PhilHealth Cataract Package

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PhilHealth Hemodialysis Benefits

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Duties and Responsibilities of a PhilHealth Member

The duties and responsibilities of a PhilHealth member are:

Have in possession at all times your PhilHealth Number Card or Identification Card;

It pays to be prepared in emergency situations such as accidents or illness. Members should always have their PhilHealth ID card or PhilHealth number card ready for presentation at the accredited health care provider to prevent delay in the availment of benefits.

Update your Member Data Record (MDR) for any change in personal information such as change in civil status or addition of a new dependent;

The Member Data Record is a document required during availment of PhilHealth benefits or claiming reimbursement. Members should keep the MDR up-to-date to prevent any inconsistency from being reflected in the MDR. The address in the MDR will be used to send the check payment and any other correspondence that will be issued by PhilHealth. There are instances when health care providers will require that the name reflected in the MDR be the same with their records in order to automatically avail the benefits and others such cases.

Request for a replacement in case of loss of PhilHealth Number Card or Identification Card;

This is in reference to the first discussed responsibility of a PhilHealth member where the PhilHealth Number Card or Identification Card should always be made available as this will be presented to the health care provider when undergoing an emergency admission or surgery. Members should not wait for the need to arise to get a replacement of their lost PhilHealth number card or identification card.

Ensure that you promptly and regularly pay your contributions (for individually paying members and Overseas Workers Program members) to avoid suspension of benefits;

Individually paying members should have a qualifying contributions in order to avail PhilHealth benefits. Moreover, some benefits require nine monthly contributions within a twelve month period prior confinement to avail the benefit, hence, if the member should miss payment for a given quarter or period, this will affect the availment of the benefit. This is the same with OWP members. Although OWP members are covered within their validity period and do not require qualifying contributions, continuous coverage or validity period should be ensured for uninterrupted eligibility for benefits.

For newly hired employees, check if your name is reported by your employer to PhilHealth in the ER2 Form (Report of Employee-Members);

The ER2 form is being submitted by the employers to PhilHealth which is basically a list that certifies the employees of the company. It should also be noted that the date of employment is required information that should be reflected in the ER2. The ER2 will serve as the baseline of the employer in the preparation of their monthly remittance report. Employed members should ensure that their employers have included their names in the ER2 and have properly reported it to PhilHealth as this serves as protection of the employees from employers that are not remitting their premium contributions to PhilHealth.

Ensure that your monthly premium contributions are deducted from your salary and promptly remitted and reported by your employer to PhilHealth;

Every month the employers are submitting a monthly remittance report which includes all employees and corresponding premium contributions that have been deducted. This report is used by PhilHealth to post the contributions to the employees' member accounts. Hence, employees should keep their payslips reflecting premium contribution deductions as this will serve as proof of deduction which may be presented to PhilHealth if a discrepancy in the number of contributions was found.

Report to PhilHealth at once an employer who does not remit premium payments;

Employers are mandated by law to deduct PhilHealth premium contributions and it is also the responsibility of the employer to report the members that have been deducted and how much premium contribution each employee has paid. Hence, if an employee found out that their employer is not remitting their premium payments, PhilHealth should immediately be notified so that they may coordinate with the employer.

Ensure that you have sufficient qualifying contributions to avail of PhilHealth benefits anytime;

Members should not start paying or continue payment when they are expected to use or avail PhilHealth benefits, it should be done regularly.

Secure an updated list of accredited facilities from any PhilHealth office wherein you can avail of benefits;

This is similar to the health management organizations (HMO) where they are providing a list of accredited partners in which the members may be able to go to. It is the responsibility of the member to keep in mind the available health care facilities and hospitals that they may go to in case of illness to prevent denial of PhilHealth benefits.

Others are:

• Submit a properly and completely filled-up PhilHealth Claim Form 1 to the hospital and ensure that all the information you stated in the said form are true and factual;

• Ensure that you properly and completely submit all the necessary documents to the hospital including a copy of your Member Data Record (MDR) to avail of PhilHealth benefits;

• Clarify with providers (hospital/doctor), the appropriate and final benefits deducted upon settlement of bills and charges;

• Ask for a copy of your Statement of Account/Billing Statement from the hospital upon discharge;

• Ask for an Official Receipt (OR) and Waiver from the hospital and doctor for payments made in full;

• Ensure that your claim, if opt for direct filing, is filed at PhilHealth within sixty (60) days from the date of discharge for local confinements and within one hundred eighty (180) days for confinements abroad;

• Be aware of amendments and updates on PhilHealth policies and benefits schedule;

• Seek clarification from any PhilHealth office on any unclear policy or guideline;

• Report at once to PhilHealth any hospital that fails, without valid reason, to accommodate a PhilHealth member who wishes to avail of benefits;

• Report at once to PhilHealth any fraudulent transactions that you know about;

• Observe and comply with PhilHealth rules and regulations as there are offenses in its Implementing Rules and Regulations that a member may be held liable for.

We hope that members are guided accordingly in order to prevent any negative experiences from occurring when transacting with PhilHealth.

Source: http://www.philhealth.gov.ph/forms/others/member_duties.pdf

Issuance of PhilHealth ID Cards and MDR to Employed Members

An official advisory has been released by PhilHealth informing the public that transactions for members belonging to the Private and Government Sectors should be facilitated by their respective Human Resource Departments (HRD).

