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PHIC_2014.ppt
1. Benefits Available to Members
During Calamities
GREGORIO C. RULLODA
Group Vice-President
Member Management Group
CY 2014 AGAP CONVENTION
CAP John Hay, Baguio City
October 23, 2014
2. Ang inyong PhilHealth ngayon:
Pinakamalawak!
81.5 million beneficiaries
globally
82% population coverage
8 of every 10 Filipinos
covered
3. Membership Category
2013 2014 *
Members and
Dependents
Members and
Dependents
Members in the Formal
Economy
(Private and government
employed)
26.34 27.32
Members in the Informal
Economy
(OFW and Individually
Paying)
17.85 6.33
Indigent Members 21.7 45.2
Sponsored Members 10.37 1.32
Lifetime 1.32 1.53
Total 76.90 81.7
Coverage Rate 67% 82% **
NHIP Coverage as of August 31, 2014
(in millions)
Ang inyong PhilHealth ngayon:
Pinakamalawak!
4. • Shifted to case-based payment system to
contain costs without sacrificing quality of
care (Fee for Service to ALL CASE RATES)
Substantial coverage for medical and
surgical cases
Substantial support for common
catastrophic cases through the Z Package
• Expands coverage of the Primary Care
Benefits
Ang inyong PhilHealth ngayon:
Tumutugon!
5. • Provides higher Financial Risk Protection
No-Balance Billing
P50.5B payments in 2013 with 54%
support value
• Provides special privileges during the
occurrence of fortuitous events to members
and non-members including their qualified
dependents
• Ensures coverage of the POOR and Indigents
Ang inyong PhilHealth ngayon:
Tumutugon!
6. • Shifted to case-based payment system to
contain costs without sacrificing quality of
care (Fee for Service to ALL CASE RATES)
Substantial coverage for medical and
surgical cases
Substantial support for common
catastrophic cases through the Z Package
• Expands coverage of the Primary Care
Benefits
Ang inyong PhilHealth ngayon:
Tumutugon!
7. Medical Cases
Dengue Fever PhP 10,000
Severe Dengue Fever 16,000
Pneumonia (moderate risk) 15,000
Pneumonia (high risk) 32,000
Essential Hypertension 9,000
Ang inyong PhilHealth ngayon:
Tumutugon!
8. Bawat Miyembro PROTEKTADO
Surgical Cases
Cholecystectomy PhP 31,000
Dilation and Curettage 11,000
Thyroidectomy 31,000
Herniorraphy 21,000
Mastectomy 22,000
Hysterectomy 30,000
Cataract Surgery 16,000
Ang inyong PhilHealth ngayon:
Tumutugon!
10. • Shifted to case-based payment system to
contain costs without sacrificing quality of
care (Fee for Service to ALL CASE RATES)
Substantial coverage for medical and
surgical cases
Substantial support for common
catastrophic cases through the Z Package
• Expands coverage of the Primary Care
Benefits
Ang inyong PhilHealth ngayon:
Tumutugon!
11. Collage here (images) of common case-rated
treatments and procedures including Z Packages
Catastrophic illnesses under the Z packages
Coronary Artery Bypass Graft
(standard risk)
550,000
Total Correction of Tetralogy of
Fallot
320,000
Closure of Ventricular Septal
Defect
250,000
Cervical Cancer:
Early Stage 120,000
Late Stage 175,000
Prosthesis (Z MORPH) 15,000
Ang inyong PhilHealth ngayon:
Tumutugon!
12. • Shifted to case-based payment system to
contain costs without sacrificing quality of
care (Fee for Service to ALL CASE RATES)
Substantial coverage for medical and
surgical cases
Substantial support for common
catastrophic cases through the Z Package
• Expands coverage of the Primary Care
Benefits
Ang inyong PhilHealth ngayon:
Tumutugon!
