TamangSagot (TS) - Philippine Health Insurance Corporation
TamangSagot (TS) - Philippine Health Insurance Corporation
TamangSagot (TS) - Philippine Health Insurance Corporation
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<strong>TamangSagot</strong> (<strong>TS</strong>)<br />
Phil<strong>Health</strong>’s Frequently Asked Questions<br />
<strong>Philippine</strong> <strong>Health</strong> <strong>Insurance</strong> <strong>Corporation</strong><br />
May 2012<br />
Updated May 20, 2012
Table of Contents<br />
A. THE ORGANIZATION .............................................................................................................................................................. 9<br />
What is Phil<strong>Health</strong>? ............................................................................................................................................................................................................. 9<br />
What is the National <strong>Health</strong> <strong>Insurance</strong> Program (NHIP)? .................................................................................................................................. 9<br />
What are the underlying principles/concepts behind the NHIP? ................................................................................................................... 9<br />
What is Phil<strong>Health</strong>‟s purpose of being? ..................................................................................................................................................................... 9<br />
When was Phil<strong>Health</strong> created? ...................................................................................................................................................................................... 9<br />
What are its enabling laws or legal bases? ............................................................................................................................................................... 9<br />
What is its vision? ................................................................................................................................................................................................................ 9<br />
What is its mission? ............................................................................................................................................................................................................ 9<br />
What is the role of Phil<strong>Health</strong>‟s Board of Directors? Who composes it? .................................................................................................. 10<br />
What is Phil<strong>Health</strong>‟s classification as a government agency?........................................................................................................................ 10<br />
What are its fund sources? ........................................................................................................................................................................................... 10<br />
Why does Phil<strong>Health</strong> have to keep a reserve fund? .......................................................................................................................................... 10<br />
With what organizations is it affiliated? .................................................................................................................................................................. 10<br />
How do I contact Phil<strong>Health</strong>? ...................................................................................................................................................................................... 10<br />
B. MEMBERSHIP ......................................................................................................................................................................... 11<br />
Who can be members of Phil<strong>Health</strong>? ...................................................................................................................................................................... 11<br />
What are the different membership types at Phil<strong>Health</strong>? ............................................................................................................................... 11<br />
Who can enrol under these different programs? ............................................................................................................................................... 11<br />
What are the fundamental processes that each member should know? ................................................................................................. 13<br />
What is my proof that I am already a registered member? ........................................................................................................................... 13<br />
C. REGISTRATION/ENROLLMENT ............................................................................................................................................ 13<br />
Who should enrol? ........................................................................................................................................................................................................... 13<br />
Is there any age limit for prospective members?................................................................................................................................................ 13<br />
How do members enrol into the program? Where can they enrol?........................................................................................................... 13<br />
What are the documents required for the registration of employers (and their employees) in the Government Sector and<br />
Private Sector? ................................................................................................................................................................................................................... 16<br />
How can LGUs enrol their underprivileged constituents into the Sponsored Program? ................................................................... 16<br />
Who can be declared as legal dependents? ......................................................................................................................................................... 16<br />
How do I activate my membership? ......................................................................................................................................................................... 16<br />
Where else can I register? ............................................................................................................................................................................................. 17<br />
Situationers for Registration/Enrolment ............................................................................................................ 17<br />
Can foreign nationals working in the <strong>Philippine</strong>s enrol? .................................................................................................................... 17<br />
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Can minors and orphaned children enrol? ............................................................................................................................................... 17<br />
In case of early retirement, can I already register as a Lifetime Member? .................................................................................. 17<br />
Is it true that retiring employees can now be automatically enrolled by the employer in the Lifetime Member<br />
Program? ................................................................................................................................................................................................................. 17<br />
Can foreign spouses of Filipino nationals be declared as dependents? ...................................................................................... 17<br />
Can unmarried members declare nephews or nieces as dependents? ........................................................................................ 18<br />
If both parents are members, can they both declare their children as dependents? ............................................................. 18<br />
How can a member declare his spouse whose membership is inactive as a dependent? ................................................... 18<br />
If all siblings are active members, can each of them declare their parents as dependents? .............................................. 18<br />
Can disabled parents (physically or mentally incapacitated) who are below 60 years old be declared as<br />
dependents? .......................................................................................................................................................................................................... 18<br />
Can my live in partner be declared as a legal dependent? How about our children? ........................................................... 18<br />
My daughter who‟s still my dependent (under 21) is about to give birth. Will my membership be able to cover<br />
her? ............................................................................................................................................................................................................................ 18<br />
Do I need to personally submit my registration documents or can I ask my representative to do so? ......................... 18<br />
D. UPDATING MEMBERSHIP RECORDS .................................................................................................................................. 18<br />
When should I update my MDR? How is this done? ......................................................................................................................................... 18<br />
How do I shift membership categories? ................................................................................................................................................................. 19<br />
Are we going to use the same Phil<strong>Health</strong> Identification Number (PIN) if we are shifting to another membership<br />
category?.............................................................................................................................................................................................................................. 19<br />
Situationers for Updating Membership Records ................................................................................................ 19<br />
I was given a Phil<strong>Health</strong> card by our LGU, but my name was misspelled and data provided were also erroneous.<br />
How do I correct this information? .............................................................................................................................................................. 19<br />
E. CONTRIBUTIONS AND MEMBERSHIP RENEWAL .............................................................................................................. 19<br />
Why must a member pay his premiums regularly? ........................................................................................................................................... 19<br />
How much is the premium contribution rate? ..................................................................................................................................................... 19<br />
Why is there a need for an increase in premium contributions? ................................................................................................................. 20<br />
Are overtime pay, commissions, and allowances included in the computation of premium contributions of employees?<br />
.................................................................................................................................................................................................................................................. 20<br />
Where can the members remit their contributions? ......................................................................................................................................... 20<br />
Aside from paying through service offices and collecting agents, is there another way for me to pay my premiums<br />
easily? .................................................................................................................................................................................................................................... 21<br />
What if I want to view my payment history for Text 7442? ............................................................................................................................ 21<br />
When is the deadline for paying my premium contribution? ....................................................................................................................... 21<br />
What is the effectivity date of Phil<strong>Health</strong> coverage? ........................................................................................................................................ 23<br />
What are the requirements for eligibility? When is a member eligible to claim? ................................................................................. 23<br />
How do I maintain my eligibility? .............................................................................................................................................................................. 23
If I missed paying in the past quarters, can I still pay for this now to become eligible again? ....................................................... 24<br />
What is the tolerable delay for paying premiums for a member to still be able to use his/her benefits? ................................. 24<br />
Situationers: Contributions and Renewal .......................................................................................................... 24<br />
Can contributions be refunded by the member who was not able to use it? ........................................................................... 24<br />
If I stopped paying my premium for a considerable amount of time, can I still use my benefits? Do I need to pay<br />
the missed contributions to be able to avail of the benefits again? ............................................................................................. 24<br />
If an employed member who was separated from service last October 2011 wants to continue his membership as<br />
an Individually Paying Member in March 2012, can he retroactively pay the premiums for Nov-Dec 2011 and first<br />
quarter 2012, in March 2012? ........................................................................................................................................................................ 25<br />
A new governor/mayor was elected in our area. Am I still considered a member under the Sponsored Program<br />
even with this change in leadership? .......................................................................................................................................................... 25<br />
What if I have multiple jobs? Can I just pay my contributions once? ........................................................................................... 25<br />
I am an employed member, but I recently found out that my employer stopped paying our contributions even<br />
though he continues to deduct the premiums from our salaries. How do we go about this? .......................................... 25<br />
What if the member passes away? Can the dependents still use their benefits? .................................................................... 25<br />
If a member has paid his premium for one year and he died during the first half of the year, can his dependents<br />
refund his premium? .......................................................................................................................................................................................... 26<br />
I already have a lifetime member card, but my current employer still continues to pay for my premiums. Can these<br />
premium contributions be credited to my son/daughter‟s membership when I retire? ...................................................... 26<br />
What if a Lifetime Member is re-hired, must he resume contributing to Phil<strong>Health</strong> through salary deduction? ...... 26<br />
Is membership transferrable? ......................................................................................................................................................................... 26<br />
Are the payments for OWWA Contributions and Phil<strong>Health</strong> premiums different?................................................................. 26<br />
If I stopped paying my premium for a considerable amount of time, how will I reactivate my membership? Do I<br />
need to apply for a new membership/PIN? ............................................................................................................................................. 26<br />
How can a SP member continue Phil<strong>Health</strong> membership when his/her Phil<strong>Health</strong> ID expires? ....................................... 26<br />
I used to be employed, but am now self-employed. Can I still continue paying for my premiums? How do I go<br />
about this? .............................................................................................................................................................................................................. 26<br />
I am a Phil<strong>Health</strong> member sponsored by an LGU; is it still necessary for me to pay my membership as an OFW? . 27<br />
Why do I have to renew my Phil<strong>Health</strong> membership every time I leave the country and work as an OFW? .............. 27<br />
What is the grace period of OFW membership renewal? .................................................................................................................. 27<br />
I am currently abroad and my coverage is about to expire. How do I continue paying for my Phil<strong>Health</strong> in case<br />
there are no available payment centers where I am? .......................................................................................................................... 27<br />
If a member has dual citizenship, can he/she still renew his/her membership and avail of the benefits whenever<br />
he/she is in the <strong>Philippine</strong>s? ........................................................................................................................................................................... 27<br />
I am already an immigrant here in the US. Can I still continue my membership with Phil<strong>Health</strong>? .................................. 27<br />
Where can I pay my premium contributions? ......................................................................................................................................... 27<br />
F. SPECIAL SECTION: INCREASE IN PREMIUM FOR OFW MEMBERS .................................................................................. 27<br />
Why is there a need to increase the annual premium of OFW members? .............................................................................................. 27<br />
What was the basis for pegging the new premium rate at P2,400 per year? ......................................................................................... 28<br />
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Were OFW members consulted by Phil<strong>Health</strong> before the increase was approved? ........................................................................... 28<br />
How much is the increase? When is this effective? ........................................................................................................................................... 28<br />
When was the last time that premium contributions of OFW members increased? ........................................................................... 28<br />
Can OFW members whose families were affected by Typhoon Sendong be exempted from paying the new premium<br />
rate? ....................................................................................................................................................................................................................................... 28<br />
Where can they pay their premium contributions in the <strong>Philippine</strong>s? How about abroad? ............................................................ 28<br />
If an OFW‟s membership coverage expires while he is still abroad, will he be required to pay, through his kin in the<br />
<strong>Philippine</strong>s, the new rate when he renews his coverage? ............................................................................................................................... 28<br />
How much is the premium if an OFW decides to pay in advance?............................................................................................................. 29<br />
What additional benefits can an OFW member expect from Phil<strong>Health</strong>? ............................................................................................... 29<br />
Will the increase in premium mean additional benefits for OFWs and their dependents as well? ............................................... 29<br />
Are these benefits available to the OFW member even while he is abroad? ......................................................................................... 29<br />
When can OFWs expect the increase in benefits? .............................................................................................................................................. 29<br />
How do you plan to inform OFWs about the new premium rate in less than two weeks‟ time? ................................................... 29<br />
Is Phil<strong>Health</strong> making any representation with <strong>Philippine</strong> Embassies and consulates overseas to inform OFWs about the<br />
increased premium? ........................................................................................................................................................................................................ 30<br />
Since Phil<strong>Health</strong> has no physical presence overseas, how do you plan to discuss the new premium rates with OFWs and<br />
OFW organizations at this time? ................................................................................................................................................................................ 30<br />
Where can OFW-members refer their inquiries pertaining to the new premium rates? ................................................................... 30<br />
G. SPECIAL SECTION: UMID CARD ACTIVATION AND BIOMETRIC CAPTURE ................................................................... 30<br />
Why must I undergo biometric capture with Phil<strong>Health</strong>? ............................................................................................................................... 30<br />
Can I choose not to have my biometric data captured by Phil<strong>Health</strong>? ..................................................................................................... 30<br />
