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  2. 2. Health insurance• Is a insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity.
  3. 3. Healthcare Benefits vs Social Protection benefitsHealthcare Benefits are provided in kind tomaintain the wellness of a personSocial Protection Benefits are provided incash or in terms of financial assistanceto people who are sick and requiremedical treatment
  4. 4. Required Health Insurance in the Philippines and its Financing Schemes INSURANCE SECTOR AGENCYA. SSS Private EmployeesB. Phil Health Private & Government EmployeesC. GSIS Government Employees
  5. 5. What is the sickness benefit?The sickness benefit is adaily cash allowance paidfor the number of days amember is unable to workdue to sickness or injury.
  6. 6. How does an SSS memberqualify for the sickness benefit?A member is qualified to avail himself of this benefit if:• He is unable to work due to sickness or injury and is thus confined either in the hospital or at home for at least four days;• He has paid at least three monthly contributions within the 12-month period immediately before the semester of sickness;• He has used up all current company sick leaves with pay for the current year• He has not notified his employer or the SSS, if he is a separated, voluntary or self-employed member.
  7. 7. How much sickness benefit is an employee entitled to receive?The amount of an employee’s sicknessbenefit is computed as: the dailysickness allowance times theapproved number of days.
  8. 8. How is the benefit computed?• Exclude the semester of sickness. A semester refers to two consecutive months ending onthe last day of March, June, September or December.Count 12 months backwards starting from the monthimmediately before the semester of sickness.• Identify the six highest monthly salary credits withinthe 12-month period.Monthly salary credit means the compensation base forcontributions and benefits related to the earnings forthe month. The maximum covered earnings orcompensation is Php15,000 beginning January 2002.
  9. 9. • Add the six highest monthly salarycredits to get the total monthly salarycredit.• Divide the total monthly salary credit by180 days to get the average daily salarycredit.• Multiply the average daily salary creditby 90 per cent to get the daily sicknessallowance.• Multiply the daily sickness allowance bythe approved number of days to arrive atthe amount of benefit due.
  10. 10. How many days in a year can a member avail himself of the sickness benefit?• A member can be granted sickness benefit for amaximum of 120 days in one calendar year. Any unusedportion of the allowable 120 days sickness benefitcannot be carried forward and added to the totalnumber of allowable compensable days in thesubsequent year.• The sickness benefit shall not be paid for more than240 days on account of the same illness. If the sicknessor injury still persist after 240 days, the claim will beconsidered a disability claim.
  11. 11. What is the maternity benefit?The maternity benefit is a dailycash allowance granted to afemale member who was unableto work due to childbirth ormiscarriage.
  12. 12. How much is the maternity benefit?The maternity allowance is equivalentto 100 percent of the member’saverage daily salary credit multipliedby 60 for normal delivery ormiscarriage , 78 days for cesareancases.
  13. 13. What is the retirement benefit?It is a cash benefit paid to amember who can no longerwork due to old age
  14. 14. Who may qualify for retirement benefit?A member who is 60 years old and unemployedand has paid at least 120 monthly contributionsprior to the semester of retirement .A member who is 65 years old, whetheremployed or not. If employed he should havepaid 120 monthly contributions prior to thesemester of retirement, whether employed ornot.
  15. 15. How much monthly pension will a retiree receive?The monthly pension will be the highest of:1. The sum of Php 300 plus 20 per cent of the average monthly salary credit plus two per cent of the average monthly salary credit for each credited year of service in excess of 10 years;2. 40 percent of the average monthly salary credit3. Php 1,200, provided, that the monthly pension is paid for not less than 60 months.
  16. 16. What is death benefit?The death benefit is cash paid tothe beneficiaries of a deceasedmember.
  17. 17. What are the beneficiaries of a deceased member?The primary beneficiaries are the legitimatedependent spouse until he or she remarries andlegitimate, legitimated, legally adopted orillegitimate dependent children of the member.In the absence of primary beneficiaries, thesecondary beneficiaries are the dependentparents of the member. In their absence, theperson designated by the member as beneficiaryin his member’s record will be recipient.
  18. 18. Phil Health - a government owned and controlledcorporation, to administer and manage asustainable program that will not only ensurebetter benefits at an affordable cost but alsoextend quality and relevant health care servicesto a broader membership base that will lead touniversal coverage.
  19. 19. Benefits: Inpatient Hospital Care• Room and board• Services of health care professionals• Diagnostic, laboratory and other medicalexamination services; use of surgical or medicalequipment and facilities• Prescription drugs and biological, subject to thelimitations stated in Section 37 of RA 7875• Inpatient education packages
  20. 20. Benefits: Outpatient Care• Services of health care professionals• Diagnostic, laboratory and other medicalexamination services• Personal preventive services• Prescription drugs and biological, subject to thelimitations described in Section 37 of RA 7875• Emergency and transfer services
  21. 21. Who are covered by the National Health Insurance Program?• Employee Members – all those employed in thegovernment and private sector• Individually Paying Members – self-employed,Overseas Filipino Workers, professionals inprivate practice• Non Paying Members – the following areentitled to lifetime coverage------ retirees and pensioners of the GSIS and SSS
  22. 22. Who are the legal dependents entitled to free coverage?• Legitimate spouse, non-member• Children (legitimate, illegitimate, adopted andstep child) below 21 years old, unmarried andunemployedNote: Children 21 years or above but sufferingfrom any congenital disability, either physical ormental or any disability: 2.12 times the monthlypension
  23. 23. Is there anything else a deceased member’s beneficiaries can avail of? Yes, the deceased member’sbeneficiaries are entitled to 13th monthpension payable every December andthe funeral grant benefit.
  24. 24. Health Maintenance Organization (HMO)A form of group practice by physicians andsupporting personnel to provide comprehensivehealth services to an enrolled group ofsubscribers who pay fixed premium.
  25. 25. HMO CoverageIn exchange for a monthly premium, the HMOprovides comprehensive care for the insured,including doctor’s visits, hospital stays,emergency care, surgery, lab test, x-rays andtherapy.Note: Coverage of health care services would bedepending on the kind of type of HMO that youare subscribing.
  26. 26. List of HMOs• Philippine Association of Food Technologies• Philippine College of Physicians• Philippine Dermatological Society• Philippine National Red Cross• Philippine Society of Gastroenterology• Philippine Urological Association, Inc.•• Insular Life Health Care• MEDICard Phils•OmniCap• Optimum Health Care System