13. • Consultation
• Regular BP measurements
• Breastfeeding program education
• Periodic clinical breast examinations
• Counseling for lifestyle modification
• Counseling for smoking cessation
• Body measurements
• Digital rectal examination
• Visual inspection with acetic acid
Primary Preventive Services:
Bawat Miyembro PROTEKTADO
Tamang Serbisyo Para sa Kalusugan ng Pamilya
(TseKaP) or Primary Care Benefits
Ang inyong PhilHealth ngayon:
Tumutugon!
15. Bawat Miyembro PROTEKTADO
Drugs and Medicines:
• Asthma including nebulisation services
• Acute Gastroenteritis (AGE) with no or mild
dehydration
• Upper Respiratory Tract Infection (URTI)
• Pneumonia (minimal and low risk)
• Urinary Tract Infection (UTI)
Primary Care Benefits
Ang inyong PhilHealth ngayon:
Tumutugon!
16. Bawat Miyembro PROTEKTADO
Primary Care Benefits
AVAILABLE FOR WHOM?
Indigents (NHTS: Listahanan
OFWs (Land-based)
Informal Group (iGroup Members)
DepEd……….494,921
Assigned: 313,024
Profiled: 127,605
Ang inyong PhilHealth ngayon:
Tumutugon!
17.
18. • Provides higher Financial Risk Protection
No-Balance Billing
P50.5B payments in 2013 with 54%
support value
• Provides special privileges during the
occurrence of fortuitous events to members
and non-members including their qualified
dependents
Ang inyong PhilHealth ngayon:
Tumutugon!
19. No-Balance Billing
This zero co-payment policy ensures that no
additional expenses are required over and above
the fixed rates for indigent and sponsored members
confined in government facilities under ward-type
accommodation.
Ang inyong PhilHealth ngayon:
Tumutugon!
20. • Provides higher Financial Risk Protection
No-Balance Billing
P50.5B payments in 2013 with 54%
support value
• Provides special privileges during the
occurrence of fortuitous events to members
and non-members including their qualified
dependents
Ang inyong PhilHealth ngayon:
Tumutugon!
21. 0
10
20
30
40
50
60
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Ang inyong PhilHealth ngayon:
Tumutugon!
Benefit payments in the last 10 years (in billion pesos)
P50.5 B
22. • Provides higher Financial Risk Protection
No-Balance Billing
P50.5B payments in 2013 with 54%
support value
• Provides special privileges during the
occurrence of fortuitous events to members
and non-members including their qualified
dependents
• Ensures coverage of the POOR and Indigents
Ang inyong PhilHealth ngayon:
Tumutugon!
24. • Provides higher Financial Risk Protection
No-Balance Billing
P50.5B payments in 2013 with 54%
support value
• Provides special privileges during the
occurrence of fortuitous events to members
and non-members including their qualified
dependents
• Ensures coverage of the POOR and Indigents
Ang inyong PhilHealth ngayon:
Tumutugon!
25. Ang inyong PhilHealth ngayon:
Tumutugon!
All indigents identified by the
Department of Social Welfare and
Development (DSWD) under the NHTS
and other such acceptable methods,
shall automatically be enrolled and
covered by PhilHealth (14.7 million
Principal Members) and FUNDED
THROUGH THE SIN TAX
Non-Member Poor can be enrolled through the Point Of CARE
26. Accredited:
9 of 10 licensed
hospitals
32,000 health
care professionals
Ang inyong PhilHealth, ngayon:
Abot-kamay na serbisyo!
Private – 60%
Gov’t – 40%
8,429 ACCREDITED FACILITIES
27. +78% satisfaction rating (as support and
protection to its members and dependents)
and as high as 75% awareness rating
on key benefits
Ang inyong PhilHealth, ngayon:
Trending!
SOURCE: Social Weather Stations, December 2013
28. Dahil trending… aalagaan kayo!
Developed a more focused and
integrated communication campaign
for Kalusugan Pangkalahatan –
ALAmin at Gamitin
Explore novel and creative ways to inform
all Filipinos particularly the of their
PhilHealth benefits and health services.
