Emailed Questions: PhilHealth Benefits for Outpatient Surgery

Would like to inquire what/how much are the benefits/rates I can get for the outpatient surgery from PhilHealth.

Surgeon, anesthesiologist, actual procedure, OR, etc.

I may need to undergo arthroscopic surgery.

Thanks.

Name withheld

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We cannot give you the actual amount that you will receive from PhilHealth since it varies depending on a number of factors. However, you may use the benefit table here http://www.philhealth.gov.ph/forms/others/lifetime_benefits.pdf to compute for the approximate amount. Same PhilHealth benefits are being provided for all member categories.

Hope this helps.

PhilHealth 101

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How about if I can be reimbursed even if the hospital is not yet accredited?

I read in the site:

What if the hospital is not accredited? Will I still get paid?

Claims of members confined in non-accredited hospitals shall not be compensated unless all of the following conditions are met:

Case is emergency as determined by PhilHealth

The hospital or facility has a current DOH license

Physical transfer/referral to an accredited facility is impossible as determined by PhilHealth.

The hospital PGH FMAB is still undergoing the Philhealth accreditation. Will I still be reimbursed even if they are not yet accredited?

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If the hospital or doctor is not accredited PhilHealth may not reimburse the doctor's fee or the hospital charges. You can try to call the PhilHealth Office or call center for the status of the accreditation of your hospital or doctor. If you are to call the PhilHealth Office, directly look for the accreditation department and inquire the new accreditation period of your hospital. Moreover, if the hospital/doctor has submitted all required documents and PhilHealth approves the renewal, the start date of the accreditation period will be the date of submission of the document or the expiry date and since filing of the renewal application is before the expiration of the accreditation period, there is a chance of continuity of the accreditation and if this happens then you will be paid for hospital charges or professional fees.

PhilHealth 101

Note: Emailed questions may sometimes be edited for brevity and/or clarity.

What medical procedures are NOT covered by PhilHealth?

The following medical procedures are NOT covered by PhilHealth (at least not at the present time):

• Fifth and subsequent normal obstetrical deliveries;
• Non-prescription drugs and devices;
• Alcohol abuse or dependency treatment;
• Cosmetic surgery;
• Optometric services;
• Other cost-ineffective procedures as defined by PhilHealth.

Can a sponsored member continue his or her membership after it expires?

Yes.

Sponsored members are those whose premiums are paid for by local government units, government agencies, or perhaps private institutions, and whose membership lasts for one (1) year. After the expiration of the membership, the member has three options:

1. If the membership is not renewed, he/she can reapply for the sponsored program again with the Department of Social Welfare and Development (DSWD) who will evaluate the application and endorse it to a sponsor;
2. Continue the membership as an Individually Paying Member(IPM). To avoid any gap in his or her coverage, it is recommended that the member pay the Individually Paying Program (IPP) dues before the expiration of his or her sponsored membership;
3. If the member manages to find employment, the employer will pay half of his or her premiums and the member will shoulder the other half via salary deduction.

It is not unusual for a PhilHealth member to move between the different classes of PhilHealth membership in a lifetime.

For more information read this post.

When is the best time to transact with PhilHealth?

This post is intended to answer inquiries of some members on the office hours of PhilHealth or when is the best time to transact with PhilHealth.

Generally, you may transact with PhilHealth from Monday to Friday from 8:00 AM to 5:00 PM at any PhilHealth Office nationwide. The same office hours are also being implemented in the operation of PhilHealth's Call Center that can address your concerns through phone. PhilHealth Offices also comply with the legal and special holidays as declared by the government.

You should also avoid the periods below if you don't want to wait for a long time as there will be more persons transacting with PhilHealth during these periods:

• 10th day of the month - deadline of premium payment of employers;
• last day of the quarter - deadline of premium payment for individual members;
• 15th day of the month - deadline of submission of the employer remittance report.

Hopefully, you won't have too difficult a time transacting with PhilHealth. Also be sure to share your experiences with us through Facebook and/or Twitter so that we may help PhilHealth improve its services through your feedback.

Are doctors or hospitals allowed to directly deduct PhilHealth benefits from their fees?

Yes, doctors or hospitals are allowed to directly deduct PhilHealth benefits from their fees, (assuming they are accredited). However, this is not mandatory, hence members have the option to pay in full the doctor's fees or hospital charges and then directly reimburse from PhilHealth.

The doctor and the patient should come to terms with the following:

• Is the patient a PhilHealth member or dependent?
• How much is the doctor's fee (if not a PhilHealth member)?
• How much will be the PhilHealth deduction?
• Will the member opt to directly file reimbursement or will the member allow the doctor or hospital for the outright deduction or availment of PhilHealth benefits?

