its
protection objectives and financial sustainability.
Exception to the 24 hour
confinement
Emergency cases as defined by PhilHealth
Patient died
Patient was transferred to another hospital
Availment Procedures
Step 1:
Members accomplishes Philhealth Claim Form 1
Step 2:
Submit the Form together with the following
Proof of Contribution
Supporting documents
Philhealth Number Card
Step 3:
The hospital will deduct the benefits from the hospital bill prior to the
discharge of the patient
Claims Prescription Period
Guidelines
All claims for payment of services rendered shall be filed within
60 calendar days from the date of discharge of the patient.
All claims returned for completion of requirements shall be re-
filled within 60 calendar days from receipt of notice.
All request for payment adjustments must be made within 60
days from date of receipt of check payment or of the benefit
payment notice

Confinement in a Non-Accredited
Hospital is possible IF:
The case is Emergency
The Hospital has a current Dept. of Health (DOH) License
And transfer/referral to a PhilHealth accredited hospital is
physically impossible.
Benefit Schedule
A B C D
Level 1 Hospital (Primary)
ROOM AND BOARD * 300/day 300/day N/A N/A
DRUGS AND MEDICINES ** 2,700 9,000 N/A N/A
X-RAY, LABORATORY, ETC. ** 1,600 5,000 N/A N/A
OPERATING ROOM FEE 500 500 N/A N/A
Level 2 Hospital (Secondary)
ROOM AND BOARD * 400 400 600 N/A
DRUGS AND MEDICINES ** 3,360 11,200 22,400 N/A
X-RAY, LABORATORY, ETC. ** 2,240 7,350 14,700 N/A
OPERATING ROOM FEE N/A
Level 3 & 4 Hospital (Tertiary)
ROOM AND BOARD * 500 500 800 1,100
DRUGS AND MEDICINES ** 4,200 14,000 28,000 40,000
X-RAY, LABORATORY, ETC. ** 3,200 10,500 21,000 30,000
OPERATING ROOM FEE
* Not exceeding 45 days for each member & another 45 days to be shared by his dependents per year
For procedures with RVU 30 and below = 1,200
For procedures with RVU 31 to 80 = 1,500
For procedures with RVU 81 to 600: RVU x PCF 20
(minimum = 3,500)
Case Type
** Refers to a confinement or series of confinements of the same illness not separated from each other by 90 days within a calendar year. In this case, a member or
beneficiary is not entitled to another set of benefits until after 90 days. They can only avail of the unused portion of the benefits and the room and board fees until the 45
days allowance is exhausted.
However, a member can avail of new set of benefits if succeeding confinements are of different illness or condition.
For procedures with RVU 30 and below = 750
For procedures with RVU 31 to 80 = 1,200
For procedures with RVU 81 to 600 = RVU x PCF 15
(Minimum = 2,200 and maximum = 7,500
Benefit Items
Claim Benefits for Confinement
Abroad
Entitlement to Benefits:
Member or his/her qualified dependents
Confinement / Surgery or OPD Benefits

Benefit & Claims Filing
180 calendar days from the date of discharge
Always payable to member
Based on application benefit schedule, case type for a Tertiary level
hospital
Confinement Abroad
Documentary Requirement
PH Form 1
Photocopy of MDR (Medical Data Record)
Medical certificate/Abstract (with English translation)
SOA with itemized charges and/or ORs (proof of hospital bill and PF)
Reason for Denial
Late filing
Less than 45 days of confinement
Not accredited hospital
Inconsistent data
Case not compensable
Same illness with in 90 days
No qualifying contribution
Maternity Care
Package
Maternity Care Package
Normal Birth
Spontaneous onset
of labor
Low risk at the start
of labor, throughout
labor, and delivery
Infant in vertex
position
37-42 completed
weeks of
pregnancy
Payment scheme
Reimbursement
utilize a Case
Payment Scheme
Case Rate: Php
4,500
Limited to NSD of
first three (3) births
Providers:
Non hospital based-
facility
RHUs/HCs
Lying-in Clinics
Hospitals based-
facility
Maternity Care Package
4,500
(per patient)
P2,000.00
For the Health
Professional
P2,500.00
For the Health
Facilities (Room &
board, drugs & meds,
diagnostics, OR fee)
Maternity Care Package
Payment for Non-hospital based facility:


Php 3,650
Prenatal
Delivery
Newborn Care
Php 850
Postnatal Care
Family Planning Service
Maternity Care Package
Claims Filing
Claims for the first payment must be filed within 60 days from
date of discharge
For the second payment, claim must be filed within 90 days from
date of discharge.
Philippine Health
Insurance
Corporation
Corporation
Tax-exempt corporation
Follows the guideline of Dept. of Health (DOH)
Board of Directors
Composition of Board of Directors
The Secretary of Health;
The Secretary of DOLE or his representative;
The Secretary of DILG of his representative;
The Secretary of DSWD or his representative;
The President of the Corporation;
A representative of the labor sector;
A representative of employers;
The SSS Administrator or his representative;
The GSIS General Manager or his representative;
A representative of the Self-employed Sector; and
A representative of health care providers.
Board of Directors
The Secretary of the Department of Finance (DOF) or a permanent
representative;
The Vice Chairperson for the basic sector of the National Anti-Poverty
Commission or a permanent representative;
The Chairperson of the Civil Service Commission (CSC) or a permanent
representative;
A permanent representative of Filipino migrant workers;
A permanent representative of the members in the informal economy;
A permanent representative of the members in the formal economy;
A permanent representative of the elected local chief executives to be
endorsed by the League of Provinces, League of Cities and League of
Municipalities;

Board of Directors
An independent director to be appointed by the Monetary
Board.
The Secretary of Health shall be the ex officio Chairperson while
the President and CEO of the Corporation shall be the Vice
Chairperson of the Board.