29. Ang inyong PhilHealth, ngayon:
Mas Pinadali!
Documentary Requirements for Registration
Baptismal Certificate / GSIS Card / SSS Card / Passport / LTO License / PRC ID / NBI Clearance / Police
Clearance / COMELEC ID / Postal ID / Senior Citizens ID / OWWA ID / Company ID / DSWD
Certification / Barangay Certification / Other IDs recognized by SEC, Insurance Commission or BSP /
Alien Certificate of Registration /
30. Ang inyong PhilHealth, ngayon:
Mas Pinadali!
A person intending
to enroll as
member (including
dependents) shall
submit a properly
accomplished
PhilHealth Member
Registration Form
The member to certify
the truthfulness and
accuracy of the
information provided
including the list of
qualified dependents
The new PMRF is enough!
31. Obligations of the Employer
Ang inyong PhilHealth:
Nagpapaalala!
REMIT ON TIME the monthly premium contributions to avoid
PENALTIES
New Payment Schedule effective March 2014 :
Employers with PENs ending 0-4 Every 11th – 15th day of the month
of the following applicable period
Employers with PENs ending 5-9 Every 16th – 20th day of the month
of the following applicable period
Implement the Expanded Modified Direct Payment
Scheme (ExMDPS) for NGAs
32. a)Register their employees and their qualified dependents by
submitting a list of their employees complete with their salary
base and other documents as may be required;
b)Report to the Corporation its newly-hired employees within
thirty (30) calendar days from assumption to office;
c)Give notice to the Corporation of an employee’s separation
within thirty (30) calendar days from separation.
a)Allow the inspection of its premises including its book and
other pertinent records.
Obligations of the Employer
Ang inyong PhilHealth:
Nagpapaalala!
33. Submit regularly the Remittance
List/Contribution Report (RF1)
Failure and/or refusal of the employer to deduct or
remit the complete employees’ and employer’s
premium contribution shall not be a basis for
denial of a property filed claim. In such a
case, the Corporation shall be entitled to
reimbursement of claims paid from the
erring or negligent employer, without
prejudice to the latter’s prosecution and other
liabilities, as may hereafter be provided by this
Rules.
Obligations of the Employer
Ang inyong PhilHealth:
Nagpapaalala!
34. Remittance of Premium for Employees with
Income Gaps:
Employees with no income for a particular
month/s due to non-rendition of service or for
such other reasons such as those who are on
leave without pay or on extended leave,
including members engaged in seasonal
employment, shall continue to pay
premiums to the Program to ensure
continuous entitlement to benefits.
Ang inyong PhilHealth:
Nagpapaalala!
35. You are a very important
stakeholder not just as an
employee but as a
PhilHealth member.
36. Kalusugan Natin SEGURADO
(Quality health care is accessible to all when
needed)
Bawat Miyembro PROTEKTADO
(Protected through Social Health Insurance)
Bawat Pilipino MIYEMBRO
(Coverage is Universal)
Vision
Mission
“Dekalidad na Serbisyo para sa Lahat”
(Optimal Benefit for every Member)
“Sulit na Benepisyo sa Bawat Miyembro”
(High Quality Service for All)
This is a time like no other. We are now covering 79.8* million beneficiaries (members and qualified dependents) not only here in the Philippines but around the globe. This translates to 82 percent* of the 2013 projected Philippine population of 97.7 million.
Given that the country welcomed the 100 millionth babies in July this year, the figures will surely adjust. We are confident that this population coverage will stay if not surpassed given our intensified efforts to enlist more and more Filipinos into the program.
Sa bawat sampung Pilipino ay higit na sa walo ang covered ng PhilHealth. Hindi na po magtatagal at masasabi na rin nating lahat na ay covered. Imagine the huge demand for media content that will be generated by this sheer number? Later I will say more about this but suffice it to say that for as long as demand for heath care increases, demand for information about their social health insurance also increases. And it is undisputed that the topmost sources of information of Filipinos is still the mass media and of course the new media.
