University Researcher, PhilHealth Research Study Group, UP Manila - National Institutes of Health

Dr. Banzuelas PhilHealth Primer

for the Med Boards

by Enrico Paolo Chiong Banzuela, MD
UP College of Medicine Class 2005
Occupational Health Specialist
Clinical Instructor, San Beda College of Medicine
I. PERTINENT LAWS
1, 2

Republic Act 7875
National Health Insurance Act of 1995 or "An Act Instituting a National Health Insurance
Program For All Filipinos and Establishing the Philippine Health Insurance Corporation
For the Purpose"
Signed into law on February 14, 1995 by Pres. Fidel Ramos

Republic Act 9241
An Act amending RA 7875

Section 11, Article XIII of the 1987 Constitution of the Republic of the Philippines
"the State shall adopt an integrated and comprehensive approach to health
development which shall endeavor to make essential goods, health and other social
services available to all the people at affordable cost. Priority for the needs of the
underprivileged, sick, elderly, disabled, women and other children shall be recognized.
Likewise, it shall be the policy of the State to provide free medical care to paupers."

Dr.Banzuela: memorize the numbers 7875 and 9241. The NHI Act of 1995 is one of the most important
laws Congress has ever passed no kidding.

II. HISTORY OF PHILHEALTH
4

In 1963, DOH secretary Francisco Quimson Duque, the father of the current DOH
secretary, proposed the formation of a National Health Service of the Philippines under
the administration of President Diosdado Macapagal
RA 6111 or the Philippine Medical Care Act was signed into law by President Ferdinand
Marcos in 1969
Medicare Program Phase I was started in 1972. Target beneficiaries were SSS/GSIS
members
Medicare Program Phase II was started in 1983. Target beneficiaries were low-income
and non-salary based populations not covered by Phase I. Tie-ups with LGUs and HMOs
were done
In the early 1990s, The Health Finance Development Project (HFDP) a DOH project
funded by USAID-MSH conducted several studies regarding social health insurance and
was crucial in the creation of PhilHealth
RA 7875 was signed into law on February 14, 1995
GSIS and SSS transfers the Medicare Program to PhilHealth in 1997
Abra was the first province in the country to adopt the Indigent Program, October 1,
1997
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Decentralization of claims processing starts in Region VI, March 1999
Launching of the Individually Paying Program for the Informal Sector, October 1, 1999
Launching of the first OPD Package in Laguna and Capitation as provider payment
scheme, July 2000
Introduction of Dialysis Package and OPD AntiTB/DOTS Benefits Package, April 1, 2003
Maternity Care Package for SVD and SARS package, May 1, 2003

Why Medicare was Replaced by PhilHealth
to accelerate universal coverage (health insurance for ALL Filipinos)
to enhance and expand a unified benefit package that can be used by ALL members,
regardless of category
consolidate separate Medicare programs given by the SSS, GSIS and OWWA

Dr.Banzuela: Before PhilHealth was created, there used to be different premium contributions and
different benefit packages for those mandated to have social health insurance. PhilHealth changed all
that by requiring EVERYONE to procure social health insurance. Also, there would be A SINGLE UNIFIED
BENEFIT PACKAGE although premium contributions are still based on salaries/wages in the case of formal
sector employees and on household earnings & assets in the case of the self-employed. The rich would
subsidize the poor and the healthy would subsidize the sick. (social solidarity concept)