What does „biometric capture‟ mean?..................................................................................................................................................................... 30<br />
Am I going to pay any fee for biometric capture? ............................................................................................................................................. 30<br />
Where can I have my biometric data captured by Phil<strong>Health</strong>? ..................................................................................................................... 30<br />
If I missed the schedule of biometric capture in our office premises, can I proceed to any Phil<strong>Health</strong> Branch for this? .... 31<br />
Are there forms I need to fill out before biometric capture day? ................................................................................................................ 31<br />
Is there a recommended attire for the biometric process? ............................................................................................................................ 31<br />
How will the biometric capture procedure go? ................................................................................................................................................... 31<br />
Will the biometric capture process eat up a lot of my time from work? .................................................................................................. 31<br />
What do I need to bring on biometric capture day? ......................................................................................................................................... 31<br />
Are there things I must ensure before I proceed with biometric capture? .............................................................................................. 31<br />
Can I update my MDR on the day of biometric capture through the UMID Mobile Team? ............................................................ 31<br />
Once my biometric data have been captured, what are the next steps? ................................................................................................. 31<br />
Where can I call if I have further questions regarding the biometric capture?...................................................................................... 31<br />
UMID Card Activation ..................................................................................................................................... 32<br />
Why must I activate my UMID card with Phil<strong>Health</strong>? .......................................................................................................................... 32
Can I choose not to activate my UMID card with Phil<strong>Health</strong>? ......................................................................................................... 32<br />
What does „card activation‟ mean? .............................................................................................................................................................. 32<br />
What are the requirements to activate my UMID card with Phil<strong>Health</strong>? ..................................................................................... 32<br />
Where can I activate my UMID card with Phil<strong>Health</strong>? ......................................................................................................................... 32<br />
If I missed the schedule of card activation in our office premises, can I proceed to any Phil<strong>Health</strong> Branch to have<br />
my UMID card activated? ................................................................................................................................................................................. 32<br />
How long does the card activation process take? ................................................................................................................................. 32<br />
Can I update my MDR on the day of card activation through the UMID Mobile Team? ..................................................... 33<br />
What are the card activation procedures? ................................................................................................................................................ 33<br />
How will I use my Phil<strong>Health</strong>-activated UMID cards? .......................................................................................................................... 33<br />
What are the contact numbers if I have further questions regarding the UMID card activation?.................................... 33<br />
H. BENEFI<strong>TS</strong> AND BENEFI<strong>TS</strong> AVAILMENT .............................................................................................................................. 33<br />
What benefits can a member avail himself of under the NHIP? .................................................................................................................. 33<br />
Where can these benefits be availed of?................................................................................................................................................................ 39<br />
How can these benefits be availed of? .................................................................................................................................................................... 39<br />
Do legal dependents enjoy the same benefits as the member? .................................................................................................................. 40<br />
What documents must a member submit to be able to avail of the benefits? ..................................................................................... 40<br />
Where and when should these documents be submitted? ............................................................................................................................ 40<br />
How can the member avail himself of Phil<strong>Health</strong> benefits if he has an existing coverage with a health maintenance<br />
organization? ...................................................................................................................................................................................................................... 40<br />
Can a senior citizen avail himself of both the Phil<strong>Health</strong> benefits and his senior citizen privilege when confined? ............. 40<br />
Can overseas Filipino worker-members reimburse their hospitalization expenses with Phil<strong>Health</strong>? ........................................... 40<br />
I‟ve been paying my premiums regularly, but I still haven‟t availed of any benefits. When will I be able to benefit from<br />
my membership? .............................................................................................................................................................................................................. 40<br />
Situationers: Benefits and Benefits Availment .................................................................................................... 41<br />
How will the member know if the Phil<strong>Health</strong> benefit deducted from his total hospital bill is correct? ......................... 41<br />
What if the amount deducted as Phil<strong>Health</strong> benefit is less than what Phil<strong>Health</strong> actually paid to the provider for<br />
the member‟s confinement? ........................................................................................................................................................................... 41<br />
If siblings are all active members, can each of them file a claim for the confinement of their parents? ....................... 41<br />
If both spouses are members, can each of them file a claim for the confinement of their children? ............................. 41<br />
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<br />
the member avail himself of the benefits? ............................................................................................................................................... 41<br />
How can members separated or resigned from employment avail themselves of maternity benefits? ........................ 41<br />
I. SPECIAL SECTION: CASE RATES FOR 23 MEDICAL AND SURGICAL PROCEDURES ........................................................ 42<br />
What is case payment? .................................................................................................................................................................................................. 42<br />
How is this different from the old system? ........................................................................................................................................................... 42<br />
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Why shift to case rate payments? What advantages will this form of benefit payment bring, especially to the members?<br />
.................................................................................................................................................................................................................................................. 42<br />
Who are entitled to these new case rate packages? ......................................................................................................................................... 42<br />
Can I avail of this benefit now?................................................................................................................................................................................... 42<br />
How will cases be reimbursed? .................................................................................................................................................................................. 42<br />
What will happen to doctor‟s professional fees? ................................................................................................................................................ 42<br />
How much will be allocated to the doctors‟ PF? ................................................................................................................................................. 42<br />
What are the surgical cases under Case Rate that can be reimbursed in particular facilities? ....................................................... 42<br />
How will hospitals be paid for 2 or more surgical case rates performed in a single confinement? ............................................. 43<br />
How will the procedures be reimbursed if a procedure performed has laterality (e.g., cataract)? ................................................ 43<br />
What will happen to major surgical procedures done in Level 1 hospitals? ........................................................................................... 43<br />
Is Case Rate covered by the rule on single period of confinement? Will the 45 days allowance apply for case rates? ....... 43<br />
If a member‟s total hospital fees for dengue I is beyond the case rate amount listed by Phil<strong>Health</strong>, will the member<br />
shoulder the balance? .................................................................................................................................................................................................... 43<br />
A member is admitted for dengue I for three days, and another member is admitted for dengue I for five days, will they<br />
be entitled to the same case rate amount for dengue I of P8,000.00? ..................................................................................................... 43<br />
What medical cases under Case Rate can be reimbursed in Level 1 hospital? Level 2 hospitals?................................................. 43<br />
For medical case rate, how will Phil<strong>Health</strong> pay for a patient admitted for several conditions? ..................................................... 44<br />
In case the member was transferred to another hospital, will Phil<strong>Health</strong> pay for both facilities? ................................................. 44<br />
For cases not included in the Case Rates table, how will Phil<strong>Health</strong> reimburse those cases? ......................................................... 44<br />
J. SPECIAL SECTION: NO BALANCE BILLING POLICY ............................................................................................................ 44<br />
What is “No Balance Billing” (NBB) and to whom it will be applicable? ................................................................................................... 44<br />
Why is this being introduced only for Sponsored Program members? .................................................................................................... 44<br />
What are the conditions for availment of benefits of SP members under the NBB policy? ............................................................. 44<br />
Is the NBB policy also applicable to other Phil<strong>Health</strong> membership types? ............................................................................................. 44<br />
If the Sponsored member under NBB bought drugs and medicines or other supplies, will he be able to reimburse then?<br />
How? ...................................................................................................................................................................................................................................... 45<br />
In case a sponsored member/dependent was admitted in a government hospital where the only available room that<br />
time for the patient is a private room, can the sponsored member be admitted in any room or private room of a<br />
government hospital? Will the NBB policy still apply? ..................................................................................................................................... 45<br />
What if a sponsored member is admitted in a private hospital? Will the NBB policy still be applicable? ................................. 45<br />
Are there sanctions for violations in NBB policy? ............................................................................................................................................... 45<br />
K. SPECIAL SECTION: ANIMAL BITE PACKAGE....................................................................................................................... 45<br />
Tamang Paggamot sa Kagat ng Hayop ................................................................................................................ 45<br />
Ano ang unang dapat gawin kapag nakagat ng hayop? ................................................................................................................... 45<br />
Bakit kailangang magpabakuna kung nakagat ng aso? ..................................................................................................................... 45<br />
Gaano katagal ba ang bisa ng bakuna? ..................................................................................................................................................... 45
Ilang beses ba akong bibigyan ng bakuna? ............................................................................................................................................. 46<br />
Kailan dapat magpabakuna? Hihintayin pa bang mamatay ang aso bago magpabakuna? ............................................... 46<br />
Kailangan pa ba akong ma-confine kung nakagat ng aso? .............................................................................................................. 46<br />
Kailangan pa ba akong mabakunahan kung kumpleto naman sa bakuna ang asong kumagat? .................................... 46<br />
Mga Paalala ............................................................................................................................................................................................................ 46<br />
Tungkol sa Animal Bite Treatment Package ng Phil<strong>Health</strong> ...................................................................................... 46<br />
Ano po ba ang kasama sa Animal Bite Treatment Package? ............................................................................................................ 46<br />
Ano ang kailangang ipakita o gawin para maka-avail ng package? ............................................................................................. 46<br />
Saan ba pwedeng maka-avail ng package? Saan ako pwedeng pumunta para magpabakuna kung nakagat ng<br />
aso? ........................................................................................................................................................................................................................... 47<br />
Kailangan ba akong bumili ng bakuna sa labas? Meron pa ba akong dapat bayaran kung may Phil<strong>Health</strong> na?...... 47<br />
Paano kung nakagat ako ulit? Ilang beses ako pwedeng makagamit ng Phil<strong>Health</strong> para sa ganitong benepisyo?47<br />
Covered din ba ang pamilya ko pag sila ay nakagat? ......................................................................................................................... 47<br />
Paano kung hindi aso ang nakakagat? Kasama pa rin po ba ito sa benepisyo? ..................................................................... 47<br />
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A. THE ORGANIZATION<br />
What is Phil<strong>Health</strong>?<br />
The <strong>Philippine</strong> <strong>Health</strong> <strong>Insurance</strong> <strong>Corporation</strong> (Phil<strong>Health</strong>) is a Government-Owned and Controlled <strong>Corporation</strong><br />
that was established to administer the National <strong>Health</strong> <strong>Insurance</strong> Program nationwide.<br />
What is the National <strong>Health</strong> <strong>Insurance</strong> Program (NHIP)?<br />
The NHIP is basically the product that Phil<strong>Health</strong> offers. This mandatory health insurance program of the<br />
government seeks to provide universal health insurance coverage and ensure affordable, acceptable, available,<br />
accessible, and quality health care services for all citizens of the <strong>Philippine</strong>s.<br />
What are the underlying principles/concepts behind the NHIP?<br />
Social health insurance is based on the principle of social solidarity. Social solidarity with respect to health care is<br />
expressed when people support each other by contributing financial resources to a pool that will pay for<br />
everyone‟s costs of care. In this set-up, Phil<strong>Health</strong> acts as the body that pools all the resources together and makes<br />
it available to each member, thereby allowing the rich to support the poor, the healthy to support the sick, the<br />
young and working to support the elderly – all in the spirit of bayanihan.<br />
What is Phil<strong>Health</strong>‟s purpose of being?<br />
Bawat Pilipino, miyembro<br />
Bawat miyembro, protektado<br />
Kalusugan natin, segurado<br />
This battle cry captures Phil<strong>Health</strong>‟s primary purpose of being, which is to ensure that all Filipinos, especially<br />
those who cannot afford the cost of health care, are given real financial risk protection. For Phil<strong>Health</strong>, real<br />
financial risk protection means that:<br />
1. All Filipinos are enrolled into the NHIP (100% coverage)<br />
2. Members are empowered to enjoy their enhanced benefits<br />
3. Each member will be assigned to a primary care provider who shall address his/her health needs<br />
4. Members have access to accredited facilities that are of superior quality<br />
5. Every Filipino who desires to avail of the No Balance Billing (zero-copayment) policy will always have an<br />
opportunity to do so anywhere in the country. This reduces, if not totally eliminates, debilitating out-ofpocket<br />
health expenses that drive families deeper into poverty.<br />
When was Phil<strong>Health</strong> created?<br />
Phil<strong>Health</strong> was established on February 14, 1995.<br />
What are its enabling laws or legal bases?<br />
It was through Republic Act 7875 or the National <strong>Health</strong> <strong>Insurance</strong> Act of 1995 that Phil<strong>Health</strong> was created. It<br />
was amended by Republic Act 9241 which was passed on February 10, 2004.<br />
What is its vision?<br />
Phil<strong>Health</strong>‟s vision is to provide adequate and affordable social health insurance coverage for all Filipinos.<br />
What is its mission?<br />
Its mission is to ensure adequate financial access of every Filipino to quality health care services through the<br />
effective and efficient administration of the National <strong>Health</strong> <strong>Insurance</strong> Program.
What is the role of Phil<strong>Health</strong>‟s Board of Directors? Who composes it?<br />
The Board of Directors is responsible for providing the overall policy and strategic direction of the <strong>Corporation</strong>.<br />
It is composed of the following members representing key government agencies and sectors of our population:<br />
Board Chair, Secretary of <strong>Health</strong><br />
Board Members Chairman, Civil Service Commission<br />
Secretary,<br />
Department of Interior and Local Government<br />
Secretary,<br />
Department of Social Welfare and Development<br />
Secretary,<br />
Department of Labor and Employment<br />
President and Chief Executive Officer,<br />
Social Security System<br />
President and General Manager,<br />
Government Service <strong>Insurance</strong> System<br />
Representative, <strong>Health</strong> Care Providers Sector<br />
Representative, Labor Sector<br />
Representative, Employers Sector<br />
Representative, Self-employed Sector<br />
Representative, Filipino Overseas Workers<br />
Chairman,<br />
National Anti-Poverty Council – Basic Sector<br />
Hon. Enrique T. Ona, MD<br />
Hon. Francisco T. Duque III, MD, MSc<br />
Hon. Jesse M. Robredo<br />
Hon. Corazon J. Soliman<br />
Hon. Rosalinda D. Baldoz<br />
Hon. Emilio S. De Quiros, Jr.<br />
Hon. Robert G. Vergara<br />
Hon. Juan M. Flavier, MD<br />
Hon. Alexander A. Ayco, MD<br />
Hon. Dr. Eduardo P. Banzon<br />
Hon. Francisco Vicente F. Lopez, MD<br />
Hon. Jane M.N. Sta. Ana<br />
Hon. Florencia Dorotan<br />
What is Phil<strong>Health</strong>‟s classification as a government agency?<br />
Similar to the SSS, GSIS and PAG-IBIG, Phil<strong>Health</strong> is a government owned and controlled corporation (GOCC).<br />
It is also an attached agency of the Department of <strong>Health</strong> (DOH).<br />
What are its fund sources?<br />
Unlike the Department of <strong>Health</strong> and other agencies that are financed through taxes, Phil<strong>Health</strong> primarily gets its<br />
funds from premiums being collected from its members. Out of the total amount collected, a percentage goes to<br />
its Corporate Budget.<br />
Why does Phil<strong>Health</strong> have to keep a reserve fund?<br />
Phil<strong>Health</strong>, as a social health insurance, uses a pay-as-you-go scheme. This simply means that out of collected funds,<br />
the <strong>Corporation</strong> is bound to allot funds for expenses to be incurred by members for a particular enrolment year.<br />
The reserve fund is only kept in anticipation of calamities and other situations where members‟ use of benefits will<br />
likely exceed that of current/projected rates, therefore demanding for more resources to pay for expenses.<br />