Appointment and Tenure
Pres. of the Phil. shall appoint the Members of the Board
Upon Recommendation of the Chairman of the Board
Each member shall have 4 years of term
Renewable for a maximum of 2 years.
Vacancy shall be filled up for the unexpired term of his
predecessor.

Meetings and Quorum
Shall hold regular meetings at least once a month
Special meeting may be convened at the call of he chairperson
or by a majority of the members of the Board
The presence of six (6) voting members shall constitute a
quorum.
In the absence of the Chairperson and Vice-Chairperson, a
temporary presiding officer shall be designated by the majority
of the quorum.

Allowance and Per Diems
The members of the Board shall receive a per diem for every
meeting actually attended subject to the pertinent budgetary
laws, rules and regulations on compensation, honoraria and
allowances.

President of the Corporation
The Pres. of the Phil. shall appoint the President and CEO of the
Corp. upon recommendation of the board with a tenure of one
(1) year in accordance with the provision of RA 10149
Must be a Filipino citizen with five (5) years experience in the
industry
Salary is being fixed by the Pres. of the Phil., payable from the
fund of the corporation
Must not involved with any health care institution as owner or
member of the board

The National Health
Insurance Fund
Sec. 24-27 of RA 7875
Sources of the Fund
Contribution from Program members
Other appropriations earmarked by the national and local govt
purposely for the implementation of the program
Subsequent appropriation earmarked by the national and local
govt purposely for the implementation of the Program
Donations and grants-in-aid
All accruals thereof

Components
The Basic Benefit Fund
The availment of the basic
minimum package by eligible
All liabilities associated with
the extension of entitlement to
the basic minimum benefit
package to the enrolled
population shall be borne by
the basic benefit fund.
Supplementary Benefit Fund
It is eligible for use to provide
supplementary coverage
various groups of the
population enjoying the basic
benefit coverage as are
affordable by their respective
funding sources.

Financial Management
All Funds under the management and control of the Corporation shall
be subject to all rules and regulations applicable to public funds.
The corporation is authorized to charge the various funds under its
control for the costs of administering the program.
Such cost may include administration, monitoring, marketing, and
promotion, research and development, audit and evaluation,
information services, and other necessary activities for the effective
program management.
The total annual cost for the shall not exceed twelve percent (12%) of
the total contribution, including govt contribution to the program
Not more than three percent (3%) of the investment earning collected
during the immediate preceding year.
Reserve Funds
The corporation shall set aside a portion of its accumulated
revenues not needed to meet the cost of the current years
expenditures as reserve funds
Provided that the total amount of reserves shall not exceed a
ceiling equivalent to the amount actuarially estimated for 2
years projected program expenditure
Provided further that whatever actual reserves exceed the
required ceiling at the end of the corporation fiscal year, the
programs benefits shall be increased or member-contributions
decreased prospectively in order to adjust expenditures or
revenues to meet the required ceiling for reserve funds.
Investment of Reserve Funds
Interest-Bearing Bonds and Securities
Interest-Bearing Deposits
Preferred Stocks

Administrative
Powers
Quasi-Legislative Powers
To sue and be sued in court;
To administer the National Health Insurance Program
To formulate and promulgate policies for the sound
administration of the program
To set standards, rules and regulations necessary to ensure
quality of care appropriate utilization of services fund viability,
member satisfaction, and over-all accomplishment of program
objectives
To acquire property, real and personal which may be necessary
or expedient for the attainment of the purposes of this act.
Quasi-Judicial Powers
Conduct investigation for the determination of a question,
controversy, complaint, or unresolved grievance brought to its
attention, and render decisions order or resolutions thereon.
To summon the parties to a controversy, issue subpoenas
requiring the attendance and testimony of witnesses or the
production of documents and other materials necessary to a just
determination of the case under investigation.
To suspend temporarily, revoke permanently, or restore the
accreditation of a health care provider or the right to benefits of
a member and/or impose fines after due notice and hearing
Grounds for Grievances
Any violation of the rights of the patients
A willful neglect of duties of program implementors that results in
the loss or non-enjoyment of benefits of members or their
dependents
Unjustifiable delay in actions on claims
Delay in processing of claims that extends beyond the period
agreed upon
Any other act or neglect that tends to undermine or defeat the
purposes of this act
Grievance and Appeal Review
Committee
Composition of Grievance Appeal Review Committee:
Three (3) to five (5) members
Grievance and Appeal Procedure
A complaint for grievance must be filed with the Office which shall rule
on the complaint within 90 calendar days from receipt thereof.
Appeals from Office decisions must be filed with the Board within 30
days from receipt of notice of dismissal or disallowance by the office.
The offices shall have no jurisdiction over any issue involving the
suspension or revocation of accreditation, the imposition of fines or the
imposition of charges on members or their dependents in case of
revocation of their entitlement.
All decisions by the Board as to entitlement to benefits of members or
to payments of health care providers shall be considered final and
executory.
Hearing Procedures
Action on Complaint
Defendants failure to answer
Power to administer Oath and issue Subpeona
Submission of Pleadings
Clarificatory Hearing
Finality of Decision