III. TERMS AND DEFINITIONS
1,2,3

1. Capitation - a payment mechanism where a fixed rate, whether per person, family,
household or group is negotiated with the health care provider who shall be
responsible for delivering or arranging the delivery of health services required by the
covered person under the conditions of a health provider contract.
2. Fee-for-Service a health care payment system in which health care providers receive a
payment for each unit of service.
3. Case Payment a health care payment system in which health care providers are given
a fixed amount for every specific case diagnosed. E.g. In PhilHealths DOTS package, a
physician is given P4,000/patient to cover for the patients drugs, his consultation fee
and additional laboratory exams needed.
4. Coverage - the entitlement of an individual, as a member or as a dependent to the
benefits of the program
5. Premium Contribution the amount paid by or in behalf of a member to the PhilHealth
program for coverage, based on salaries/wages in the case of formal sector employees,
and on household earnings and assets in the case of self-employed, or on other criteria
as maybe defined by PhilHealth in accordance with the guiding principles of Act I of RA
7875
6. Dependents - legal dependents are
a. legitimate spouse who is not a member
b. unmarried and unemployed legitimate, legitimated, illegitimate, acknowledged
children as appearing in the birth; legally adopted or stepchildren below 21 years of
age
c. children who are twenty-one years old or above but suffering from congenital
disability, either physical or mental or any disability acquired that renders them
totally dependent on the member for support
d. parents who are 60 years old or above whose monthly income is below the amount to
be determined by the Corporation in accordance with the guiding principles set for
in Article I of RA 7875

Dr.Banzuela: memorize who the legal dependents are. Remember that queridas are not covered by
PhilHealth, but mga anak sa labas are as long as they are below 21 years of age. If the children are
physically/mentally handicapped, they are still considered dependents even if they are more than 21
years of age. Note that parents greater than 60 years old are considered dependents also.

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5. Emergency an unforeseen combination of circumstances which calls for immediate
action to preserve the life of a person or to preserve the sight of one or both eyes; the
hearing of one or both ears; or one or two limbs at or above the ankle or wrist.

Dr.Banzuela: Its important to know PhilHealths definition of emergency. There are a lot of unsavory
hospitals that do not reimburse PhilHealth claims in the emergency room; alledging that these cases are
considered more appropriate for the OPD

6. Health Care Provider - refers to:
a. Health care institution such as hospitals, maternity clinics, nurseries, dispensaries,
etc.
b. Health care professional such as doctors, nurses, midwives, dentists
c. Health maintenance organizations (HMOs) - entity that provides, offers, or arranges
for coverage of designated health services needed by plan members for a fixed
prepaid premium
d. Preferred provider organizations (PPO), which is a network of providers whose
services are available to enrollees at lower cost than the services of non-network
providers. PPO enrollees may choose any network provider anytime.
e. Community-based health care organization (CBHCO), which is an association of
indigenous members of the community organized for the purpose of improving the
health status of the community through preventive, promotive and curative health
services.
6. Indigent - a person who has no visible means of income, or whose income is insufficient
for the subsistence of his family, as identified by the Local Health Insurance Office and
based on specific criteria set by the Corporation in accordance with the guiding
principles set for in Article I of RA 7875. At present, LGUs use the means test to
identify indigents. See #9 below.
7. Philippine National Drug Formulary - the essential drugs list for the Philippines which is
prepared by the National Drug Committee of the Department of Health in consultations
with experts and specialists from organized professional medical societies, medical
academe and pharmaceutical industry and which is updated every year.

Dr.Banzuela: Remember that the only the drugs in the PNDF are PhilHealth reimbursable drugs.

8. Public Health Services the Government shall be responsible for providing public health
services for all groups such as women, children, indigenous, people, displaced
communities and communities in environmentally endangered areas, while the NHIP
shall focus on the provision of personal health services. Preventive and promotive
health services are essential for reducing the need and spending for personal health
service.
9. Means Test a social research survey conducted to identify the indigent members of
the community
10. Single Period of Confinement a series or successive confinements for the SAME
illness/injuries not separated from each other by more than 90 days. PhilHealth gives a
member/dependent a 45-days allowance, after which it would not pay anymore.
11. Relative Unit Value (RUV) scale listing of common surgical procedures where each
procedure is assigned a corresponding relative unit value (RUV) depending on the
complexity of the procedure. PhilHealth uses this to compute for the surgeons fee.
PhilHealth pays P420/unit with a maximum of P15,930/operation. Anesthesiologists
fee is 30% of the total RUV.