With what organizations is it affiliated?<br />
Phil<strong>Health</strong> is a member of several organizations involved in social security, such as the International Social<br />
Security Association, ASEAN Social Security Association, and the <strong>Philippine</strong> Social Security Association<br />
(PHILSSA), among others.<br />
How do I contact Phil<strong>Health</strong>?<br />
There are many ways to reach Phil<strong>Health</strong>:<br />
Website: www.philhealth.gov.ph<br />
Email: info@philhealth.gov.ph<br />
Facebook: www.facebook.com/Phil<strong>Health</strong><br />
Twitter: www.twitter.com/teamphilhealth<br />
Trunkline: 441-7444 (connecting all departments)<br />
Call Center: 441-7442<br />
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B. MEMBERSHIP<br />
Who can be members of Phil<strong>Health</strong>?<br />
All Filipino citizens are mandated to enrol into the National <strong>Health</strong> <strong>Insurance</strong> Program.<br />
What are the different membership types at Phil<strong>Health</strong>?<br />
There are currently five membership types/programs under the NHIP. These are:<br />
1. Sponsored Program<br />
2. Individually Paying Program<br />
3. Employed Sector Program<br />
4. Overseas Workers‟ Program<br />
5. Lifetime Member Program<br />
Who can enrol under these different programs?<br />
As a general rule, remember that each Filipino is entitled to become part of the National <strong>Health</strong> <strong>Insurance</strong><br />
Program. Your type of membership depends primarily on two things: 1) capacity to pay and 2) employment.<br />
Those who are below 21 are generally considered as dependents, rather than primary members.<br />
Sponsored Program<br />
Under the Sponsored Program, indigents belonging to the lowest 40% (Quintiles 1 and 2) of the <strong>Philippine</strong><br />
population in terms of income may enrol, including:<br />
1. Families listed under the National Household Targeting System for Poverty Reduction (NH<strong>TS</strong> – PR) of<br />
the Department of Social Welfare and Development (DSWD)<br />
2. Families identified poor by the sponsoring Local Government Units (LGUs).<br />
Individuals are encouraged to check whether they belong to the DSWD/LGU lists. Identified members and their<br />
dependents shall be considered part of the NHIP.<br />
Individually Paying Program<br />
Under the Individually Paying Program, the following may enrol:<br />
1. Self-employed individuals. These are individuals who work for him/herself and are therefore both the<br />
employer and employee of their businesses. These include but are not limited to the following:<br />
a. Self-earning professionals (ex. doctors and lawyers)<br />
b. Business partners and single proprietors/proprietresses<br />
c. Freelancers, actors, actresses, directors, scriptwriters and news reporters who are not under an<br />
employer-employee relationship<br />
d. Professional athletes, coaches, trainers and jockeys<br />
e. Farmers and fisherfolk<br />
f. Workers in the informal sector (ex. ambulant vendors, watch-your-car boys, hospitality girls, tricycle<br />
drivers, etc.)<br />
2. Separated from employment. These are individuals who were previously formally-employed (with employeremployee<br />
relationship) and are separated from employment.<br />
3. Employees of international organizations and foreign governments based in the <strong>Philippine</strong>s without agreement with<br />
Phil<strong>Health</strong> for the coverage of their Filipino employees in the program.<br />
4. All other individuals not covered under the previous categories mentioned, including but are not limited<br />
to the following:<br />
a. Parents who are not qualified as legal dependents, indigents or retirees/pensioners<br />
b. Retirees who did not meet the minimum of 120 monthly premium contributions to qualify as nonpaying<br />
members<br />
c. Children who are not qualified as legal dependents<br />
d. Unemployed individuals who are not qualified as indigents
Employed Sector Program<br />
Under the Employed Sector Program, the following may enrol:<br />
1. Government Sector. Employees of the government, whether regular, casual or contractual, who renders<br />
services in any government branches, military or police force, political subdivisions, agencies, or<br />
instrumentalities, including government-owned and controlled corporations, financial institutions with<br />
original charter, constitutional commissions, and is occupying either an elective or appointive position,<br />
regardless of status of appointment.<br />
2. Private Sector. Employees who render services in any of the following:<br />
a. <strong>Corporation</strong>s, partnerships, or single proprietorships, non-government organizations, cooperatives,<br />
non-profit organizations, social, civic, or professional or charitable institutions, organized and based<br />
in the <strong>Philippine</strong>s<br />
b. Foreign corporations, business organizations, non-government organizations based in the <strong>Philippine</strong>s<br />
c. Foreign governments or international organizations with quasi-state status based in the <strong>Philippine</strong>s<br />
which entered into an agreement with Phil<strong>Health</strong> to cover their Filipino employees<br />
d. Foreign business organizations based abroad with agreement with Phil<strong>Health</strong> to cover their Filipino<br />
employees<br />
e. Sea-based OFWs<br />
f. Household employees<br />
Overseas Workers Program<br />
Under the Overseas Workers Program, the following may enrol:<br />
1. Active land-based OFWs who underwent the normal process of registration as an OFW at POEA<br />
Offices<br />
2. OFWs who are currently abroad but are not yet registered with Phil<strong>Health</strong><br />
Lifetime Member Program<br />
Under the Lifetime Member Program, the following may enrol:<br />
1. Old-age retirees and pensioners of the GSIS, including uniformed and non-uniformed personnel of the<br />
AFP, PNP, BJMP and BFP who have reached the compulsory age of retirement before June 24, 1997,<br />
and retirees under Presidential Decree 408<br />
2. GSIS disability pensioners prior to March 4, 1995<br />
3. SSS pensioners prior to March 4, 1995<br />
4. SSS permanent total disability pensioners<br />
5. SSS death/survivorship pensioners<br />
6. SSS old-age retirees/pensioners<br />
7. Uniformed members of the AFP, PNP, BFP and BJMP who have reached the compulsory age of<br />
retirement on or after June 24, 1997, being the effectivity date of RA 8291 which excluded them in the<br />
compulsory membership to the GSIS<br />
8. Retirees and pensioners who are members of the judiciary<br />
9. Retirees who are members of Constitutional Commissions and other constitutional offices<br />
10. Former employees of the government and/or private sectors who have accumulated/paid at least 120<br />
monthly premium contributions as provided for by law but separated from employment before reaching<br />
the age of 60 years old and thereafter have reached 60 years old<br />
11. Former employees of the government and/or private sectors who were separated from employment<br />
without completing 120 monthly premium contributions but continued to pay their premiums as<br />
Individually Paying Members until completion of the required 120 monthly premium contributions and<br />
have reached 60 years old as provided for by law<br />
12. Individually Paying Members, including SSS self-employed and voluntary members, who continued<br />
paying premiums to Phil<strong>Health</strong>, have reached 60 years old and have met the required 120 monthly<br />
premiums as provided for by law<br />
13. Retired underground mine workers who have reached the age of retirement as provided for by law and<br />
have met the required premium contributions<br />
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What are the fundamental processes that each member should know?<br />
Each member ought to be familiar with the following fundamental processes:<br />
1. Enrolling or registering into the NHIP<br />
2. Updating their records regularly<br />
3. Paying for their premiums on-time<br />
4. Getting their claims from Phil<strong>Health</strong><br />
5. Knowing their benefits<br />
What is my proof that I am already a registered member?<br />
After registering, each member should receive the following important documents:<br />
1. Phil<strong>Health</strong> ID – contains the member‟s PIN (Phil<strong>Health</strong> Identification Number), name, picture, and<br />
signature. Remember that each member should have only one PIN.<br />
2. Member Data Record (MDR) – contains the member‟s name, address and legal dependents listed in the<br />
Phil<strong>Health</strong> database<br />
C. REGISTRATION/ENROLLMENT<br />
Who should enrol?<br />
All Filipinos aged 21 years old and above (no longer qualified as dependents) must register and have their own<br />
Phil<strong>Health</strong> ID Number or PIN. Once a legal dependent reaches 21 years of age, he/she must apply for his/her<br />
membership.<br />
Is there any age limit for prospective members?<br />
None, the NHIP promotes mandatory coverage for all Filipinos.<br />
How do members enrol into the program? Where can they enrol?<br />
Sponsored Program<br />
Members whose names appear in the NH<strong>TS</strong>-PR list or LGU‟s list of priority families are automatically enrolled<br />
into the program. Their IDs may be claimed from the Local Social Welfare and Development Office. To date, the<br />
NH<strong>TS</strong> list has been distributed to providers and has been made available online through Phil<strong>Health</strong>‟s website:<br />
http://www.philhealth.gov.ph/members/sponsored/nhts-pr_list.html.<br />
If members feel like they should be part of the SP, he/she can approach their local DSWD office,which in turn,<br />
will evaluate and determine if he/she is qualified to join the program. The DSWD shall then endorse the list of<br />
possible beneficiaries to the Local Government Unit (LGU) or any Sponsor.<br />
Individually Paying Program<br />
In general, these are the steps that each member has to go through to register. The following section details the<br />
documents/protocols that are unique to each member type.<br />
STEP 1<br />
Fill out the PMRF<br />
(2 copies)<br />
STEP 2<br />
Prepare supporting<br />
documents<br />
(see list below).<br />
STEP 3<br />
Go to the nearest<br />
Phil<strong>Health</strong> Service Office<br />
to submit the docs and<br />
pay your premium.<br />
1. Fill out two copies of the Phil<strong>Health</strong> Member Registration Form (PMRF).
2. Attach a clear copy of the following supporting documents to this form (for the applying member and<br />
his/her qualified dependents):<br />
a. Member – Birth/baptismal certificate or any ID card issued by a government official authority<br />
b. Dependents<br />
i. Spouse: Marriage certificate/contract<br />
ii. Children below 21: Birth certificate; court decree of adoption (for adopted children)<br />
iii. Parents 60 and above: Birth certificate<br />
3. Submit these documents to the nearest Phil<strong>Health</strong> Service Office for processing.<br />
4. Upon submission of documents, the registrant will be issued his/her Phil<strong>Health</strong> Identification Number<br />
(PIN) and a Member Data Record (MDR).<br />
5. He/she shall then be asked to pay the required premium through the Phil<strong>Health</strong> Cashier or any<br />
accredited collecting agent (banks, local government units, etc.)<br />
Online Registration<br />
STEP 1<br />
Visit the Phil<strong>Health</strong><br />
website<br />
eregister.philhealth.gov.ph<br />
STEP 2<br />
Fill out and submit<br />
online registration<br />
form.<br />
STEP 3<br />
Go to the nearest<br />
Phil<strong>Health</strong> Service Office<br />
to pay your premium.<br />
1. Members also have an option to register online. Simply visit http://eregister.philhealth.gov.phand go<br />
through the procedures indicated in the site.<br />
Employed Sector Program<br />
1. For newly hired employees without PIN yet (Also applicable to existing employees without PIN):<br />
a. Fill out two copies of the Phil<strong>Health</strong> Member Registration Form (PMRF).<br />
b. Attach a clear copy of the following supporting documents to this form (for the applying member<br />
and his/her qualified dependents):<br />
i. Member – Birth/baptismal certificate or any ID card issued by a government official authority<br />
ii. Dependents<br />
1. Spouse: Marriage certificate/contract<br />
2. Children below 21: Birth certificate; court decree of adoption (for adopted children)<br />
3. Parents 60 and above: Birth certificate<br />
c. Submit these documents to the company‟s HR Department that is in charge of forwarding the<br />
documents to Phil<strong>Health</strong> together with the ER2 Form (Report of Employee-Members).<br />
d. After processing, Phil<strong>Health</strong> will send the member, through the employer, his/her Phil<strong>Health</strong><br />
Identification Number (PIN) and a copy of the Member Data Record (MDR).<br />
2. Newly hired employees with PIN need only to report their PIN to their employers for them to be<br />
specified in their ER2 (and subsequently updated in Phil<strong>Health</strong>‟s database).<br />
Overseas Workers Program<br />
When in the <strong>Philippine</strong>s:<br />
1. Submit the following documents to any Phil<strong>Health</strong> office:<br />
a. Duplicate copies of Phil<strong>Health</strong> Member Registration Form (PMRF)<br />
b. Supporting documents:<br />
i. Member – Birth/baptismal certificate or any ID card issued by a government official authority<br />
ii. Dependents<br />
1. Spouse: Marriage certificate/contract<br />
2. Children below 21: Birth certificate; court decree of adoption (for adopted children)<br />
3. Parents 60 and above: Birth certificate<br />
c. Any of the following as proof of being an active OFW:<br />
i. Valid Overseas Employment Certificate (OEC) or E-receipt<br />
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ii. Valid overseas employment contract or certificate of employment<br />
iii. Valid re-entry visa<br />
iv. Valid job contract<br />
2. Pay the one-year premium of PhP 1,200. If you have already paid PhP900 during your last transaction,<br />
please expect a notice from Phil<strong>Health</strong> charging the additional PhP300 to complete your annual premium.<br />
When abroad:<br />
1. Submit the following documents to any Phil<strong>Health</strong> office:<br />
a. Phil<strong>Health</strong> Premium Payment Slip (PPPS)<br />
b. Duplicate copies of the Phil<strong>Health</strong> Member Registration Form (for initial registration)<br />
c. Supporting documents (birth certificate, baptismal certificate, POEA ECARD/SSS/Company ID,<br />
Passport or any valid ID)<br />
2. Pay the one-year premium of PhP 1,200. If you have already paid PhP900 during your last transaction,<br />
please expect a notice from Phil<strong>Health</strong> charging the additional PhP300 to complete your annual premium.<br />
Lifetime Members Program<br />
Members are qualified to enrol as lifetime members if they satisfy the following conditions:<br />
1. They are 60 years old and above, AND<br />
2. They have given at least ten years‟ worth of premiums to the NHIP.<br />
To register, simply follow these steps:<br />
1. Submit the following to any Phil<strong>Health</strong> Office nearest you:<br />
a. Duly accomplished Phil<strong>Health</strong> Membership Registration Form<br />
b. Two (2) latest 1" x 1" ID picture<br />
c. Certified True Copy (CTC) of the SSS or GSIS Retirement Certification or the following as<br />
applicable:<br />
For SSS Retirees/Pensioners:<br />
1. Printout of Death, Disability and Retirement (DDR) from any SSS office indicating that the<br />
type of claim is retirement in nature and the effectivity date of pension; and<br />
2. Printout of contributions issued by any SSS office indicating the latest contributions (if<br />
he/she retires after March 4, 1995.<br />
For GSIS Retirees - any of the following:<br />
1. Certification/Letter of Approval of Retirement from the GSIS indicating the effectivity date<br />
of retirement;<br />
2. Service Record issued by the employer/s indicating not less than 120 months of service<br />
excluding leave of absences without pay;<br />
3. Certification/retirement Gratuity from the employer indicating not less than 120 months of<br />
service.<br />
For AFP, PNP, BFP and BJMP Retirees/Pensioners - those who are in active military service until they<br />
retire at age 56 and those separated by retirement or other reasons prior to the said age but have<br />
reached the age of 60, shall submit any of the following:<br />
1. Statement of Services issued by previous employer indicating not less than 120 months of<br />
service excluding leave of absences without pay;<br />
2. Certification/Letter of Approval of Retirement from the GSIS indicating not less than 120<br />
months of service;<br />
3. General, Bureau or Special Order indicating the effectivity date of retirement.<br />
d. Certified true copy (CTC) of Birth Certificate or any two of the following:<br />
1. CTC of Baptismal Certificate<br />
2. CTC of Marriage Contract/Certificate<br />
3. Passport<br />
4. Driver's License<br />
5. SSS Members ID
6. Alien Certificate of Registration (ACR)<br />
7. Service Record/s<br />
8. Employee ID<br />
9. School records<br />
10. Voter's ID<br />
11. Senior Citizens ID<br />
12. Duly notarized joint affidavit of two disinterested persons attesting to the fact of birth of the<br />
registrant<br />
e. Any other valid documents acceptable by Phil<strong>Health</strong><br />
2. After submission and processing, member will be issued his/her Phil<strong>Health</strong> Lifetime Member Card,<br />
which shall serve as a valid ID to be used in all Phil<strong>Health</strong> transactions.<br />
What are the documents required for the registration of employers (and their employees) in<br />
the Government Sector and Private Sector?<br />
For Government Employers:<br />
1. Employer Data Record or ER1 (in duplicate)<br />
2. PMRF for each employee (in duplicate)<br />
For Private Employers:<br />
1. Employer Data Record or ER1 (in duplicate)<br />
2. Business Permit/license to operate and/or any of the following as applicable:<br />
1. Single proprietorships – Department of Trade & Industry (DTI) Registration<br />
2. Partnerships & <strong>Corporation</strong>s – Securities & Exchange Commission (SEC) Registration<br />
3. Foundations & Non-profit Organizations – Securities & Exchange Commission (SEC) Registration<br />
4. Cooperatives – Cooperative Development Authority (CDA) Registration<br />
5. Backyard industries/ventures and micro-business enterprises – Barangay Certification and/or<br />
Mayor‟s Permit<br />
3. PMRF for each employee (in duplicate)<br />
How can LGUs enrol their underprivileged constituents into the Sponsored Program?<br />
LGUs that wish to enrol their constituents through the Partial Subsidy Scheme must go through the following<br />
steps:<br />
1. Submission of letter of intent<br />
2. Submission of certified list of enrolees and accomplished PMRF<br />
3. Payment of premium contribution<br />
Who can be declared as legal dependents?<br />
The following can be declared as a principal member‟s legal dependents:<br />
1. Legal spouse (non-member or membership is inactive)<br />
2. Child or children<br />
b. Legitimate, legitimated, acknowledged and illegitimate (as appearing in birth certificate), adopted or<br />
step below 21 years of age, unmarried and unemployed<br />
c. 21 years old or above but suffering from congenital disability, either physical or mental, or any<br />
disability acquired that renders them totally dependent on the member for support<br />
3. Parents (non-members or membership is inactive) who are 60 years old and above, including stepparents<br />
(biological parents already deceased) and adoptive parents (with adoption papers).<br />
How do I activate my membership?<br />
In order to activate your membership, you must immediately remit your premium contribution. More details on<br />
this in the next section.<br />
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Where else can I register?<br />
Aside from Phil<strong>Health</strong> Offices, you may also enrol through our registration partners in SM malls, Bayad Centers,<br />
and mobile registration sites. The same procedures and requirements apply for these partners.<br />
Situationers for Registration/Enrolment<br />
Can foreign nationals working in the <strong>Philippine</strong>s enrol?<br />
Yes, the Implementing Rules and Regulations of RA 7875, as amended by RA 9241, provide for the inclusion to<br />
the NHIP the citizens of other countries residing and/or working in the <strong>Philippine</strong>s. If the foreign national is<br />
employed, he/she shall be registered under the Employed Sector Program.<br />
Meanwhile, if he/she is self-employed or merely residing in the country, he may enrol as an Individually Paying<br />
Member. He/she only needs to accomplish the following documents and submit these to any Phil<strong>Health</strong> office:<br />
1. Phil<strong>Health</strong> Member Registration Form (PMRF)<br />
2. Photocopy of his/her Alien Certificate of Registration (ACR) issued by the Bureau of Immigration (BI)<br />
to prove his/her residency in the country.<br />
Can minors and orphaned children enrol?<br />
Yes, minors are allowed to enrol into the NHIP. They must go through the following steps:<br />
1. Submit two (2) copies of the Phil<strong>Health</strong> Member Registration Form (PMRF) which must be signed by the<br />
minor-enrolee and countersigned by the guardian.<br />
2. A Notarized Affidavit of Guardianship is required as a supporting document for the purpose.<br />
3. Upon submission of documents, the minor-enrolee has to pay the required contributions.<br />
In case of early retirement, can I already register as a Lifetime Member?<br />
One is qualified to register as a Lifetime Member if the both of the following conditions are met:<br />
1. He/she is already 60 years of age<br />
2. Member has made at least 120 monthly contributions to Phil<strong>Health</strong> and the previous Medicare<br />
Hence, if you retired for instance, at the age of 50, you must continue paying premiums as an Individually Paying<br />
Member until you reach the age of 60 and have made the required number of premium contributions.<br />
Is it true that retiring employees can now be automatically enrolled by the employer in the<br />
Lifetime Member Program?<br />
Yes. As per Phil<strong>Health</strong> Circular No. 28, s-2010, retiring employees in the government and private sectors must be<br />
enrolled into the Lifetime Member Program and their enrolment must be facilitated by their employers at least<br />
three (3) months prior to the date of retirement.<br />
The application for Lifetime Member Program shall be filed with Phil<strong>Health</strong> as soon as the employee's retirement<br />
application has been approved by the employer. The employer's Human Resource Management Office, through<br />
its authorized representative, shall ensure that the documentary requirements for registration are forwarded to<br />
Phil<strong>Health</strong> for processing.<br />
Can foreign spouses of Filipino nationals be declared as dependents?<br />
Yes, foreign nationals who are spouses of Filipino nationals can be declared as legal dependents. The principal<br />
member has to submit a copy of their marriage contract so that the foreign national-spouse can be included in the<br />
member‟s MDR.
