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. Healthcare Benefits vs
Social Protection benefits
Healthcare Benefits are provided in kind to
maintain the wellness of a person
Social Protection Benefits are provided in
cash or in terms of financial assistance
to people who are sick and require
medical treatment
4. Required Health Insurance
in the Philippines and its
Financing Schemes
INSURANCE SECTOR
AGENCY
A. SSS Private Employees
B. Phil Health Private & Government
Employees
C. GSIS Government
Employees
5.
6. What is the sickness benefit?
The sickness benefit is a
daily cash allowance paid
for the number of days a
member is unable to work
due to sickness or injury.
7. How does an SSS member
qualify 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.
8. How much sickness benefit is an
employee entitled to receive?
The amount of an employee’s sickness
benefit is computed as: the daily
sickness allowance times the
approved number of days.
9. How is the benefit computed?
• Exclude the semester of sickness.
A semester refers to two consecutive months ending on
the last day of March, June, September or December.
Count 12 months backwards starting from the month
immediately before the semester of sickness.
• Identify the six highest monthly salary credits within
the 12-month period.
Monthly salary credit means the compensation base for
contributions and benefits related to the earnings for
the month. The maximum covered earnings or
compensation is Php15,000 beginning January 2002.
10. • Add the six highest monthly salary
credits to get the total monthly salary
credit.
• Divide the total monthly salary credit by
180 days to get the average daily salary
credit.
• Multiply the average daily salary credit
by 90 per cent to get the daily sickness
allowance.
• Multiply the daily sickness allowance by
the approved number of days to arrive at
the amount of benefit due.
11. How many days in a year can a member
avail himself of the sickness benefit?
• A member can be granted sickness benefit for a
maximum of 120 days in one calendar year. Any unused
portion of the allowable 120 days sickness benefit
cannot be carried forward and added to the total
number of allowable compensable days in the
subsequent year.
• The sickness benefit shall not be paid for more than
240 days on account of the same illness. If the sickness
or injury still persist after 240 days, the claim will be
considered a disability claim.
12. What is the maternity benefit?
The maternity benefit is a daily
cash allowance granted to a
female member who was unable
to work due to childbirth or
miscarriage.
13. How much is the maternity
benefit?
The maternity allowance is equivalent
to 100 percent of the member’s
average daily salary credit multiplied
by 60 for normal delivery or
miscarriage , 78 days for cesarean
cases.
14. What is the retirement benefit?
It is a cash benefit paid to a
member who can no longer
work due to old age
15. Who may qualify for retirement
benefit?
A member who is 60 years old and unemployed
and has paid at least 120 monthly contributions
prior to the semester of retirement .
A member who is 65 years old, whether
employed or not. If employed he should have
paid 120 monthly contributions prior to the
semester of retirement, whether employed or
not.
16. 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 credit
3. Php 1,200, provided, that the monthly pension is
paid for not less than 60 months.
17. What is death benefit?
The death benefit is cash paid to
the beneficiaries of a deceased
member.
18. What are the beneficiaries of a
deceased member?
The primary beneficiaries are the legitimate
dependent spouse until he or she remarries and
legitimate, legitimated, legally adopted or
illegitimate dependent children of the member.
In the absence of primary beneficiaries, the
secondary beneficiaries are the dependent
parents of the member. In their absence, the
person designated by the member as beneficiary
in his member’s record will be recipient.
19.
20. Phil Health
- a government owned and controlled
corporation, to administer and manage a
sustainable program that will not only ensure
better benefits at an affordable cost but also
extend quality and relevant health care services
to a broader membership base that will lead to
universal coverage.
21. Benefits: Inpatient Hospital Care
• Room and board
• Services of health care professionals
• Diagnostic, laboratory and other medical
examination services; use of surgical or medical
equipment and facilities
• Prescription drugs and biological, subject to the
limitations stated in Section 37 of RA 7875
• Inpatient education packages
22. Benefits: Outpatient Care
• Services of health care professionals
• Diagnostic, laboratory and other medical
examination services
• Personal preventive services
• Prescription drugs and biological, subject to the
limitations described in Section 37 of RA 7875
• Emergency and transfer services
23. Who are covered by the National
Health Insurance Program?
• Employee Members – all those employed in the
government and private sector
• Individually Paying Members – self-employed,
Overseas Filipino Workers, professionals in
private practice
• Non Paying Members – the following are
entitled to lifetime coverage
------ retirees and pensioners of the GSIS and SSS
24. Who are the legal dependents entitled
to free coverage?
• Legitimate spouse, non-member
• Children (legitimate, illegitimate, adopted and
step child) below 21 years old, unmarried and
unemployed
Note: Children 21 years or above but suffering
from any congenital disability, either physical or
mental or any disability: 2.12 times the monthly
pension
25. Is there anything else a deceased
member’s beneficiaries can avail of?
Yes, the deceased member’s
beneficiaries are entitled to 13th month
pension payable every December and
the funeral grant benefit.
26. Health Maintenance Organization (HMO)
A form of group practice by physicians and
supporting personnel to provide comprehensive
health services to an enrolled group of
subscribers who pay fixed premium.
27. HMO Coverage
In exchange for a monthly premium, the HMO
provides comprehensive care for the insured,
including doctor’s visits, hospital stays,
emergency care, surgery, lab test, x-rays and
therapy.
Note: Coverage of health care services would be
depending on the kind of type of HMO that you
are subscribing.
28. 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.
• PSEM.org
• Insular Life Health Care
• MEDICard Phils
•OmniCap
• Optimum Health Care System