IV. FACTS ABOUT PHILHEALTH
1,2,3

The purpose of PhilHealth is to ensure the provision of affordable, available and
accessible health care services for ALL citizens of the Philippines.
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PhilHealths goal is universal coverage (defined as 85% of the Philippine population) by
the year 2010

Dr.Banzuela: Its impossible to cover 100% of the Philippine population; so PhilHealth has defined
universal coverage as 85%. In 2004, PhilHealth claimed the coverage is 81% already due to extensive
enrolment of people in the Indigent program using the giveaway PhilHealth cards (though these
PhilHealth cards expired after one year their premium contributions have to be shouldered by the
Local Government Units or they must enroll in the Individually-Paying Program to continue receiving
PhilHealth benefits)

Limited to paying for the utilization of health services by the covered beneficiaries or
to purchasing health services in behalf of the beneficiaries
Prohibited from:
1. Providing health care directly
2. Buying and dispensing drugs and pharmaceuticals
3. Employing physicians and other professionals for the purpose of directly
rendering care
4. Owning or investing in health care facilities

Dr Banzuela: With P60 Billion to work with, (the DOH budget is around P10B only) PhilHealth is not
allowed to engage in public health, only personal health services. Repeat, only personal health services.
Most of its money goes to a reserve fund

Exempted from paying corporate taxes because it is a government owned and
controlled corporation
Can sue and be sued in court
Has quasi-judicial powers can issue subpoenas, investigate, and decide upon
complaints. PhilHealth is NOT bound by the technical rules of evidence
All government and private EMPLOYERS are required to register their employees with
PhilHealth within 30 days after hiring them
Members and their dependents are eligible for confinements outside the country
provided the following are submitted within 180 days after discharge: official receipt
from the health care institution and certification of the attending physician as to the
final diagnosis, period of confinement and services rendered.
Sec.54 of RA 9241 Oversight Provision Congress shall conduct a regular review of
the National Health Insurance Program which shall entail a systematic evaluation of the
Programs performance, impact or accomplishments with respect to its objectives or
goals. Such review shall be undertaken by the Committees of the Senate and the House
of Representatives which have legislative jurisdiction over the Program. The National
Economic and Development Authority, in coordination with the National Statistics
Office and the National Institutes of Health of the University of the Philippines shall
undertake studies to validate the accomplishments of the program. The budget
required to undertake such study shall come from the income of PhilHealth.

V. PHILHEALTH BOARD OF DIRECTORS
3

All are appointed by the President of the Philippines
Will each serve a 4-year term renewable for a maximum of two years except for
Cabinet secretaries
Mandated to hold meetings at least once a month. Each would receive a per diem for
every meeting attended
PhilHealth President/CEO qualifications:
o Filipino citizen with appropriate training and at least 5 years experience in the
filed of health care financing and corporate management
o Must NOT be involved in any health care institution as owner or member of its
board

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Composition:
1. DOH secretary shall be the ex-officio Chairperson Francisco T. Duque, MD, MSc
2. President/CEO of PhilHealth shall be vice-chairperson now classified as a cabinet
position Lorna Fajardo (acting)
3. DOLE secretary or representative
4. DILG secretary or representative Austere A. Panadero
5. DSWD secretary or representative Esperanza Cabral, MD
6. Representative from the labor sector
7. Representative of employers Asuncion B. Santos
8. SSS Administrator or her representative Corazon Dela Paz
9. GSIS General manager or his representative Roy Joseph M. Rafols
10. Representative of the self-employed sector Asuncion E. Villanueva
11. Representative of Health Care Providers to be endorsed by the national associations
of health care institutions and medical health professionals Arlene Grace V. Guico
12. Vice-Chairperson for the basic sector of the National Anti-Poverty Commission or his
representative Susanita G. Tesiorna
13. Overseas Filipino Workers Sector Teresita F. De Venecia