Can unmarried members declare nephews or nieces as dependents?<br />
Nephews and nieces are not considered as qualified legal dependents of principal members under Section 1 of RA<br />
9241.<br />
If both parents are members, can they both declare their children as dependents?<br />
Phil<strong>Health</strong> does NOT allow multiple declaration and application of Phil<strong>Health</strong> entitlements of both spouses. We<br />
advise you to decide who among you will declare and provide for the Phil<strong>Health</strong> coverage of your only<br />
child/children as dependents.<br />
How can a member declare his spouse whose membership is inactive as a dependent?<br />
The active member-spouse must submit the following at any Phil<strong>Health</strong> Office:<br />
1. 2 copies of duly accomplished Phil<strong>Health</strong> Member Registration Form<br />
2. Clear copy of Marriage Certificate/Contract with registry number (original copy to be presented for<br />
validation)<br />
3. Request letter to be declared as legal dependent signed by the inactive/unemployed spouse<br />
After processing, Phil<strong>Health</strong> will issue a new (updated) Member Data Record which indicates the name of the<br />
spouse (inactive) as legal dependent.<br />
If all siblings are active members, can each of them declare their parents as dependents?<br />
Multiple declarations of dependents are not allowed. Members are advised to decide who among them will declare<br />
their parents as dependents.<br />
Can disabled parents (physically or mentally incapacitated) who are below 60 years old be<br />
declared as dependents?<br />
No; only parents who are 60 years old and above are qualified as dependents.<br />
Can my live in partner be declared as a legal dependent? How about our children?<br />
While the live in partner cannot be declared as a legal dependent (one of the supporting documents required is the<br />
marriage certificate), your children can still qualify as dependents. Simply update your MDR and submit the<br />
necessary supporting documents (i.e., birth certificate) for your children.<br />
My daughter who‟s still my dependent (under 21) is about to give birth. Will my<br />
membership be able to cover her?<br />
Do I need to personally submit my registration documents or can I ask my representative to<br />
do so?<br />
There is no need for you to personally submit your registration documents. Your representative is allowed to<br />
submit your documents to Phil<strong>Health</strong> for processing as long as you have affixed your signature/thumbmark<br />
(whichever is applicable) on the registration form.<br />
D. UPDATING MEMBERSHIP RECORDS<br />
When should I update my MDR? How is this done?<br />
Ideally, members should update their MDR when:<br />
1. They have to shift membership categories (e.g. individually paying to employed)<br />
2. They get married<br />
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3. New dependents shall be declared<br />
4. There‟s incorrect information in the old MDR<br />
To update your MDR, simply submit an updated PMRF to the nearest Phil<strong>Health</strong> Office, along with the necessary<br />
supporting documents (marriage certificate, birth certificate, etc.).<br />
How do I shift membership categories?<br />
1. Fill out two (2) copies of the Phil<strong>Health</strong> Member Registration Form indicating the new membership<br />
category and submit these to any Phil<strong>Health</strong> office<br />
2. Await a copy of the member‟s updated MDR<br />
Are we going to use the same Phil<strong>Health</strong> Identification Number (PIN) if we are shifting to<br />
another membership category?<br />
Your Phil<strong>Health</strong> Identification Number (PIN) is your Phil<strong>Health</strong> number for life. Hence, if you are shifting to<br />
another membership category, you will be using the same PIN.<br />
Situationers for Updating Membership Records<br />
I was given a Phil<strong>Health</strong> card by our LGU, but my name was misspelled and data provided<br />
were also erroneous. How do I correct this information?<br />
If there‟s incorrect information in your ID/MDR, you will have to update your MDR by going through the<br />
following steps:<br />
1. Submit two (2) copies of the PMRF with the corrected information to the nearest Phil<strong>Health</strong> Office,<br />
along with the necessary supporting documents (birth certificate of any valid ID)<br />
2. Wait for your updated MDR and ensure that the information has been corrected<br />
E. CONTRIBUTIONS AND MEMBERSHIP RENEWAL<br />
Why must a member pay his premiums regularly?<br />
Regularly contributing to the NHIP assures the member of hassle-free availment of hospitalization benefits when<br />
medical needs arise. This will also ensure the member‟s qualification/eligibility to register under the Lifetime<br />
Member Program upon reaching the age of 60 years old, provided he has paid at least 120 monthly premium<br />
contributions.<br />
How much is the premium contribution rate?<br />
The premium contribution that each member has to pay is detailed in the following table:<br />
How much?<br />
Jan-June<br />
2012<br />
Overseas<br />
Workers<br />
P1200/year<br />
Employed Sponsored Individually Paying Member<br />
(IPM)<br />
NH<strong>TS</strong>-PR LGU Professionals Low Income<br />
Up to 3% of<br />
monthly basic<br />
salary (with<br />
P50,000 cap)<br />
P2400<br />
P1200/year for<br />
2-year lock in<br />
period)<br />
P2400/year<br />
P300 monthly<br />
P200 Monthly<br />
July-Dec P1200/year<br />
2012<br />
2013 P2400/year<br />
Who Member Employer National LGU Member Member
emits?<br />
Gov’t<br />
When? Annually Monthly Annual Annual/Biannual Quarterly<br />
Semi-annually<br />
Annually<br />
Monthly<br />
Quarterly<br />
Semi-annually<br />
Annually<br />
Effective January 2012, premium contributions will increase to a minimum of P2400, depending on the<br />
membership category (with OFWs as an exception). Different arrangements are being crafted to give payers ample<br />
time to prepare for this increase. Here are the updates for the different programs:<br />
1. Sponsored Program<br />
a. Premiums of NH<strong>TS</strong>-PR poor amounting to P2400 by January 2012 will be fully subsidized by the<br />
National Government.<br />
b. Through the partial subsidy scheme, LGUs and other donors may provide the full/partial subsidy to<br />
finance the premiums of identified families within their jurisdiction. Premiums will increase to P2400<br />
by July 2012. Prior to this increase, LGUs are given an option to avail of the two-year lock in deal<br />
(P1200/year for two years).<br />
2. Individually Paying<br />
a. For high income members (monthly salary > P25000), premiums will be pegged at P300/month or<br />
P3600/year.<br />
b. For low income members (monthly salary < P25000), premiums will be pegged at P200/month or<br />
P2400/year.<br />
3. Employed. The premium contribution of each employed member is up to 3% of their basic monthly<br />
salary (with P50000 cap). For this category, the employer and employee split the premium, which is<br />
directly deducted from the members‟ salaries and remitted to Phil<strong>Health</strong> by the employer.<br />
4. Overseas Workers. By January 2012, premiums of overseas workers will increase from P900 to P1200.<br />
By January 2013, premiums for this segment will further increase to P2400. This has to be settled before<br />
the member leaves the country.<br />
5. Lifetime Members. Members under this category no longer have to pay their premiums, since they have<br />
already completed their 120 monthly contributions.<br />
Why is there a need for an increase in premium contributions?<br />
Phil<strong>Health</strong> is in a process of enhancing its benefits in order to provide bigger and better benefits and services to<br />
its members. Hence, we will need to increase our collections to be able to sustain this move.<br />
Are overtime pay, commissions, and allowances included in the computation of premium<br />
contributions of employees?<br />
No, they are not included. The amount of monthly premium contribution of members shall be based on the<br />
employee‟s salary or wage which is the basic monthly compensation received for services rendered.<br />
Where can the members remit their contributions?<br />
1. Phil<strong>Health</strong> has over 100 service offices all over the country wherein members can pay for their<br />
premiums.<br />
2. Phil<strong>Health</strong> has also accredited the following collecting agents:<br />
a. More than 1,000 CIS Bayad Centers<br />
b. Collecting Banks<br />
c. MLhuillier <strong>Philippine</strong>s Pawnshops<br />
d. LBC Express outlets<br />
e. Offices of the <strong>Philippine</strong> Postal <strong>Corporation</strong><br />
f. Selected Local Government Units<br />
3. For Overseas Workers Program Members, i-Remit branches, other partner agents, and foreign offices of<br />
<strong>Philippine</strong> Veterans Bank (UK, Abu Dhabi and Qatar) also accept premium payments.<br />
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Aside from paying through service offices and collecting agents, is there another way for me<br />
to pay my premiums easily?<br />
Yes. Currently, Phil<strong>Health</strong> in collaboration with Smart, Inc. has come up with Text 7442, an easy-to-use service<br />
that will allow Smart/Talk N‟ Text pre-paid subscribers to pay for their premiums through SMS. To avail of this<br />
service; just remember the following steps:<br />
1. Type “PHIC (space) ” and send to 7442. (Example: PHIC 123456789012)<br />
2. After this, you will receive a text message containing your PIN, and name (Last Name, First Name,<br />
Middle Name) as it appears in the Phil<strong>Health</strong> database. (Example: PIN 12345679012 Lapuz, Harold,<br />
Chan)<br />
3. If the name and PIN are correct, type “PHIC (space) YES” to confirm your premium payment for the<br />
current month. Each transaction is worth one-month of premium plus a transaction fee.<br />
4. After sending, you will receive a confirmation message, which contains your PIN and Reference Number<br />
for the transaction. Keep this reference number, as you‟ll need it to download your proof of payment.<br />
What if I want to view my payment history for Text 7442?<br />
1. Simply type “PHIC (space) HISTORY (space) ” and send to 7442 to view your payment history.<br />
2. You may also download the payment history through www.philhealth.gov.ph. Your payment history will<br />
serve as your proof of payment when availing benefits.<br />
When is the deadline for paying my premium contribution?<br />
The following table summarizes when premiums have to be in for each member category:<br />
Membership Category<br />
Overseas Worker<br />
Employed<br />
Sponsored<br />
Individually Paying<br />
Deadline for Paying Premium<br />
Before leaving the country or before the last contribution expires<br />
Tenth day of the following month<br />
Based on the agreement between the Sponsor and Phil<strong>Health</strong><br />
1. Semi-Annually/Annually – last day of the third month of the first quarter<br />
2. Quarterly – last day of the third month of a quarter<br />
3. Monthly (through Text 7442) – last day of the month<br />
(See tables below)<br />
For Individually Paying<br />
Quarterly<br />
1. First Payment<br />
2012<br />
First Quarter Second Quarter Third Quarter Fourth Quarter<br />
Jan Feb March April May June July Aug Sept Oct Nov Dec<br />
Mar 31<br />
June<br />
Sep 30 Dec. 31<br />
30<br />
2. Second Payment<br />
2012<br />
First Quarter Second Quarter Third Quarter Fourth Quarter<br />
Jan Feb March April May June July Aug Sept Oct Nov Dec<br />
June<br />
30<br />
3. Third Payment<br />
2012<br />
First Quarter Second Quarter Third Quarter Fourth Quarter<br />
Jan Feb March April May June July Aug Sept Oct Nov Dec<br />
Sep 30
4. Fourth Payment<br />
2012<br />
First Quarter Second Quarter Third Quarter Fourth Quarter<br />
Jan Feb March April May June July Aug Sept Oct Nov Dec<br />
Dec. 31<br />
Semi-Annually<br />
2012 2013<br />
First Quarter Second Quarter Third Quarter Fourth Quarter First Quarter<br />
Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March<br />
Mar 31<br />
Sep30<br />
- First Payment - - Second Payment -<br />
2012 2013<br />
First Quarter Second Quarter Third Quarter Fourth Quarter First Quarter<br />
Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March<br />
June<br />
30<br />
Dec.<br />
31<br />
- First Payment - - Second Payment -<br />
2012 2013<br />
First Quarter Second Quarter Third Quarter Fourth Quarter First Quarter<br />
Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March<br />
Sept.<br />
30<br />
Mar<br />
31<br />
- First Payment - - Second Payment -<br />
2012 2013<br />
First Quarter Second Quarter Third Quarter Fourth Quarter First Quarter<br />
Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March<br />
Dec.<br />
31<br />
- First Payment -<br />
Annually<br />
2011 2012<br />
J F M A M J J A S O N D J F M A M J J A S O N D<br />
31<br />
2011 2012<br />
J F M A M J J A S O N D J F M A M J J A S O N D<br />
30<br />
2011 2012<br />
J F M A M J J A S O N D J F M A M J J A S O N D<br />
31<br />
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2011 2012<br />
J F M A M J J A S O N D J F M A M J J A S O N D<br />
31<br />
What is the effectivity date of Phil<strong>Health</strong> coverage?<br />
Phil<strong>Health</strong> benefit coverage starts upon payment of premium (no waiting period) and is valid for one year from<br />
the date of payment.<br />
What are the requirements for eligibility? When is a member eligible to claim?<br />
In order to become eligible to claim benefits, a member must pay premium contributions regularly. If the member<br />
missed paying for a certain period, he/she and his/her dependents may not be able to use the benefits. The table<br />
below summarizes the eligibility requirements:<br />
Sponsored Members<br />
Individually Paying<br />
Members<br />
Lifetime Member<br />
Employed Members<br />
Overseas Workers<br />
Date of hospitalization/availment must be within the<br />
effectivity period indicated in the member‟s ID and<br />
MDR.<br />
1. There are certain confinement cases wherein three<br />
months’ worth of premium within the last six<br />
months (3/6) prior to confinement is acceptable.<br />
2. For pregnancy-related cases, dialysis, chemotherapy,<br />
radiotherapy and other selected surgical procedures,<br />
the member must have paid nine months worth of<br />
premium within the last twelve months (9/12)<br />
prior to confinement in order to become eligible.<br />
The member just has to show their Lifetime ID Card; no<br />
need to pay premiums anymore.<br />
Three months worth of premium within the last six<br />
months (3/6) prior to hospitalization<br />
Date of hospitalization/availment must be within the<br />