*As of April 2014 per CorPlan
Narito po ang ilang halimbawa sa mga tukoy na halaga ng benepisyo sa mga karaniwang pagpapagamot ngayon. Ito ay bunga na ng paglipat namin sa case-based payment system kung saan all-in na ang treatment namin sa pagbabayad… ika nga ay pakyawan na ito! Sa mga halagang ito ay pasok na ang lahat ng mga dapat isagawa at ipagkaloob sa pasyente, walang labis walang kulang, gaya halimbawa ng…
Continued…
Sa nakaraang sampung taon ay nakapagbayad kami ng P271.4 bilyong piso kung saan halos mahigit sa 18 percent nito (18.6%) ay kumakatawan sa benefit payment namin nuon lamang taong 2013 na umabot sa P50.5 B.
Maliwanag na tumutugon ang PhilHealth para mabawasan kung hindi man matakpan ang kabuuan ng bayarin ng mga miyembro sa kanilang pagpapaospital.
Good news ito dahil malinaw na ipinapakita nito na ang pera ng ating mga miyembro ay napupunta mismo sa kanila.
Sources: Annual Reports CY 2004 to 2012 and Stats and Charts 2013
To give you an idea on the extent of our reach when it comes to providing members with access to quality health care, we have accredited a total of 1,077* accredited hospitals.
Total accredited facilities is at 8,429* which include hospitals, primary care facilities, Ambulatory Surgical Clinics, Freestanding Dialysis Centers, PCB1 or those providing our Tamang Serbisyo para sa Kalusugan ng Pamilya or TSEKaP, Maternity Clinics, DOTS and Animal Bite Centers.
To complement this are 31,715 accredited professionals and they are specialists, general practitioners, dentists and midwives (as of February 28, 2014).
Ganito po kalawak ang aming network of providers para matiyak na malapit lang ang tatakbuhan ng miyembro sakaling may pasyente siya.
*as of February 28, 2014 per PhilHealth website
Another good news: According to the Social Weather Stations in its December 2013 survey, PhilHealth’s net satisfaction rating (% satisfied minus % dissatisfied) remained excellent at net +78 insofar as support and protection to its members and dependents are concerned.
No doubt that PhilHealth is already a byword and already on top of everyone’s consciousness.
OPTIONAL: What we then tried to find out is how fully aware are our members with our benefits and services. Also in the said survey, awareness is very high of our maternity care package at 75%, closely followed by our inpatient services (or the services they actually avail of in hospitals) at 74%, and newborn care package at 54%.
Mataas na ang kamalayan ng mga miyembro hindi lang sa kanilang membership at sa ahensiyang nagkakaloob sa kanila ng benepisyong medikal, kundi mataas din ito kung ang pag-uusapan ay kung ano ba ang naitutulong sa kanila ng PhilHealth.
For this we sincerely thank you for standing by us and helping us in achieving this very high level of awareness among our kababayans. Salamat po ng marami sa inyo.
Another good news: According to the Social Weather Stations in its December 2013 survey, PhilHealth’s net satisfaction rating (% satisfied minus % dissatisfied) remained excellent at net +78 insofar as support and protection to its members and dependents are concerned.
No doubt that PhilHealth is already a byword and already on top of everyone’s consciousness.
OPTIONAL: What we then tried to find out is how fully aware are our members with our benefits and services. Also in the said survey, awareness is very high of our maternity care package at 75%, closely followed by our inpatient services (or the services they actually avail of in hospitals) at 74%, and newborn care package at 54%.
Mataas na ang kamalayan ng mga miyembro hindi lang sa kanilang membership at sa ahensiyang nagkakaloob sa kanila ng benepisyong medikal, kundi mataas din ito kung ang pag-uusapan ay kung ano ba ang naitutulong sa kanila ng PhilHealth.
For this we sincerely thank you for standing by us and helping us in achieving this very high level of awareness among our kababayans. Salamat po ng marami sa inyo.