VI. MONEY, MONEY, MONEY
3

The National Health Insurance Fund, the money PhilHealth is working with, has 3
components:
1. Basic benefit funds
2. Supplementary benefit funds
3. Reserve funds
Basic benefit funds shall finance the basic minimum package to be enjoyed by ALL
members. The National Government and the Local Government Unit pays for the
premium contributions of indigents. For non-indigents, premium prices for specific
population shall be actuarially determined based on a.) Variations in risk b.) Capacity
to pay and c.) Projected costs of services utilized
Supplementary benefit funds shall finance the extension and availment of ADDITIONAL
BENEFITS not included in the basic minimum benefit package BUT approved by the
Board. However, in accordance with the principles of equity and social solidarity, after
5 years, such funds shall be merged into the basic benefit fund.
Reserve funds is a portion of PhilHealths accumulated revenues not intended to meet
the cost of the current years expenditures; it shall not exceed a ceiling equivalent to
the amount actuarially estimated for two years of projected program expenditures.
The funds are to be invested in interest-bearing bonds, securities,
deposits/loans/securities to any domestic bank and stocks of corporations.
Administration costs of PhilHealth shall not exceed 12% of the total contributions,
including government contributions to the program AND not more than 3% of the
investment earnings collected during the immediate preceding year.
PhilHealth has the following sources of funds:
1. Premiums
a. Individual
b. National Government
c. Local Government
2. Grants and Donations
3. Investment Earnings
4. Sin Taxes





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National Health Insurance Program
pine Health Insurance Corporation Philip
Employed
IPP


Sponsored
Sector

NATIONAL HEALTH
INSURANCE FUND
INVESTMENT

FOREIGN GRANTS LOCAL GOVERNMENT


NATIONAL GOVERNMENT



VII. MEMBERSHIP
3, 6

Initial members of the program in 1995
1. SSS/GSIS members, retirees, pensioners and their dependents under Medicare Program I
2. Those enrolled in local government unit sponsored health insurance plans (who are
mostly indigents and lowly-paid workers) under the Medicare Program II
3. Members of other government-initiated health insurance programs, community based
health care organizations, cooperatives or private non-profit health insurance plans
who are subsequently accredited by PhilHealth

Current Members are classified as follows:
1. Paying Members
a. Government employee
b. Private Sector employee including househelps and sea-based OFWs
c. Individually-Paying Member including fishermen, farmers, businessmen,
professionals,(doctors, lawyers, etc.) land-based OFWs
2. Indigent Member
3. Privately-Sponsored Member
4. Non-Paying Member or NPM (retiree-members of SSS/GSIS including personnel of AFP,
PNP, BFP and BJMP)

Dr.Banzuela: A doctor practicing in hospitals or clinics (even if hes a neurosurgeon earning P500,000 a
month) is considered an Individually-Paying Member and is required to pay a fixed premium contribution
of only P100/monthly.

Requirements for Membership Registration (any of the following)
1. Birth Certificate
2. Baptismal Certificate
3. GSIS/SSS Members ID
4. Passport
5. Any other valid ID/document acceptable to the Corporation

Requirements for Declaration of Dependents
1. Marriage Contract/Marriage Certificate
2. Birth/Baptismal Certificate
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3. Court Order on Adoption
4. Birth/baptismal certificate of the member and dependent parents
5. Marriage Contract of the parent and stepfather/stepmother and birth certificate of the
dependent stepchildren
6. Joint affidavit of two disinterested persons and other relevant information (date of
birth, etc.) attesting to the fact of the relationship of the dependents to the supposed
members except declaration of spouse
7. Certificate from the DSWD or Punong Barangay attesting to the fact of the relationship
of the dependents to the supposed members
8. Any other valid ID or document acceptable to the Corporation

Requirements for Registration of Employers (together with their business permit/license to
operate)
1. For single proprietorships DTI registration
2. For partnerships and corporations SEC registration
3. For foundation and other non-profit organizations SEC registration
4. For cooperatives Cooperative Development Authority (CDA) registration
5. For backyard industries/ventures and micro-business enterprises Barangay
Certification and/or Mayors Permit