coverage period specified in the member‟s MDR<br />
Just remember the 3/6, 9/12, and effectivity period requirements and you‟re good to go.<br />
How do I maintain my eligibility?<br />
The key to maintaining eligibility is paying your premiums on-time. If there are gaps in premium contribution,<br />
eligibility will also be affected. Here are several tips for each member category to ensure that you‟ll always be able<br />
to use your benefits:<br />
1. Sponsored Members<br />
If the member‟s card is about to expire already, the member must proactively inquire<br />
whether the Sponsor will renew his/her membership.<br />
If not, the member may opt to register as an Individually Paying Member.<br />
2. Individually Paying Member<br />
Ensure that each calendar quarter has been paid.<br />
If possible, pay your premiums yearly for your own convenience.<br />
3. Overseas Workers Program Member<br />
Premiums must be remitted prior to your membership‟s expiration.<br />
If your contract abroad has already terminated, make sure that you shift member category<br />
from OWP to IPM (or other applicable categories) to be able to pay premiums again.<br />
4. Employed Members
For seasonal employment or if you‟re going to take a leave without pay, just head to the<br />
nearest Phil<strong>Health</strong> Service Office to pay your contributions during those months wherein<br />
you will not be compensated. You may continue paying your premiums as an Individually<br />
Paying Member (IPM).<br />
To pay your premiums as an IPM, visit any Phil<strong>Health</strong> office and present a copy of the RF-1<br />
from your employer indicating that you are on leave without pay or a Certification from your<br />
employer indicating the same.<br />
Once you get separated from employment, make sure that you shift category to IPM.<br />
If I missed paying in the past quarters, can I still pay for this now to become eligible again?<br />
This is an example of a retroactive payment. Unfortunately, Phil<strong>Health</strong> does not accept retroactive payments to<br />
avoid abuse of benefits. This policy has to be in place to avoid those instances when members only choose to pay<br />
when they get sick or need to avail of benefits (and conversely stop paying when they don‟t need it), which will be<br />
unfair for those who pay their premium contributions regularly.<br />
What is the tolerable delay for paying premiums for a member to still be able to use his/her<br />
benefits?<br />
None. Phil<strong>Health</strong> strictly follows its policies on premium payment and benefit availment.<br />
Situationers: Contributions and Renewal<br />
Can contributions be refunded by the member who was not able to use it?<br />
No. Phil<strong>Health</strong> is a social health insurance program, wherein members‟ premiums are pooled into a single fund<br />
used to pay for the benefits of sick members. Even if a member is not able to use benefits or does not get sick<br />
within a particular enrolment year, funds are kept in the pool.<br />
If I stopped paying my premium for a considerable amount of time, can I still use my<br />
benefits? Do I need to pay the missed contributions to be able to avail of the benefits<br />
again?<br />
No. Only active members are eligible to avail of Phil<strong>Health</strong> benefits. Member should have paid at least three<br />
months premium contributions within the immediate six month period prior to medical confinement. However,<br />
payment of at least nine months within the last 12 months shall be asked of Individually Paying Members availing<br />
of the following procedures/packages:<br />
• Pregnancy-related cases<br />
• Dialysis (except those undergoing emergency dialysis service during confinement)<br />
• Chemotherapy<br />
• Cataract Extraction<br />
• Radiotherapy<br />
• Selected surgical procedures<br />
Individually Paying Members and Employed Members will now be required to have at least nine (9) months<br />
contributions within twelve (12) months prior to the month of availment for all confinements including availment<br />
of outpatient benefits).<br />
On retroactive payments:<br />
As per Phil<strong>Health</strong> Circular No. 06, series of 2001, retroactive payments are not allowed except when a member<br />
can show proof of sufficient regularity of premium contributions or payment of nine (9) consecutive months or<br />
three consecutive quarters within the last 12 months prior to the missed quarter. If you meet this condition, you<br />
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shall be given a grace period of one month immediately after the missed quarter to pay retroactively including the<br />
current calendar quarter.<br />
For newly enrolled members (with less than 12 months totalled from date of enrolment), retroactive payment for<br />
the missed quarter including the current calendar quarter shall also be allowed within the month immediately<br />
following the missed period.<br />
This privilege is granted only once every 12 months.<br />
If an employed member who was separated from service last October 2011 wants to<br />
continue his membership as an Individually Paying Member in March 2012, can he<br />
retroactively pay the premiums for Nov-Dec 2011 and first quarter 2012, in March 2012?<br />
Yes, for the employed member who wants to continue his membership as IPM but failed to immediately pay<br />
his/her premium within the quarter of separation, he/she shall be given a grace period of one calendar quarter<br />
immediately after the unpaid quarterly period to retroactively settle his obligation.<br />
A new governor/mayor was elected in our area. Am I still considered a member under the<br />
Sponsored Program even with this change in leadership?<br />
It is the validity period that determines your membership status. Yes, you are still considered a member even if a<br />
new governor/mayor was elected, so long as your membership has not yet expired.<br />
To ensure the renewal of your membership post-validity date, you can go to the local office of the DSWD thatis<br />
in charge of evaluating and determining if you are qualified to join the program. The DSWD shall then endorse<br />
your name to the Local Government Unit (LGU) or any Sponsor for enrolment.<br />
What if I have multiple jobs? Can I just pay my contributions once?<br />
Section 18-20 of the Implementing Rules and Regulations of RA 7875, as amended, mandates employers to enroll<br />
their employees, deduct from their salaries the required premium contribution, and remit the same, together with<br />
the corresponding employer share, to Phil<strong>Health</strong>. As each employer has to adhere to this law, those who are<br />
engaged in multiple employment should consequently be deducted of their corresponding employee share by each<br />
and every employer with which they are currently employed.<br />
I am an employed member, but I recently found out that my employer stopped paying our<br />
contributions even though he continues to deduct the premiums from our salaries. How do<br />
we go about this?<br />
If the employer failed to remit their employees‟ contributions, the employer will have to reimburse Phil<strong>Health</strong>‟s<br />
payment forclaims filed by concerned employees or his/ her qualified dependent/s.<br />
Employees should report through writing if they suspect that their employers are not remitting contributions to<br />
the <strong>Corporation</strong> so that appropriate action will be taken against them.<br />
What if the member passes away? Can the dependents still use their benefits?<br />
In case the member dies, his/her membership privileges also terminate. However, dependents of Sponsored<br />
Members may still avail of the Phil<strong>Health</strong> 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,<br />
can his dependents refund his premium?<br />
If the member has dependents, they can avail of Phil<strong>Health</strong> benefits for the unexpired portion of the member‟s<br />
contributions. However, similar to other members, they are not allowed to refund his premium that has already<br />
been channeled to the health insurance pool.<br />
I already have a lifetime member card, but my current employer still continues to pay for my<br />
premiums. Can these premium contributions be credited to my son/daughter‟s membership<br />
when I retire?<br />
Since you are considered to formally employed, your employer is really mandated to continue paying for your<br />
premiums. However, payments made are non-transferrable and cannot be credited to your son/daughter‟s<br />
membership when you retire.<br />
What if a Lifetime Member is re-hired, must he resume contributing to Phil<strong>Health</strong> through<br />
salary deduction?<br />
A Lifetime Member who acquires regular employment shall temporarily cease to be covered under the Lifetime<br />
Member Program, and shall instead be covered under the formally employed segment. After separation from<br />
his/her regular employment, he can resume his membership as Lifetime Member.<br />
Is membership transferrable?<br />
No, membership is non-transferrable.<br />
Are the payments for OWWA Contributions and Phil<strong>Health</strong> premiums different?<br />
Yes, they are different. OWWA contributions serve as a life insurance of the OFW abroad while Phil<strong>Health</strong><br />
premiums ensure the health benefits of the OFW and his/her dependents in case of illness or injury requiring<br />
hospitalization.<br />
If I stopped paying my premium for a considerable amount of time, how will I reactivate my<br />
membership? Do I need to apply for a new membership/PIN?<br />
There is no need to apply for a new PIN. Using your old PIN, simply carry out the following steps:<br />
1. Fill out two (2) copies of the Phil<strong>Health</strong> Member Registration Form indicating the new membership<br />
category and submit these to any Phil<strong>Health</strong> office<br />
2. Await a copy of the member‟s updated MDR, and proceed to any of Phil<strong>Health</strong>‟s accredited collecting<br />
agent to pay for the applicable premium using the same Phil<strong>Health</strong> identification number (PIN).<br />
How can a SP member continue Phil<strong>Health</strong> membership when his/her Phil<strong>Health</strong> ID expires?<br />
To continue his/her Phil<strong>Health</strong> membership once his/her ID expires and granting that it has not been 'renewed',<br />
a Sponsored Member should enroll as an Individually Paying Member and pay his/her premiums within the<br />
calendar quarter or before the expiry date as reflected in the Phil<strong>Health</strong> Identification Card.<br />
I used to be employed, but am now self-employed. Can I still continue paying for my<br />
premiums? How do I go about this?<br />
In case you get separated from employment, you may continue your Phil<strong>Health</strong> membership by becoming an<br />
Individually Paying Member and paying the applicable premium. Simply accomplish the Phil<strong>Health</strong> Member<br />
Registration Form (PMRF) and tick the box "For Updating" and the appropriate box of the membership category<br />
to which you are shifting. Make sure you continuously and religiously pay your premiums so as to avoid<br />
suspension of benefits.<br />
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I am a Phil<strong>Health</strong> member sponsored by an LGU; is it still necessary for me to pay my<br />
membership as an OFW?<br />
If a member is sponsored by an LGU and the membership is still active, the member shall pay for his/her<br />
Phil<strong>Health</strong> membership as an OFW when the coverage of his/her sponsored membership expires.<br />
If in case the member already paid his/her membership as an OFW while his/her sponsored membership is still<br />
active, the member is advised to go to any Phil<strong>Health</strong> office to make necessary adjustments on his/her<br />
membership coverage.<br />
Why do I have to renew my Phil<strong>Health</strong> membership every time I leave the country and work<br />
as an OFW?<br />
It's not actually renewal of membership but an updating of your premiums, which shall be equivalent to the length<br />
(in years) of your fresh contract. It will also ensure your continuous eligibility to Phil<strong>Health</strong> benefits.<br />
What is the grace period of OFW membership renewal?<br />
OFWs are allowed to pay the applicable premium within one (1) month from the date of expiry. Payment within this<br />
period shall retroactively commence the coverage of membership from date of expiration.<br />
I am currently abroad and my coverage is about to expire. How do I continue paying for my<br />
Phil<strong>Health</strong> in case there are no available payment centers where I am?<br />
You may ask your relatives in the <strong>Philippine</strong>s to pay your premiums on your behalf to avoid any lapses or delays.<br />
They only need to present a valid ID and an authorization letter from you as the member and any document that<br />
would attest that you are still an active OFW.<br />
If a member has dual citizenship, can he/she still renew his/her membership and avail of the<br />
benefits whenever he/she is in the <strong>Philippine</strong>s?<br />
Yes. Those with dual citizenship still have the option to continue paying for their Phil<strong>Health</strong> coverage also as<br />
individually paying members. Entitlement to benefits if confined in the <strong>Philippine</strong>s will depend on such factors as<br />
the member‟s qualifying contributions and the accreditation of the health care providers.<br />
I am already an immigrant here in the US. Can I still continue my membership with<br />
Phil<strong>Health</strong>?<br />
Yes. You can still continue paying for your Phil<strong>Health</strong> coverage as an Individually Paying Member and not as an<br />
Overseas Worker Member.<br />
Where can I pay my premium contributions?<br />
If abroad, you may pay at any Phil<strong>Health</strong> Overseas Accredited Payment Centers. In the <strong>Philippine</strong>s, you or your<br />
immediate family or representative may pay at any Phil<strong>Health</strong> Offices and Accredited Collecting Partners.<br />
F. SPECIAL SECTION: INCREASE IN PREMIUM FOR OFW MEMBERS<br />
Why is there a need to increase the annual premium of OFW members?<br />
The increase in premium across all paying sectors is in line with our continuing efforts to enhance our existing<br />
benefit packages, sustain the provision of better benefits to our members and provide true financial protection for<br />
our members to be able to fully achieve the objectives of Universal <strong>Health</strong> Care (UHC). The increase, which is<br />
inevitable if we want to meet our UHC goals by 2013, does not only apply to our OFW-members but also to the<br />
Employed, Sponsored and Individually Paying members as well.