Employees that are not yet registered with PhilHealth and those without PhilHealth Identification Numbers (PIN) should submit a fully accomplished PhilHealth Membership Registration Form (PMRF) with attached supporting documents:

• Clear copy of employee's birth certificate/baptismal certificate or one (1) valid ID;
• Clear copy of legal supporting documents of declared dependent/s such as birth certificate, marriage certificate and others as necessary.

Submit all the requirement to the HRD of the company you are in. They will in turn submit the documents together with the ER2 (Employer-Employee List) to PhilHealth. PhilHealth in turn will process your documents and forward your PhilHealth ID Card (PIC) and Member Data Record (MDR) to your office's HRD for distribution.

New employees whether newly employed or transferred who are existing PhilHealth members would just need to inform their current employer of their PhilHealth Identification Number (PIN) for the preparation of the Monthly Employer's Remittance Report (RF-1).

Source: PhilHealth Advisory No. 08-01-2011

Is PhilHealth coverage mandatory for all Filipinos?

Yes. Put another way, PhilHealth membership is compulsory.

SEC. 6. Coverage. - All citizens of the Philippines shall be covered by the National Health Insurance Program. In accordance with the principles of universality and compulsory coverage enunciated in Section 2 (b) and 2 (1) hereof, implementation of the Program shall, furthermore, be gradual and phased in over a period of not more than fifteen (15) years: Provided, That the Program shall not be made compulsory in certain provinces and cities until the Corporation shall be able to ensure that members in such localities shall have reasonable access to adequate and acceptable health care services. (underlining supplied)

Reference: Art. III, Sec. 6, R.A. 7875 

SECTION 4. Objective – It is the main objective of the NHIP to provide all Filipinos with the mechanism to gain financial access to quality health care services within the first 15 years of its implementation. Coverage of the employed members in the government and private sectors, individually-paying, retirees, and indigent families shall be ensured. (underlining supplied)

Reference: Title III, Rule 1, Sec. 4, IRR of R.A. 7875

Please note though, that membership and eligibility to avail of benefits are two different things. You may be a member, but if you are not paying your PhilHealth contributions with the required frequency, you are not eligible to avail of your PhilHealth benefits.

This applies to everyone who is employed, regardless if it is with the government or the private sector, or Overseas Filipino Workers (OFWs).

Individually Paying Members (IPMs) may or may not choose to register or pay premiums under the IPM program. If they choose not to, they are not eligible for PhilHealth benefits. It is strongly recommended that those qualified as IPMs register and pay their contributions.

Lifetime members need not pay as they are already retired and have already made at least 120 monthly contributions.

The contributions for those belonging to sponsored program are paid for by government or private entities.

For further information on who can enroll or register as a PhilHealth member, read this post.

Who can Enroll or Register as a PhilHealth Member?

This post aims to discuss the different types of membership programs of the National Health Insurance Program. PhilHealth members are divided into five (5) main categories broken down as follows:

• Employed;
• Individually Paying Members (IPM);
• Sponsored Members;
• Lifetime Members;
• Overseas Filipino Workers.

The Employed category are basically those individuals that are employed either in a private or government institution and are therefore further classified into Private/Government. Individuals under this category are enrolled in PhilHealth through the employers in compliance with the law.

Individuals that are classified under the Individually Paying Member (IPM) are those that are directly paying their premium contributions to PhilHealth and belong to either of the cases below. Participation under this scheme is voluntary.

• Professional individuals are those whose professions are included in this list;
• Non-professional individuals which include individual farmers and fisherfolk;
• Individuals who are separated from work;
• Parents not qualified as legal dependents, sponsored members or lifetime members;
• Children not qualified as legal dependents;
• Unemployed individuals not qualified as a sponsored member;
• Citizens of the Philippines residing in other countries;
• Citizens of other countries (foreigners) residing/or working in the Philippines.

Sponsored members are those who are being paid for by local government units, government agencies or private institutions which fall under the implementation of the government subsidy program. Members under this category are usually covered on a yearly basis. Availment of PhilHealth benefits depends on the effectivity or coverage period as reflected in their membership.

Lifetime members generally covers retirees/pensioners who have reached the retiring age as defined by law and have met the required 120 monthly PhilHealth premium contributions. Individuals under this classification no longer need to be paying members in order for them or their dependents to avail of PhilHealth benefits.

Overseas Filipino Workers (Land-based) were previously under the IPM category. Due to the differences in the needs of the members under this category and the efforts with which these were addressed, PhilHealth decided to separate the monitoring and evaluation of those individuals who are working out of the country, hence a separate category was created. OFWs are required to enroll and pay a one-year premium contribution prior to leaving the country and to continue being an active member, OFWs would need to pay continuously to the program after the expiry of the one-year coverage.

Reference: Title III-Section 5 of the Implementing Rules and Regulations of the National Health Insurance Act of 1995

Do you get deducted for premium contributions if you are not a PhilHealth member?

You can't NOT be a PhilHealth member if you're employed.

Membership, coverage, and premium contributions are compulsory/mandatory for those with employment (formal sector).

Reference: Title III, Rule I, Implementing Rules and Regulations of the National Health Insurance Act.