VIII. ACCREDITATION
3

Requirements:
1. Health care institution must be operating for at least the past three years. This 3 year
requirement is waved if:
a. Managing health care professional has had working experience in another
accredited health care institution for at least 3 years
b. Operates as a tertiary facility
c. Operates in a LGU where the accredited health care provider cannot
adequately or fully service its population
d. Other conditions set by the Corporation
2. Adequate quality human resources, equipment and physical structure
3. All personnel must be members of the NHIP
4. Physician must be registered members of PMA and/or its specialty organizations
5. Health care providers must have their own ongoing formal program of quality assurance
6. Must adopt all referral protocols, CPGs, payment mechanisms, health resource sharing
arrangements of the NHIP
7. Must recognize and respect the rights of patients
8. Must comply with all information system requirements set by the Corporation
9. Must accept any and all corrective actions prescribed by the Corporation
10. Must allow the Corporation to inspect and secure reproduction of certified true copies
of their medical and financial records and to visit, enter and inspect their respective
premises and facilities
11. Must comply with all requirements and provisions of RA 7875 as amended by RA 9241

Additional Requirements for Hospitals
1. Licensed by DOH
2. Comply at all times with RA 4226 or The Hospital Licensure Act and its implementing
rules and regulations
3. Must be a member of good standing of any national association of licensed hospitals in
the Philippines
4. All secondary hospitals must establish a therapeutic committee and other committees
that will ensure rational drug use
5. All tertiary hospital must establish therapeutics and infection control committees and
other committees that will ensure rational drug use
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Additional Requirements for HMOs and PPOs
1. Clearance to operate from DOH
2. SEC registration
3. Its lab, x-ray and diagnostic facilities must comply with the rules, regulations and
licensing requirements of DOH
4. A Corporate HMO must be a member of good standing of any national association of
HMOs in the Philippines
5. A Cooperative HMO must be a member of good standing of any regional or national
federation of cooperatives

Additional Requirements for CBHCOs
1. Must be organized/owned/managed by an association of members of the community for
the purpose of improving the health status of the community through preventive,
promotive and curative health services
2. SEC and/or CDA registered
3. Its lab, x-ray and diagnostic facilities must comply with the rules, regulations and
licensing requirements of DOH

Additional Requirements for Physicians
1. PRC license
2. Must be PhilHealth members themselves
3. Must submit certificate of good standing from respective national associations
4. Must abide by the Code of Ethics as prescribed under Section 24, Paragraph 12 of the
Medical Act of 1959
5. Must comply with practice guidelines or protocols, peer review and payment
mechanisms of NHIP
6. Must not charge over and above the professional fees provided by the NHIP for
members admitted to a PhilHealth bed
7. Must comply with any other requirements set by the Corporation

Dr.Banzuela so basically, if you want to be accredited by PhilHealth as a health care provider, you
need three things: a PRC ID, membership in the Philippine Medical Association and PhilHealth
membership

IX. BENEFIT PACKAGE
2, 3, 5, 6

The Benefit package to be enjoyed by ALL members includes the following:
1. Inpatient hospital care
a. Room and board
b. Services of health care professionals
c. Diagnostic, laboratory and other medical examination services
d. Use of surgical or medical equipment and facilities
e. Prescription drugs and biologicals; subject to limitations stated in Section 37 of
RA 7875
2. Outpatient care
a. Services of health care professionals
b. Diagnostic, laboratory and other medical examination services
c. Personal preventive services
d. Prescription drugs and biologicals, subject to limitations stated in Section 37 of
RA 7875
3. Health Education Packages
4. Emergency and transfer services
5. Other health care services that PhilHealth shall determine to be appropriate and cost-
effective

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The following are NOT included in the benefit package unless PhilHealth recommends
otherwise after actuarial studies:
1. non-prescription drugs and devices
2. drug/alcohol abuse or dependency treatment
3. cosmetic surgery
4. optometric services
5. fifth and subsequent normal obstetrical delivery
6. cost ineffective procedures which shall be defined by PhilHealth

Note: in RA 7875, normal obstetrical deliveries, out-patient psychotherapy and counseling for
mental disorders and home & rehabilitation services used to be part of excluded personal
health services. After RA 9241 amended RA 7875, PhilHealth could now include these services
in the minimum basic package. PhilHealth currently pays up to 2 normal spontaneous vaginal
deliveries.