What was the basis for pegging the new premium rate at P2,400 per year?<br />
One of the studies conducted by our Actuarial Services Sector several years ago, revealed that the premium of<br />
the OFWs should already be set at P 1,800.00 to P 2,000.00 per year, but we decided to still peg the<br />
annual rate for OFWs at P 900.00, the same rate they have been enjoying since we took over the Medicare<br />
program from the OWWA in 2005. However, with the new directions of the present administration to provide<br />
true financial protection for our members wherein Phil<strong>Health</strong> will fully subsidize the roll out of primary care<br />
benefits that will entitle members to basic quality health care services, the prevailing rate of P900.00 has to be<br />
increased to P 2,400.00.<br />
Were OFW members consulted by Phil<strong>Health</strong> before the increase was approved?<br />
The planned increase had been extensively discussed and debated on within our Board of Directors where the<br />
OFW sector is adequately represented. We have commenced our media guestings and tapped print materials<br />
(newspapers, etc.) informing the public about the new rates and we shall continue organizing round-table<br />
discussions with our key stakeholders to address whatever other issues they may have on the matter.<br />
How much is the increase? When is this effective?<br />
For the NH<strong>TS</strong>-identified poor, premiums have increased to P 2,400 by January 1, 2013 (see Circular 007, s-<br />
2012). Premiums for members, sponsored by local government units (LGUs), for Individually Paying Members<br />
(IPMs) and OFWs will also increase to P 2,400 by July 1, 2012. For the formal employed sector, premium rates<br />
will be pegged at 3% of the basic monthly salary by January 1, 2013 with a maximum salary base of P 50,000.00.<br />
This means that employers whose monthly salary is P50,000 & above will be paying P750.00 and the employer will<br />
provide a counterpart amount of P 750.00 per month.<br />
When was the last time that premium contributions of OFW members increased?<br />
As far as OFWs are concerned, the annual rate of P 900.00 has been in place since Phil<strong>Health</strong> took over the<br />
Medicare Program from the OWWA in 2005 and no adjustments have been introduced since then, despite the<br />
series of increases in benefit packages that we have implemented across all member-types over the years.<br />
Can OFW members whose families were affected by Typhoon Sendong be exempted from<br />
paying the new premium rate?<br />
No. However, Phil<strong>Health</strong> Advisory No. 01-03-2012, extended the deadline of premium payment of members<br />
affected by Typhoon Sendong up to March 31, 2012.<br />
Where can they pay their premium contributions in the <strong>Philippine</strong>s? How about abroad?<br />
Overseas Worker-members may pay at the POEA, or at any of our Service Offices nationwide or through any of<br />
our accredited collecting agencies locally or overseas.<br />
If an OFW‟s membership coverage expires while he is still abroad, will he be required to pay,<br />
through his kin in the <strong>Philippine</strong>s, the new rate when he renews his coverage?<br />
An OFW-member may ask his kin in the <strong>Philippine</strong>s to pay for his membership renewal provided he sends his kin<br />
the following:<br />
1. Copies of the required documents such as:<br />
a. Valid overseasemployment certificate<br />
b. Valid working visa/re-entry permit<br />
c. Valid job employment contract<br />
d. Certificate of employment from employer abroad<br />
e. Valid company ID issued by employer abroad<br />
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2. Cash remittance from member abroad at least 2 months prior to the date of renewal or payment. If the<br />
membership expired last December 31, 2011, the OFW, through his kin, will be required to pay the new<br />
rate of P1,200.00, if he pays anytime between January 1 and June 30, 2012.<br />
How much is the premium if an OFW decides to pay in advance?<br />
OWP members can avail themselves of a lower premium, equivalent to P 1,200.00 per year, if they pay two<br />
(2) years‟ worth of Phil<strong>Health</strong> premium betweenJanuary 1 to December 31, 2012.<br />
What additional benefits can an OFW member expect from Phil<strong>Health</strong>?<br />
OFWs can expect the following improvements in the benefit packages soon:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Basic benefit package<br />
Inpatient and outpatient benefits<br />
Expansion of No Balance Billing to other member types like OFWs & employed sector when confined in<br />
government hospitals<br />
Special rates for 20 identified catastrophic cases, such as cancer, etc.<br />
Shift in reimbursement policies (Fee for Service to Case Rates)<br />
Outpatient primary care package (1,000 pesos worth of benefits per member)<br />
Obligated preventive and diagnostics services<br />
Out-patient drugs and medicines (anti-hypertensive, anti-diabetics and antibiotics) and outpatient diagnostics<br />
and specialist care<br />
Supplemental benefit package – Phil<strong>Health</strong> Plus and Catastrophic Fund<br />
Special Benefits : rehabilitation package, vaccination package (rabies), enhanced peritoneal dialysis benefit<br />
package, health promotion (smoking cessation)<br />
Will the increase in premium mean additional benefits for OFWs and their dependents as<br />
well?<br />
Yes. Not only will there be an increase in benefits, but also an improvement in frontline services and access to<br />
these benefits.<br />
Are these benefits available to the OFW member even while he is abroad?<br />
Only some of the upcoming hospitalization benefits and other selected services will be available to the OFW<br />
while he is abroad since some packages are and will be offered by local health facilities. However, all qualified legal<br />
dependents of OFW-members can avail themselves of these benefits locally.<br />
When can OFWs expect the increase in benefits?<br />
Benefit enhancements are targeted to be released by June 2012.<br />
How do you plan to inform OFWs about the new premium rate in less than two weeks‟<br />
time?<br />
Phil<strong>Health</strong> intends to go full blast in its IEC initiative. The following will be conducted:<br />
Send advisories to all recruitment agencies, PDOS providers and accredited collecting agents abroad<br />
Distribute flyers at POEA<br />
Post tarpaulin at POEA<br />
Conduct orientation meetings with OFWs at POEA<br />
Conduct meeting with OFW organizations<br />
Tri-media exposures<br />
Post advisory at OWP and in the official Facebook and Twitter accounts
Is Phil<strong>Health</strong> making any representation with <strong>Philippine</strong> Embassies and consulates overseas<br />
to inform OFWs about the increased premium?<br />
We will communicate and send advisories to all <strong>Philippine</strong> Posts abroad to help spread the word about the new<br />
premium rates.<br />
Since Phil<strong>Health</strong> has no physical presence overseas, how do you plan to discuss the new<br />
premium rates with OFWs and OFW organizations at this time?<br />
We will seek the assistance of our Embassies and Consulates in discussing this increase together with the leaders<br />
of OFW organizations while we send individual e-mail and text messages to our OFW contacts.<br />
Where can OFW-members refer their inquiries pertaining to the new premium rates?<br />
OFW members can refer their inquiries to the following:<br />
Phil<strong>Health</strong> Call Center 4417442<br />
Mobile Numbers 09189635396/09175129149<br />
OFW members can also e-mail us at:<br />
1. owp@philhealth.gov.ph<br />
2. itu_owp@philhealth.gov.ph<br />
3. philhealth_hk@philhealth.gov.ph<br />
4. philhealth_ksa@philhealth.gov.ph<br />
5. philhealth_sg@philhealth.gov.ph<br />
G. SPECIAL SECTION: UMID CARD ACTIVATION AND BIOMETRIC CAPTURE<br />
Why must I undergo biometric capture with Phil<strong>Health</strong>?<br />
Submitting yourself to biometric capture will prepare you for the eventual generation of the Common Reference<br />
Number (CRN) which will help facilitate the subsequent issuance of your Unified Multi-Purpose Identification<br />
(UMID) card.<br />
Can I choose not to have my biometric data captured by Phil<strong>Health</strong>?<br />
Choosing not to have your biometrics taken at this time might inconvenience you later on, especially when<br />
Phil<strong>Health</strong> starts issuing the UMID card to the members in the Informal Sector. Only those who have submitted<br />
themselves to biometric capture will be prepped for UMID card issuance, thus, we advise you to proceed with<br />
your biometric capture.<br />
What does „biometric capture‟ mean?<br />
Biometric capture means that your biometric data will be captured and matched with your Phil<strong>Health</strong> member<br />
data, to ascertain your identity in preparation for the issuance of the CRN later on. Among the biometric data<br />
that will be taken are as follows: facial image (photo), electronic signature and fingerprints.<br />
Am I going to pay any fee for biometric capture?<br />
No, Phil<strong>Health</strong> is not charging any transaction fee for biometric capture.<br />
Where can I have my biometric data captured by Phil<strong>Health</strong>?<br />
The Phil<strong>Health</strong> UMID Mobile Team will be in your office premises on a schedule to be agreed upon with your<br />
Human Resource Department (HRD). The schedule will be announced by your HRD days before the UMID<br />
Mobile Team will set up shop in your office for the biometric capture.<br />
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If I missed the schedule of biometric capture in our office premises, can I proceed to any<br />
Phil<strong>Health</strong> Branch for this?<br />
You may call the UMID Project Management Office to ask for the next schedule at your office premises, or if the<br />
UMID Mobile Team has a scheduled biometric capture activity near your office location.<br />
Are there forms I need to fill out before biometric capture day?<br />
It is advisable for you to fill out the UMID Registration Form (URF) before going to the biometric capture<br />
station.<br />
Is there a recommended attire for the biometric process?<br />
Since the biometric capture activity will be held at your office premises during business hours, it is expected that<br />
you come properly dressed in business or office attire.<br />
How will the biometric capture procedure go?<br />
The biometric capture procedure is very simple. Simply follow these steps:<br />
1. Fill up the UMID Registration Form (URF)<br />
2. Submit the URF to the UMID Team for encoding<br />
3. Check if the encoded data are correct<br />
4. Have your photograph taken<br />
5. Sign on signature pad<br />
6. Press the required fingers on the fingerprint scanner<br />
7. Receive the registration receipt/claim stub from the UMID Team member.<br />
Will the biometric capture process eat up a lot of my time from work?<br />
No, the biometric capture process itself takes only about 6 minutes.<br />
What do I need to bring on biometric capture day?<br />
You have to bring one (1) valid ID card, meaning, this should have your photo and your signature. You must also<br />
bring either a copy of your Member Data Record (MDR) or your Phil<strong>Health</strong> ID/Number Card.<br />
Are there things I must ensure before I proceed with biometric capture?<br />
Make sure that your MDR is updated with Phil<strong>Health</strong> prior to biometric capture activity and the UMID<br />
Registration Form properly filled up.<br />
Can I update my MDR on the day of biometric capture through the UMID Mobile Team?<br />
Updating of MDR cannot be made on the day of the biometric capture. It is advised that you update your MDR<br />
before the day of the biometric capture.<br />
Once my biometric data have been captured, what are the next steps?<br />
Your biometric data will be processed then forwarded to Central Verification System (CVS) for CRN generation<br />
and for UMID card issuance later on.<br />
Where can I call if I have further questions regarding the biometric capture?<br />
Further questions on the UMID Biometric Capture may be referred to the UMID Project Management Office at<br />
441-7444 extension 7671 or 7672.
UMID Card Activation<br />
Why must I activate my UMID card with Phil<strong>Health</strong>?<br />
Activating your UMID card will prepare you for Phil<strong>Health</strong>‟s shift to paperless transactions. Your UMID card will<br />
eventually enable you to access health care services at accredited facilities without having to submit documentary<br />
requirements anymore.<br />
Can I choose not to activate my UMID card with Phil<strong>Health</strong>?<br />
Opting not to activate your UMID card with Phil<strong>Health</strong> might render inconvenience for you at point-of-service,<br />
i.e., at the hospital billing section if you or your legal dependent is hospitalized. Once Phil<strong>Health</strong> goes into<br />
paperless transactions, its accredited hospitals only need to swipe the members‟ UMID cards to check on their<br />
eligibility to avail themselves of Phil<strong>Health</strong> benefits. If your UMID card is not yet Phil<strong>Health</strong>-activated, you will<br />
be required to submit documentary requirements to support your claim for benefits.<br />
What does „card activation‟ mean?<br />
Activation of your UMID card with Phil<strong>Health</strong> means that your Member Data Record (MDR) will be loaded<br />
electronically into your UMID card. The MDR contains your basic information as a Phil<strong>Health</strong> member, such as<br />
your Phil<strong>Health</strong> ID number, date of birth, civil status, address, employer, and your list of legal dependents. Your<br />
premium contribution payments for the last two years (2010 and 2011) will also be loaded into your UMID card<br />
during card activation.<br />
What are the requirements to activate my UMID card with Phil<strong>Health</strong>?<br />
Do I need to pay any fee for card activation?<br />
No, Phil<strong>Health</strong> is not charging any transaction fee for card activation.<br />
Are there forms I need to fill out before card activation day?<br />
None, you will not be required to fill out any forms prior to nor during card activation day.<br />
What do I need to bring on card activation day?<br />
You only need to bring your UMID card.<br />
Are there things I must ensure before I proceed with activating my UMID card?<br />
First, make sure that your UMID card is already activated with the GSIS. There are GSIS kiosks in selected<br />
local government units where your UMID card may be activated.Second, make sure that your MDR is<br />
updated; otherwise, the MDR that is currently posted in our database will be loaded into your UMID card<br />
once card activation takes place.<br />
Where can I activate my UMID card with Phil<strong>Health</strong>?<br />
The Phil<strong>Health</strong> UMID Mobile Team will be in your office premises on a schedule to be agreed upon with your<br />
Human Resource Department. The schedule will be announced by your HRD days before the UMID Mobile<br />
Team will set up shop in your office for the card activation.<br />
If I missed the schedule of card activation in our office premises, can I proceed to any<br />
Phil<strong>Health</strong> Branch to have my UMID card activated?<br />
You may call the UMID Project Management Office to ask for the next scheduleat your office premises, or if the<br />
UMID Mobile Team has a scheduled card activation near your office location so you can activate your card.<br />
How long does the card activation process take?<br />
The card activation process takes only about five (5) minutes. Since you will only be required to proceed to the<br />
card activation venue on your appointed day and time, you need not spend hours at the venue to wait for your<br />
turn.<br />
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Can I update my MDR on the day of card activation through the UMID Mobile Team?<br />
The UMID Mobile Team will be busy handling the card activation process and they will not be able to attend to<br />
your MDR updating requirements. We advise you to do this at least three (3) days before the schedule of card<br />
activation. Your HRD can help you update your Phil<strong>Health</strong> records.<br />
What are the card activation procedures?<br />
The card activation procedure is very simple. Simply follow these steps:<br />
1. Tap your UMID card on card reader<br />
2. Press any of your registered fingers into the fingerprint scanner<br />
3. Validate your Member Data shown onscreen<br />
4. If data are accurate, choose „Overwrite Data on Card‟; otherwise, choose „Cancel‟<br />
5. Press finger on fingerprint scanner to signify end of procedure<br />
6. Remove card from card reader<br />
How will I use my Phil<strong>Health</strong>-activated UMID cards?<br />
Procurement of kiosks through which the Phil<strong>Health</strong>-activated UMID cards can be read is underway. Once these<br />
are installed at selected locations nationwide, you can check on your Phil<strong>Health</strong> data anytime, anywhere. You can<br />
also use the UMID card to track the status of your Phil<strong>Health</strong> claim, to verify if a dependent has been declared in<br />
your MDR, or verify if your premium contributions have been posted.<br />
What are the contact numbers if I have further questions regarding the UMID card<br />
activation?<br />
Further questions on the UMID card activation may be referred to the UMID Project Management Office at 441-<br />
7444 extension 7671 and 7672.<br />
H. BENEFI<strong>TS</strong> AND BENEFI<strong>TS</strong> AVAILMENT<br />
What benefits can a member avail himself of under the NHIP?<br />
Phil<strong>Health</strong> offers a roster of benefits to ensure that members are given true financial risk protection. This section<br />
provides a glimpse of these benefits that each member can enjoy.<br />
Basic Benefit Package for Hospitalization<br />
This package is available to all member-types based on the hospital category and type of illness of the patient. It<br />
covers:<br />
1. Allowance for Room and Board<br />
2. Allowance for Drugs and Medicines<br />
3. X-ray, laboratory and others<br />
4. Professional fees<br />
5. Use of the Operating Room complex<br />
This package varies according to several factors – hospital level, case type of disease, relative value unit, and<br />
doctor‟s qualifications.<br />
1. Case Types (varies according to severity of illness)<br />
a. Case Type A – simple illnesses<br />
b. Case Type B – moderate cases<br />
c. Case Type C – severe cases<br />
d. Case Type D – extremely severe illnesses<br />
2. Relative Value Unit (RVU). Benefit allowances for operations vary according to their complexity; this<br />
complexity is reflected in the Relative Value Unit or RVU. The more complex the procedure, the higher<br />
the RVU and the corresponding benefit allowances.
3. Doctor‟s Qualifications –Professional fees vary for general practitioners, general practitioners with<br />
training, and specialists. The Peso Conversion Factor (PCF) also varies for the PF of the surgery they<br />
conducted.<br />
The following tables show the existing coverage based on the combination of the factors mentioned above:<br />
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Case Rates for Medical and Surgical Cases<br />
Members may also avail of the Phil<strong>Health</strong> benefits for Case Rate Payment for eleven (11) leading medical cases<br />
and twelve (12) surgical cases:<br />
Medical Cases<br />
Dengue I P 8,000.00<br />
Dengue II P 16,000.00<br />
Pneumonia I P 15,000.00<br />
Pneumonia II P 32,000.00<br />
Essential Hypertension P 9,000.00<br />
Cerebral Infarction P 28,000.00<br />
Cerebro-vascular accident with hemorrhage P 38,000.00<br />
Acute Gastroenteritis P 6,000.00<br />
Typhoid Fever P 14,000.00<br />
Asthma P 9,000.00<br />
Newborn Care Package P 1,750.00<br />
Surgical Procedures<br />
Radiotherapy P 3,000.00<br />
Hemodialysis P 4,000.00<br />
Maternity Care Package P 8,000.00<br />
NSD, Level 1 P 8,000.00<br />
NSD, Levels 2-4 P 6,500.00<br />
Caesarean Section<br />
P19,000.00<br />
Appendectomy P 24,000.00<br />
Cholecystectomy P 31,000.00<br />
Dilatation and curettage P 11,000.00<br />
Thyroidectomy P 31,000.00<br />
Herniorrhaphy P 21,000.00<br />
Mastectomy P 22,000.00<br />
Hysterectomy P 30,000.00<br />
Cataract surgery P 16,000.00<br />
Outpatient Packages - Primary Care Benefit and MDG Benefits<br />
Primary Care Benefit<br />
The Primary Care Benefit provides a per-household capitation of PhP500 for families assigned to a<br />
particular outpatient provider (i.e., accredited rural health units and health centers). This amount covers:<br />
1. Provision of preventive services (consultation, BP measurement, counselling, etc.)<br />
2. Diagnostic services<br />
3. Drugs and medicines (for asthma, upper respiratory tract infection, acute gastroenteritis and urinary<br />
tract infection)<br />
In the future, a second component of this package will be rolled out, giving an additional PhP 400 for<br />
outpatient medicines covering diseases like hypertension and diabetes. Moreover, this is coupled with a<br />
performance incentive of PhP100 which rewards data quality, and eventually, the actual quality of care being<br />
given to patients.<br />
MDG Benefits<br />
Benefit Amount Covered Description<br />
Goal 4: Reduce Child Mortality<br />
Newborn Care Package PhP1,750 This package for newborn dependents covers the following:<br />
1. Necessary/essential newborn care – P500<br />
2. Newborn screening test – P550<br />
3. Newborn hearing screening test – P200<br />
4. Professional fee – P500
Goal 5: Improve Maternal <strong>Health</strong><br />
Normal Spontaneous PhP6,500 – 8,000<br />
Delivery (NSD) Package<br />
The NSD Package is the benefit provided by Phil<strong>Health</strong> for the coverage of normal<br />
deliveries of the first four births in accredited government and private hospitals.<br />
Maternity Care Package<br />
(MCP)<br />
PhP8,000<br />
For Level 1 Hospitals, this covers:<br />
1. Prenatal care – P1,500<br />
2. Facility including professional fee – P6,500<br />
For Levels 2-4 Hospitals, this covers:<br />
1. Prenatal care – P1,500<br />
2. Facility including professional fee – P5,000<br />
The MCP Package is the benefit provided by Phil<strong>Health</strong> for the coverage of normal<br />
deliveries of the first four births in non-hospital facilities (lying-in clinics, maternity<br />
clinics, birthing homes and RHUs). This covers:<br />
1. Facility fee (including professional fee) – P6,500<br />
2. Member’s prenatal care fee – P1,500<br />
Goal 6: Combat HIV/AIDS, Malaria, and other Diseases<br />
Outpatient HIV/AIDS<br />
Treatment Package,<br />
PhP30,000<br />
This benefit aims to increase the proportion of the population having access to<br />
effective HIV/AIDS treatment and patient education measures. This covers:<br />
1. All necessary diagnostics – P3,000/year<br />
2. Professional fee – P2,000/year (P400 per single check-up)<br />
3. Retrovirals – P2,500/month<br />
Outpatient Malaria<br />
Package<br />
Outpatient Anti-<br />
Tuberculosis/DO<strong>TS</strong><br />
Benefit Package<br />
Animal Bite Package<br />
(Rabies Post-exposure<br />
prophylaxis)<br />
SARS and Avian<br />
Influenza Package<br />
PhP600<br />
PhP4,000<br />
PhP3,000<br />
Php50,000 –<br />
100,000<br />
The case rate for this package covers the following services that the patient<br />
requires:<br />
1. Diagnostic malaria smears and other laboratory procedures<br />
2. Drugs and medicines<br />
3. Consultation services, including patient education and counselling<br />
This case rate shall be paid to accredited DO<strong>TS</strong> facilities, and shall cover diagnostic<br />
work-up, consultation services, and anti-TB drugs that the patient requires in an<br />
outpatient set-up. Payment will be split as follows:<br />
1. Intensive Phase of DO<strong>TS</strong> Treatment – P2,500<br />
2. Maintenance Phase – P1,500<br />
Effective May 3, 2012, this benefit package aims to support the National Rabies<br />
Prevention and Control Program by defraying the cost of post-exposure<br />
prophylaxis (PEP) treatment to animal bite patients who are Phil<strong>Health</strong><br />
beneficiaries. This package covers:<br />
1. Drugs (vaccine, immunoglobulin, and antibiotics) and supplies – P2,700<br />
2. <strong>Health</strong> staff service fee – P300<br />
Amount of coverage:<br />
1. For members and their qualified dependents – P50,000 per case<br />
2. For healthcare workers (forefront and high risk) – P100,000 per case<br />
Novel Influenza<br />
A(H1N1) Package<br />
This amount covers:<br />
1. Professional fees – P2,500 (pay to doctor)<br />
2. Hospital charges – P42,500 (pay to hospital)<br />
3. Official receipts amounting to P12,000 (P5,000 – pay to member)<br />
Treated as Case Type A under Fee-For-Service (see pp. 34-36).<br />
Other Benefits<br />
AnEnhanced Outpatient Package for OWP members and dependents is also available in participating DOHretained<br />
hospitals nationwide.We also cover dialysis, day surgeries and chemotherapy in accredited facilities.<br />
All lifetime members can also take advantage of the 60% discount on the pneumococcal vaccine beginning June<br />
1, 2012 in Phil<strong>Health</strong>-accredited hospitals.<br />
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Where can these benefits be availed of?<br />
Members and their qualified dependents may avail of the benefits in any Phil<strong>Health</strong> accredited hospitals,<br />
ambulatory clinics, rural health units/health centers, and free standing clinics nationwide.<br />
Phil<strong>Health</strong> will also reimburse overseas confinements and shall be paid based on Level 3 Hospitals benefit rates.<br />
How can these benefits be availed of?<br />
Availment Conditions<br />
Employed and KASAPI Members<br />
Individually Paying Members<br />
OWP Members<br />
Sponsored Program Members<br />
Lifetime Members<br />
Payment of at least 3 monthly premiums within the<br />
immediate six months prior to confinement<br />
Payment of at least 3 monthly premiums within the<br />
immediate six months prior to confinement (for some<br />
confinement cases). Payment of 9 months premiums<br />
within the immediate 12 month period prior to<br />
confinement (for selected surgical procedures and<br />
pregnancy-related cases.<br />
Confinement should be within the effectivity period<br />
stated in the Member Data Record or Phil<strong>Health</strong><br />
Official Receipt (MDR).<br />
Confinement should be within the effectivity period as<br />
stated in the Phil<strong>Health</strong> Identification Card and<br />
Member Data Record (MDR)<br />
The only requirement is the Phil<strong>Health</strong> Lifetime<br />
Member Identification Card<br />
Automatic Deduction of Benefits<br />
Automatic deduction of benefits simply means that the benefits are automatically deducted from the hospital bill<br />
prior to the patient‟s discharge. For this option, simply follow these steps:<br />
1. Prior to discharge from the hospital, submit the following documents to the hospital‟s billing section:<br />
a. Duly accomplished Phil<strong>Health</strong> Claim From 1(original)<br />
b. Clear Copy of Member Data Record (MDR)<br />
c. If your dependent is the patient, and he/she is not yet listed in the MDR, submit an applicable<br />
proof of dependency<br />
2. Agree with your attending physicians on the professional fee that shall be covered.<br />
3. Upon submission of all documents, the billing section will compute and deduct your benefits from your<br />
total hospital bill.<br />
Direct Filing/Reimbursement<br />
If benefits were not availed of at the hospital, members still have this option to reimburse what they spent during<br />
their last confinement. Simply submit the following documents to the nearest Phil<strong>Health</strong> office within sixty (60)<br />
days after discharge:<br />
1. Phil<strong>Health</strong> Claim Form 1 filled out by member<br />
2. Phil<strong>Health</strong> Claim Form 2 filled out by hospital and attending physician<br />
3. MDR/Phil<strong>Health</strong> ID<br />
4. Proof of premium payment<br />
5. Official receipts for hospital services and professional fees<br />
6. Official receipts for medicines and procedures paid for outside the hospital while confined<br />
7. Statement of account<br />
8. Waiver from the hospital and physician stating that benefits were not claimed at the point of service<br />
9. Copy of operative record (for surgical procedures)<br />
10. Phil<strong>Health</strong> Claim Form 3<br />
11. Results of laboratory and diagnostic exam for case rates claims
Do legal dependents enjoy the same benefits as the member?<br />
Yes, members and dependents will enjoy the same benefit packages. Members have 45 days in a year to avail the<br />
benefits while his/her dependents will have another set of 45 days which will be shared among them.<br />
What documents must a member submit to be able to avail of the benefits?<br />
The following documents are needed to avail of the automatic deductions of the benefits from the hospital:<br />
Phil<strong>Health</strong> Claim Form 1<br />
(For employed members, Part II must be signed by the employer)<br />
Photocopy of MDR and other supporting document if the patient is not reflected as dependent in the<br />
MDR<br />
For IPMs: Proof of premium contribution (Phil<strong>Health</strong> Agent Receipt, Phil<strong>Health</strong> OR, MLhuillier Kwarta<br />
Padala SOF/RT, duly validated Bayad Center Payment Form, LBC Payment/Acknowledgement Receipt)<br />
For LP and Sponsored members:Photocopy of Phil<strong>Health</strong> ID Card<br />
For KASAPI members: Copy of Certificate of Premium Payment from Phil<strong>Health</strong><br />
Where and when should these documents be submitted?<br />
Members need to submit said documents to the hospital billing section to avail of outright /automatic deductions<br />
of benefits.<br />
How can the member avail himself of Phil<strong>Health</strong> benefits if he has an existing coverage with<br />
a health maintenance organization?<br />
For Phil<strong>Health</strong> members who have an existing coverage with a health maintenance organization (HMO),<br />
Phil<strong>Health</strong> benefits should be the first peso to be deducted from the hospital bill. The HMO will cover the<br />
expenses after the deduction of Phil<strong>Health</strong> benefits.<br />
Can a senior citizen avail himself of both the Phil<strong>Health</strong> benefits and his senior citizen<br />
privilege when confined?<br />
Yes. The senior citizen privilege is a separate benefit and the 20% discount must first be deducted from your<br />
hospital bill prior to the application of Phil<strong>Health</strong> benefits.<br />
Can overseas Filipino worker-members reimburse their hospitalization expenses with<br />
Phil<strong>Health</strong>?<br />
Confinement due to sickness or for an operation is compensable with Phil<strong>Health</strong> even if it is done abroad.<br />
Members are given 180 days or 6 months to file your claim for reimbursement at any Phil<strong>Health</strong> office near your<br />
local residence.<br />
a. Phil<strong>Health</strong> Claim Form 1 accomplished and signed by the member or his authorized representatives;<br />
b. Photocopy of MDR or latest receipt;<br />
c. Medical certificate with complete diagnosis, period of confinement and services rendered;<br />
d. Statement of Account and/or Official Receipts with itemized charges; and other supporting documents.<br />
(Items c & d should be translated in ENGLISH)<br />
I‟ve been paying my premiums regularly, but I still haven‟t availed of any benefits. When will<br />
I be able to benefit from my membership?<br />
Perhaps you have managed to stay healthy, therefore not needing to be admitted in the hospital, which is why you<br />
have not yet availed of any benefits. Depending on your membership type (applicable for Sponsored, OWP,<br />
Lifetime), you may still avail of preventive services and vaccines in the outpatient setting to improve your health.<br />
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Situationers: Benefits and Benefits Availment<br />
How will the member know if the Phil<strong>Health</strong> benefit deducted from his total hospital bill is<br />
correct?<br />
Members are sent a benefit payment notice or BPN to report the actual payments made by Phil<strong>Health</strong> relative to<br />
their confinement/availment. The BPN is sent to the address indicated by the member in their claim form. Should<br />
there be discrepancies in the payments and the actual benefits deducted from your hospital and doctors' bills, you<br />
may present your BPN, your copy of the hospital's Statement of Account/Billing Statement, and Official Receipts<br />
to your health care provider for appropriate action to be taken.<br />
What if the amount deducted as Phil<strong>Health</strong> benefit is less than what Phil<strong>Health</strong> actually paid<br />
to the provider for the member‟s confinement?<br />
Members are sent a benefit payment notice or BPN to report the actual payments made by Phil<strong>Health</strong> relative to<br />
their confinement/availment. The BPN is sent to the address indicated by the member in his claim form.Should<br />
there be discrepancies in the payments and the actual benefits deducted from your hospital and doctors' bills, you<br />
may present your BPN, your copy of the hospital's Statement of Account/Billing Statement, and Official Receipts<br />
to your health care provider for appropriate action to be taken.<br />
If siblings are all active members, can each of them file a claim for the confinement of their<br />
parents?<br />
No. Phil<strong>Health</strong> does not allow multiple declaration and application of Phil<strong>Health</strong> entitlements. The siblings<br />
should decide who will declare and provide for the Phil<strong>Health</strong> coverage of their parents.<br />
If both spouses are members, can each of them file a claim for the confinement of their<br />
children?<br />
No. Phil<strong>Health</strong> does not allow multiple declaration and application of Phil<strong>Health</strong> entitlements of both spouses.<br />
If the spouse‟s, child‟s or parent‟s name is not listed in the member‟s MDR at the time of<br />
confinement, how can the member avail himself of the benefits?<br />
If the dependent gets hospitalized and he/she is not listed in the principal member‟s MDR yet, the member may<br />
submit a clear copy of the following as proof of dependency:<br />
1. Spouse - marriage contract/certificate<br />
2. Children - birth certificate<br />
3. Parents - birth certificate of member and patient or Senior Citizen's ID<br />
How can members separated or resigned from employment avail themselves of maternity<br />
benefits?<br />
After separation from employment, the member must immediately enrol/shift his/her membership from<br />
employed to Individually Paying Program (IPM) to avoid the gap on his/her Phil<strong>Health</strong> contributions. As an IPM<br />
member the following documents must be submitted to the billing section of the hospital:<br />
1. Fully accomplished Phil<strong>Health</strong> Claim Form 1 (CF 1)<br />
2. Clear copy of Member Data Record (MDR)<br />
3. Proof of premium payments - nine (9) monthly premium contributions within the immediate twelve<br />
(12) months prior to availment of benefits. If the delivery date may cover the contributions during<br />
employment, secure copy of RF-1 (reflecting the member‟s name) with proof of payment from<br />
previous employer or “Certificate of Contribution” from any Phil<strong>Health</strong> Office.