The following are entitled to the above-mentioned benefits:
1. A member who has paid 3 months worth of premium contributions within 6 months
before his availment of the benefits. He should have a PhilHealth ID and he should NOT
be currently subject to legal penalties by PhilHealth
2. SSS/GSIS members more than 65 years old and have paid at least 120 monthly
contributions
3. Enrolled indigents

UNIFIED MEDICARE BENEFITS
For all Members and Dependents under the National Health Insurance Program
HOSPITAL CATEGORY
BENEFITS
PRIMARY SECONDARY TERTIARY
ROOM AND BOARD
Not exceeding 45 days for each
member & another 45 days to be
shared by his dependents
200 300 400
DRUGS & MEDICINES
Per single period of confinement
a. Ordinary
b. Intensive
c. Catastrophic
1,500
2,500
0
1,700
4,000
8,000
3,000
9,000
16,000
X-RAY, LAB, ETC.
Per single period of confinement
a. Ordinary
b. Intensive
c. Catastrophic
350
700
0
850
2,000
4,000
1,700
4,000
14,000
PROFESSIONAL FEES
Per single period of confinement
shall not exceed:
P 150/day for General Practitioner
P 250/day for Specialist
a. Ordinary
General Practitioner
Specialist
600
1,000
600
1,000
600
1,000
b. Intensive
General Practitioner
900
1,500
900
1,500
900
1,500
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Specialist
b. Catastrophic
General Practitioner
Specialist
900
1,500
900
1,500
900
2,500
OTHERS
Operating Room
a. RVU of 30 and below
b. RVU of 31 to 80
c. RVU of 81 and above
385
0
0
670
1,140
2,160
1,060
1,350
3,490
Surgeon Maximum of 16,000
Anesthesiologist Maximum of 5,000
Compensable Outpatient Services:
Ambulatory surgeries and procedures including dialysis,
radiotherapy and chemotherapy
TB DOTS

Classification of Cases
1. Catastrophic Cases
Illnesses or injuries such as cancer cases requiring chemotherapy and/or
radiotherapy, meningitis, encephalitis, cirrhosis of the liver, myocardial infarction,
cerebrovascular attack, rheumatic heart disease grade III, renal conditions
requiring dialysis or transplant, massive hemorrhage
Surgical Procedures or multiple surgical procedures done in one sitting with total
Relative Unit Value of 20 and above such as coronary bypass, open heart surgery or
neurosurgery
2. Intensive Cases
All confinements in the ICY other than those classified as catastrophic
Other similar serious illnesses or injuries such as cancer, pneumonia, moderately
and far advanced PTB including its complications, cardiovascular attack, diseases of
the heart, COPD, liver disease, typhoid fever, H-fever, kidney disease, septicemia,
diarrhea with severe dehydration, severe injuries, black water fever
Surgical procedure or multiple surgical procedures done in one sitting with a total
Relative Unit Value of 8-19.99
3. Ordinary Cases
Illnesses/injuries other than those enumerated above shall be considered as
ordinary cases


X. PREMIUM CONTRIBUTIONS
3, 6

The amount of premium contribution shall NOT exceed 3% of the members respective
monthly salaries to be shared equally by the employer and employee. The members
monthly contribution shall be automatically deducted by the employer from the
formers salary, wage or earnings.
At present, ones premium contribution is 2.5% of the salary base (SB) divided equally
at 1.25% each for the employee and the employer. The salary cap is set at P25,000,
above which ones monthly premium contribution remains the same, e.g. Ones
monthly contribution remains at a total of P625 even if ones salary is P25,000, P50,000
or P500,000 a month.