I. SPECIAL SECTION: CASE RATES FOR 23 MEDICAL AND SURGICAL PROCEDURES<br />
What is case payment?<br />
Case payment (also called per-case payment) is a different way of paying providers for services offered to our<br />
members.<br />
How is this different from the old system?<br />
Unlike the fee-for-service system wherein fees for drugs, supplies, and doctors‟ fees differ depending on the<br />
patient‟s case or hospital where the patient was admitted, case payment offers a fixed rate for each treated case. For<br />
example, cases of appendicitis would be reimbursed at the same rate in all hospitals. It is very similar to the<br />
concept of “pakyawan,” since all items/services necessary for a case is already covered by a single rate.<br />
Why shift to case rate payments? What advantages will this form of benefit payment bring,<br />
especially to the members?<br />
With case rates, hospital charges are no longer a mystery! Since rates remain the same in all facilities, you will<br />
immediately know how much subsidy you can get from Phil<strong>Health</strong> for particular diseases and surgical procedures.<br />
At the same time, this simpler method will help Phil<strong>Health</strong> speed up its processes, which means that your claims<br />
will be released faster.<br />
Who are entitled to these new case rate packages?<br />
By virtue of being a member, you and your dependents are entitled to the new case rate packages.<br />
Can I avail of this benefit now?<br />
Yes! The new case payments already took effect last September 1, 2011 in all accredited providers.<br />
How will cases be reimbursed?<br />
Reimbursement for the said case rates shall be made directly to the facility. This payment given to the hospital<br />
already covers hospital and professional fees.<br />
What will happen to doctor‟s professional fees?<br />
Professional fees of all accredited doctors who attended or managed a specific case are already included in the<br />
calculated case rates.<br />
How much will be allocated to the doctors‟ PF?<br />
1. Forty percent (40%) of the total amount for each surgical case rate<br />
2. Thirty percent (30%) for each medical case rate<br />
3. For hemodialysis, P500 per session is allocated<br />
What are the surgical cases under Case Rate that can be reimbursed in particular facilities?<br />
Level-I Hospitals:<br />
a. D & C (Completion and Fractional Curettage)<br />
b. Normal Spontaneous Delivery<br />
Note: The said case shall be reimbursed as NSD package in Level I hospitals (P8,000)<br />
c. Newborn Care Package<br />
Ambulatory Surgical Clinics (ASCs):<br />
a. D & C (Fractional Curettage)<br />
b. Herniorrhaphy<br />
c. Laparoscopic cholecystectomy<br />
d. Cataract<br />
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Freestanding Dialysis Centers<br />
a. Hemodialysis<br />
How will hospitals be paid for 2 or more surgical case rates performed in a single<br />
confinement?<br />
Phil<strong>Health</strong> shall reimburse all packages if two or more different surgical case rates are performed in separate<br />
operative sessions even within a confinement period.<br />
How will the procedures be reimbursed if a procedure performed has laterality (e.g.,<br />
cataract)?<br />
The hospital shall be paid once if the procedure performed has laterality (e.g., cataract), whether done in one or<br />
different operative session in a single confinement or different confinement within 90 days.<br />
What will happen to major surgical procedures done in Level 1 hospitals?<br />
If the procedure is an emergency, payment shall be paid through a fee-for-service scheme based on RVU 30 but if<br />
the procedure is considered as non-emergency the claim shall be denied.<br />
Is Case Rate covered by the rule on single period of confinement? Will the 45 days<br />
allowance apply for case rates?<br />
Yes, the rule on single period of confinement still applies except for hemodialysis and radiotherapy packages,<br />
where availment is on a per session basis but subject to 45-days allowance in a year.<br />
If a member‟s total hospital fees for dengue I is beyond the case rate amount listed by<br />
Phil<strong>Health</strong>, will the member shoulder the balance?<br />
Yes. The member shall shoulder the amount in excess of what we will provide under the new case rate packages,<br />
except for those covered under the NBB policy in government accredited facilities.<br />
A member is admitted for dengue I for three days, and another member is admitted for<br />
dengue I for five days, will they be entitled to the same case rate amount for dengue I of<br />
P8,000.00?<br />
Yes. Whether a member uses up three days or ten days for a particular medical condition, they will still be entitled<br />
to the same amount. Phil<strong>Health</strong> will reimburse to the health care facility the case rate amount indicated in the list.<br />
What medical cases under Case Rate can be reimbursed in Level 1 hospital? Level 2<br />
hospitals?<br />
a. Dengue I (Dengue Fever and Dengue Hemorrhagic Fever Grades I and II)<br />
b. Dengue II (Dengue Hemorrhagic Fever Grades III and IV)<br />
Note: The said cases managed in Level I hospitals shall only be reimbursed as Dengue I package<br />
c. Pneumonia I (Moderate Risk Pneumonia)<br />
d. Pneumonia II (High Risk Pneumonia)<br />
Note: The said case managed in Level I hospitals shall only be reimbursed as Pneumonia I package<br />
e. Essential Hypertension<br />
f. Cerebral Infarction (CVA I)<br />
g. Cerebro-vascular Accident with Hemorrhage (CVA II)
Note: The said case managed in Level I hospitals shall only be reimbursed as CVA I package<br />
h. Asthma<br />
i. Typhoid Fever<br />
j. Acute Gastroenteritis<br />
k. NSD<br />
Note: In level I hospitals the benefit amount is Php 8000 while in Levels 2-4 hospitals the benefit is Php 6500.<br />
For medical case rate, how will Phil<strong>Health</strong> pay for a patient admitted for several conditions?<br />
Phil<strong>Health</strong> shall reimburse the medical case rates based on the main condition. Therefore, cases with several comorbidities<br />
shall have no additional payment.<br />
In case the member was transferred to another hospital, will Phil<strong>Health</strong> pay for both<br />
facilities?<br />
The member is entitled to one package and this will be reimbursed to the referral facility. Cost incurred at the<br />
referring facility will be shouldered by the member and the claim filed by the facility will be denied except<br />
MCP.<br />
For cases not included in the Case Rates table, how will Phil<strong>Health</strong> reimburse those cases?<br />
Phil<strong>Health</strong> will continue to reimburse those cases through the existing benefit table of fee for service scheme.<br />
J. SPECIAL SECTION: NO BALANCE BILLING POLICY<br />
What is “No Balance Billing” (NBB) and to whom it will be applicable?<br />
NBB means that no other fees shall be charged or paid for by the Phil<strong>Health</strong> patients beyond the identified case<br />
rates. NBB policy generally covers the Sponsored member/dependents of Phil<strong>Health</strong>.<br />
Why is this being introduced only for Sponsored Program members?<br />
Among our primary objectives for introducing the case rate packages is to provide optimal financial risk<br />
protection, especially to the most vulnerable groups which are the poorest of the poor. Through Phil<strong>Health</strong> Board<br />
Resolution 1441 series of 2010, the NBB policy was adopted for the most common medical and surgical<br />
conditions experienced in the country which are identified/specified under the new case payments.<br />
What are the conditions for availment of benefits of SP members under the NBB policy?<br />
The NBB policy applies only to all Phil<strong>Health</strong> Sponsored Program members and their dependents that avail of the<br />
specified cases under the following conditions:<br />
When they are admitted in government facilities/hospitals in defined NBB Beds<br />
When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in<br />
accredited government hospitals and non-hospital facilities<br />
When availing of existing outpatient packages, including Maternity Care Package and Newborn Care<br />
Package, TB-DO<strong>TS</strong>, Malaria, HIV-AIDS, and Animal Bite Package<br />
Is the NBB policy also applicable to other Phil<strong>Health</strong> membership types?<br />
The NBB policy shall also apply to any other membership type (Employed, Individually Paying, Overseas<br />
Workers, Lifetime) who will avail themselves of the Maternity Care Package (MCP) and Newborn Care Package in<br />
all accredited (MCP) non-hospital providers (e.g. maternity clinics, birthing homes).<br />
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If the Sponsored member under NBB bought drugs and medicines or other supplies, will he<br />
be able to reimburse then? How?<br />
Yes. If the Sponsored member/dependent purchased necessary items and services during confinement, the health<br />
facility is required to attach the official receipt/s detailing the purchases in the claim application for the said<br />
confinement.<br />
In case a sponsored member/dependent was admitted in a government hospital where the<br />
only available room that time for the patient is a private room, can the sponsored member<br />
be admitted in any room or private room of a government hospital? Will the NBB policy still<br />
apply?<br />
Yes, with the discretion of the hospital. The sponsored member can still be admitted in any available room and<br />
the NBB policy applies.<br />
What if a sponsored member is admitted in a private hospital? Will the NBB policy still be<br />
applicable?<br />
The NBB policy will not apply, unless the private hospital voluntarily implements it. The sponsored member and<br />
his/her dependents will pay the excess of the hospitalization costs including the PF for the attending physician/s<br />
after deduction of the applicable case rates.<br />
Are there sanctions for violations in NBB policy?<br />
Yes, accredited providers that violate the NBB policy shall be given appropriate sanctions and penalties by the<br />
<strong>Corporation</strong>.<br />
K. SPECIAL SECTION: ANIMAL BITE PACKAGE<br />
Tamang Paggamot sa Kagat ng Hayop<br />
Ano ang unang dapat gawin kapag nakagat ng hayop?<br />
Bago magtungo sa pinakamalapit na Animal Bite Treatment Center, kailangang linisin ng maigi ang sugat na<br />
natamo mula sa kagat ng hayop. Gawin ang mga sumusunod na hakbang:<br />
a. Kumuha ng malinis na tela at diinan ang sugat hanggang sa humupa ang pagdurugo.<br />
b. Linisin ang sugat nang sabon at tubig.<br />
c. Lagyan ng alcohol, povidone-iodine (halimbawa: betadine) o kahit anong panlinis ang sugat.<br />
d. Takpan ang sugat nang malinis at tuyong gauze. Maari ring magpahid ng antibiotic ointment<br />
upang maiwasan ang impeksiyon.<br />
e. Matapos linisin ang sugat, magpunta agad sa pinakamalapit na Animal Bite Treatment Center.<br />
Ang hayop na nangagat ay kinakailangang obserbahan sa loob ng dalawang linggo.<br />
Bakit kailangang magpabakuna kung nakagat ng aso?<br />
Ang rabies ay isang sakit na nakamamatay. Tanging ang pagbabakuna lamang ang paraan upang maiwasan ang<br />
pagkakaroon ng impeksiyon sa rabies.<br />
Gaano katagal ba ang bisa ng bakuna?<br />
Panghabambuhay na ang bisa ng bakuna kung nakumpleto ang dosaheng kinakailangan. Gayunpaman, kapag<br />
nakagat muli ng aso ang taong nakakumpleto ng bakuna, kinakailangan pa rin ng booster doses.
Ilang beses ba akong bibigyan ng bakuna?<br />
Karamihan ng pasyente ay kinakailangan lamang mabigyan ng 3 dose ng bakuna. Ngunit may mga pasyenteng<br />
nangangailangan ng pang-apat ng dose:<br />
a. kung ang nakakagat na hayop ay napatunayang may rabis<br />
b. kung ang nakakagat na hayop ay namatay nang hindi nagagawan ng eksaminasyon<br />
c. kung ang nakakagat na hayop ay may sintomas ng rabis<br />
d. kung ang nakakagat na hayop ay hindi maaring obserbahan ng 14 na araw<br />
Kailan dapat magpabakuna? Hihintayin pa bang mamatay ang aso bago magpabakuna?<br />
Kahit na buhay pa ang asong nakakagat, maiging kumunsulta na agad sa pinakamalapit na Animal Bite Treatment<br />
Center para mabakunahan. Kailangan pa rin ng pasyente ng tatlong dose ng bakuna kahit na nanatiling buhay ang<br />
aso.<br />
Kailangan pa ba akong ma-confine kung nakagat ng aso?<br />
Hindi lahat ng nakagat ay kinakailangang ma-confine. Kung galos o hindi naman malalim ang sugat, kinakailangan<br />
lamang na malinisan ang sugat at mabigyan ng bakuna.<br />
Kailangan pa ba akong mabakunahan kung kumpleto naman sa bakuna ang asong<br />
kumagat?<br />
Oo, sapagkat iba ang bakuna ng aso sa bakuna na para sa tao. Kahit kumpleto ang bakuna ng asong kumagat,<br />
kinakailangan pa ring mabakunahan ang pasyente upang masiguro ang proteksiyon laban sa rabies.<br />
Mga Paalala<br />
a. Ipaalam sa baranggay o munisipyo kung may mga asong gala sa inyong lugar na maaaring<br />
mangagat at maging sanhi ng rabies.<br />
b. Pabakunahan ang inyong alagang aso at wag pabayaang pagala-gala sa labas ng bahay o bakuran.<br />
Tungkol sa Animal Bite Treatment Package ng Phil<strong>Health</strong><br />
Ano po ba ang kasama sa Animal Bite Treatment Package?<br />
a. Bakuna laban sa rabies<br />
b. Rabies immunoglobulin<br />
c. Paggamot sa sugat<br />
d. Bakuna para sa tetano<br />
e. Antibiotics kung kinakailangan<br />
Ito ay maaring ibigay sa mga sumusunod na kasong maituturing na Category III Rabies Exposure na naidulot ng<br />
hayop (aso, pusa, baka, baboy, kabayo, kambing, paniki at unggoy) o pasyenteng napatunayang may rabies.<br />
a. Kagat/kalmot ng hayop na tumagos sa balat at nagdurugo<br />
b. Kagat o pagpasa ng laway/fluids (sa mata, ilong, maseselan na bahagi ng katawan at bukas na<br />
sugat) ng pasyenteng mayroong rabies<br />
c. Paghawak ng bangkay ng hayop na may rabies o pagkain ng laman ng hayop na mayroong rabies<br />
d. Kalmot at sugat (kahit na hindi nagdurugo) na natamo sa ulo at leeg<br />
Ano ang kailangang ipakita o gawin para maka-avail ng package?<br />
Kapag nakagat ng aso, magpunta lamang sa kahit anong Animal Bite Treatment Center na Phil<strong>Health</strong>-Accredited.<br />
Upang makagamit ng package, kailangang magpadala ng patunay na ikaw ay miyembro ng Phil<strong>Health</strong> (gaya ng<br />
MDR). Kailangan ding tiyakin na ikaw ay eligible para sa benepisyo:<br />
a. Para sa mga employed at IPP, kinakailangang may kontribusyon na 3 buwan sa loob ng nakalipas<br />
na anim na buwan.<br />
b. Para sa sponsored at OWP, tiyaking hindi pa expired ang inyong membership o within the period<br />
of validity ang pag-avail ng package.<br />
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c. Para sa lifetime member, ipakita lamang ang inyong Phil<strong>Health</strong> ID card.<br />
Saan ba pwedeng maka-avail ng package? Saan ako pwedeng pumunta para magpabakuna<br />
kung nakagat ng aso?<br />
Pumunta lamang sa kahit anong Phil<strong>Health</strong>-Accredited na Animal Bite Treatment Center upang makagamit ng<br />
benepisyong ito.<br />
Kailangan ba akong bumili ng bakuna sa labas? Meron pa ba akong dapat bayaran kung<br />
may Phil<strong>Health</strong> na?<br />
Kung ikaw ay isang sponsored member, wala nang kailangan pang bilhin na gamot o bakuna. Sagot na dapat ng<br />
Animal Bite Treatment Center ang lahat ng kakailanganin sa paggamot ng kagat.<br />
Para sa ibang miyembro ng Phil<strong>Health</strong>, hanggang PhP3,000 lamang na halaga ng bakuna, gamot at gamit ang<br />
kasama sa package. Kapag naubos na ang PhP 3,000, kailangan ng bayaran o bilhin ng miyembro ang natitirang<br />
gamit, gamot o bakuna. Tandaan na kinakailangang makumpleto ang 3 o 4 na dose ng bakuna upang ito ay maging<br />
mabisa.<br />
Paano kung nakagat ako ulit? Ilang beses ako pwedeng makagamit ng Phil<strong>Health</strong> para sa<br />
ganitong benepisyo?<br />
Hangga‟t ikaw ay lehitimong miyembro ng Phil<strong>Health</strong>, maaari kang makagamit ng benepisyong ito kapag ikaw ay<br />
nakagat ng hayop. Para sa mga kailangan para maka-avail ng package, tingnan ang sagot sa question #2.<br />
Covered din ba ang pamilya ko pag sila ay nakagat?<br />
Ang miyembro at ang lahat ng kanyang qualified dependents na nakalista sa MDR ay maaaring maka-avail ng<br />
package.<br />
Paano kung hindi aso ang nakakagat? Kasama pa rin po ba ito sa benepisyo?<br />
Hindi lahat ng kagat ng hayop ay may rabies. Tanging ang kagat ng aso, pusa, baka, baboy, kabayo, kambing,<br />
paniki at unggoy lamang ang kasama sa benepisyo. Ang kagat ng daga, guinea pig o kuneho ay hindi<br />
nangangailangan ng bakuna laban sa rabies kung kaya‟t hindi kasama sa benepisyo.