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For the Formal/Employed Sector, the premium contribution is dependent upon ones salary
and is as follows:
Monthly
Salary
Bracket
Monthly Salary
Range
Salary
Base (SB)
Total
Monthly
Contribution
Employee
Share (EeS)
(Ees = 0.5 x
TMC)
Employer Share
(ErS)
(Ers = 0.5 x
TMC)
1 4,999.99 and Below 4,000.00 100.00 50.00 50.00
2 5,000.00 to
5,999.99
5,000.00 125.00 62.50 62.50
3 6,000.00 to
6,999.99
6,000.00 150.00 75.00 75.00
4 7,000.00 to
7,999.99
7,000.00 175.00 87.50 87.50
5 8,000.00 to
8,999.99
8,000.00 200.00 100.00 100.00
6 9,000.00 to
9,999.99
9,000.00 225.00 112.50 112.50
7 10,000.00 to
10,999.99
10,000.00 250.00 125.00 125.00
8 11,000.00 to
11,999.99
11,000.00 275.00 137.50 137.50
9 12,000.00 to
12,999.99
12,000.00 300.00 150.00 150.00
10 13,000.00 to
13,999.99
13,000.00 325.00 162.50 162.50
11 14,000.00 to
14,999.99
14,000.00 350.00 175.00 175.00
12 15,000.00 to
15,999.99
15,000.00 375.00 187.50 187.50
13 16,000.00 to
16,999.99
16,000.00 400.00 200.00 200.00
14 17,000.00 to
17,999.99
17,000.00 425.00 212.50 212.50
15 18,000.00 to
18,999.99
18,000.00 450.00 225.00 225.00
16 19,999.99 to
19,999.99
19,000.00 475.00 237.50 237.50
17 20,000.00 to
20,999.99
20,000.00 500.00 250.00 250.00
18 21,000.00 to
21,999.99
21,000.00 525.00 262.50 262.50
19 22,000.00 to
22,999.99
22,000.00 550.00 275.00 275.00
20 23,000.00 to
23,999.99
23,000.00 575.00 287.50 287.50
21 24,000.00 to
24,999.99
24,000.00 600.00 300.00 300.00
22 25,000.00 and up 25,000.00 625.00 312.50 312.50

For the Individually-Paying Members (Volunteers) the premium contribution is fixed at
P100/month.

Premium Sharing Schedule for the Indigent Program
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City Municipality Year
1
st
-6
th
Class 1
st
-3
rd
Class 4
th
-6
th
Class
1
st
year 90-10
2
nd
year 90-10
3
rd
year 85-15
4
th
year 80-20
5
th
year 75-25
6
th
year 70-30
7
th
year 65-35
8
th
year 60-40
9
th
year 55-45
10
th
year






50-50






50-50
50-50

XI. PAYMENT OF CLAIMS TO HEALTH CARE PROVIDERS
3, 5, 6

Mechanisms:
1. Fee for service
2. Capitation payment
3. Case Payment

Notes:
All claims by doctors should be filed within 60 days from date of discharge of the
patient. Extension period of 60 days if there are natural calamites/other fortuitous
events.
Health care institutions MAY NOT charge for PhilHealth forms and processing fees
PhilHealth would only pay for drugs included in the Philippine National Drug Formulary
(PNDF)
Professional fees for services rendered by salaried health care providers may be
retained by the health care institution in which the services are rendered for pooling
and distribution among health personnel. The manner of distributing the professional
fees is left to the discretion of the health care institution.

Dr. Banzuela: In charity hospitals like the PGH, the physicians fee is paid by PhilHealth. The fee
doesnt go to the resident physician but is pooled into a PhilHealth Trust Fund.

Hospital confinements of less than 24 hours shall be compensated only if:
The patient dies
Patient is transferred to another health care institution
Emergency cases
Claims in non-accredited health care institutions shall be compensated if it meets the
following conditions:
Health care institution has DOH license
Emergency case
Physical transfer/referral to accredited health care institution is impossible
Physicians must not charge over and above the professional fees provided by the NHIP
for members admitted to PhilHealth bed

XII. OFFENSES
3

Offenses of Institutional Health Care Providers (punishments includes a fine bet P10,000-
P50,000, suspension of accreditation for 3 months or more and criminal liability)
1. Padding of claims
2. Making claims for non-admitted patient
3. Extending period of confinement
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4. Post-dating of claims
5. Misrepresentation by furnishing false/incorrect information
6. Filing of multiple claims
7. Unjustified admission beyond accredited bed capacity
8. Unauthorized operations beyond service capability (performing complex procedures in a
primary hospital)
9. Fabrication/Possession of fabricated forms and supporting documents
10. Other fraudulent acts

Offenses of Health Care Professionals (punishments includes a fine between P10,000-P50,000,
suspension of accreditation for 6 months-3 years and criminal liability)
1. Misrepresentation by false/incorrect information
2. Breach of warranties of accreditation
3. Other violation whether willful or negligent

Offenses of Employers
1. Failure/Refusal to deduct contributions
2. Failure/Refusal to remit contributions
3. Unlawful deductions
4. Offenses committed by an institution(association, partnership, corporation, etc)

XIII. STATISTICS
7,8

Year Collection Benefit Payments Members +
Dependents
Percentage of
the Population
Covered
2004 16,515,723,554.00 12,953,288,449.84 69,500,000 81%
2003 13,151,720,380.00 10,956,629,035.00
2002 12,271,040,389.11 8,839,294,863.02 43,564,611 54.30%
2001 11,068,892,896.18 7,740,168,979.49 37,460,401 48.10%
2000 8,557,124,578.23 6,763,502,012.02 54%
1999 5,400,000,000.00 4,217,691,182.25
1998 4,851,566,626.00 2,998,948,511.59 37,100,000
1997 4,419,303,494.00 20,637,278
1996 4,710,860,000.00 3433.08M 34,510,000 50%
1995 4,359,170,000.00 2560395M

In 2004(Latest Stats)
LGU participation: 68 out of 79 provinces, 113 out of 118 cities, 1,365 out of 1,492
municipalities
1,579 accredited facilities - 18 dialysis clinics, 71 Maternity Care Clinics, 29 DOTS
Centers
Reserve Funds of P35,287,000,000

XIV. SOURCES

1. RA 7875
2. RA 9141
3. PhilHealth Implementing Rules and Regulation
4. The PhilHealth Chronicles
5. You and your Medicare Benefits A Primer on the Most Commonly Asked Questions on
the National Health Insurance Program
6. PhilHealth Website
7. PhilHealth Annual Reports 1996-2004
8. PhilHealth Stats and Charts 1996-2004
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XV. GREETINGS

To avoid the bad luck of having a 13-paged primer, I decided to add a greetings part
to this primer. =)

Thank you, thank you, thank you very much to the following people: (in no particular order)
To the very kind Buching Paterno, MD, MPH, our boss at the PhilHealth Research Study
Group at the UP-NIH.
To my friends/co-workers/foodtrip partners at PRSG Dr.Kokoi Domingo, Dr.Valerie
Buenviaje-Cu and Ate Raquel Mijares.
To Dr.Anthony Cordero who, despite being a member of a rival fraternity, was so kind
and compassionate as to help me land my first job here at PRSG. Malaki po utang na loob ko sa
inyo sir.
To my bosses Dr.Noel Guison, Dr.Francis Cid, Dr.Helen Sigua and Dr. Hazel Paragua for
their all-out support and for giving me an opportunity to work under them.
To my parents, Zeus and Arabella Banzuela
To Dr.Robert Arias, for the many employment opportunities he has given me and for
the comprehensive exams he has made for San Beda.
To all my students and friends at the San Beda College of Medicine, especially members
of SBCM Class 2007 and SBCM Class 2009. To the SBCM tropa salamat sa lahat.
To Dr.Jun Logronio, for giving me an opportunity to work under him at the Cebu Review
Medical Center, one of the premier medical board review centers in the Philippines.
To Dr.June Ann Rosales, for the invitation to lecture at her medical school.
To Mrs.Cherrie Gal Espiritu for giving me an opportunity to lecture to her doctors-to-
be. Her Fairview dormitory exclusive for those taking the medical board exams has topnotch
facilities and excellent service.
To all the brods of the Most Venerable Fraternity of the UP College of Medicine, the Phi
Kappa Mu.
To God, to country and to our profession.

THIS PRIMER TO PHILHEALTH IS SPONSORED BY:


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loroteyang@yahoo.com Page 14 of 14