Please note that in the real world, physicians sometimes charge differently depending on whether the patient is a PhilHealth member or not, and sometimes, the deductions representing the PhilHealth benefits made by the doctor or the hospital do not reflect the maximum possible amount. For this reason, check the Benefit Payment Notice (BPN) that you will be receiving, You may use this document to validate if the amount deducted by the hospital and doctor tallies with the amount they received from PhilHealth. If the amount they received from PhilHealth is greater than the amount they have deducted, then you may request for a refund from the hospital and the doctor. If the balance was returned to PhilHealth you may contact the PhilHealth Office near you.

For other tips regarding availment of PhilHealth claims, you can read this blog post.

How long does it take PhilHealth to process a claim?

Sixty (60) days.

If the claim is under investigation, it may take longer.

Reference: Sec. 3 j) R.A. 7875, Sec. 47 o., IRR of R.A. 7875

Can registration, PIN inquiry, viewing of contributions be done online?

Unfortunately, the answer at this time is no.

Online services are still not available for the following PhilHealth Services:

• Member registration or amendment/updating of member profile;
• Employer registration (currently in development through the DTI-PBR facility);
• Inquiry of contributions or premium payment;
• Inquiry on status of claim or benefit availment;
• Checking of existing PhilHealth Identification Number (PIN) (The previous mobile service is no longer available).

Online Services or Facilities that are available are:

• Electronic Premium Reporting System (EPRS) that facilitates the preparation and submission of the Monthly Employer Remittance Report (RF-1/RF1) online;
• PhilHealth-DepEd Textfile Uploading Facility that facilitates registration of DepEd employees and submission of the RF-1/RF1;
• eGroup System used by the organized groups such as the MFIs, Cooperatives and others participating in the KaSAPI Program which facilitates enrollment of their members and payment of their members' premiums.

We will be posting updates if the available online facilities change.

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.

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.

If I lapsed with my 1st quarter PhilHealth payment can i still pay it?

Normally, no.

There are exceptions though.

As per PhilHealth Circular No. 06, series of 2001, retroactive payments are not allowed except when a member can show proof of sufficient regularity of premium contributions or payment of nine (9) consecutive months or three consecutive quarters within the last 12 months prior to the missed quarter. If you meet this condition, you shall be given a grace period of one month immediately after the missed quarter to pay retroactively including the current calendar quarter.

For newly enrolled members (with less than 12 months reckoned from date of enrollment), retroactive payment for the missed quarter including the current calendar quarter shall also be allowed within the month immediately following the missed period.

This privilege is granted only once every 12 months.

Reference: PhilHealth IPM FAQs.

However, even if you miss a quarterly payment, you may still be eligible to avail of PhilHealth benefits if there is sufficient regularity.

Save yourself the worry and just pay your premiums on time.

If I lapse one month PhilHealth payment within a year can I still avail of PhilHealth benefits?

Yes.

The keyword is sufficient regularity.

Can I cancel my PhilHealth membership to be a dependent?

It depends. If you meet the requirements to be a dependent, yes. If not, no.

Does PhilHealth cover medicines?

Yes. But not all.

Paid PhilHealth for the first time, can I use it immediately?

No.

Addendum: Unless you're an OFW.

Can my brother or sister be my dependent in PhilHealth?

No.

Is Philhealth a mandatory requirement for working abroad?

Yes.

Is it important?

Yes.

Are all OFWs happy about this?

Apparently, no.

Can a deactivated Philhealth member qualify as Philhealth dependent of her spouse?

Yes.

Where Do I Pay my Premium Contributions?

If you were wondering where to pay your premium contributions aside from the PhilHealth Offices, check out the List of Accredited Collecting Agents below.

LOCAL

BANKS

• Allied Banking Corporation
• Asia Trust Bank
• Asia United Bank
• Asian Hills Bank, Inc.
• Banco de Oro - EPCI
• Bank of Commerce
• Bank One Savings and Trust Corp.
• Bukidnon Cooperative Bank
• Century Rural Bank, Inc.
• Century Savings Bank
• China Banking Corporation
• Citibank N. A.
• Citystate Savings Bank
• Country Rural Bank of Taguig, Inc.
• Development Bank of the Phils.
• Enterprise Bank, Inc.
• Export & Industry Bank
• Green Bank of Caraga (A Rural Bank)
• Gulf Bank (Rural Bank of Lingayen, Inc.)
• Land Bank of the Philippines
• Maybank of the Philippines, Inc.
• Metropolitan Bank and Trust Company*
• Money Mall Rural Bank, Inc.
• One Network Bank, Inc.
• Peninsula Rural Bank, Inc.
• People's Bank of CARAGA
• Philippine Business Bank
• Philippine National Bank
• Philippine Postal Savings Bank
• Philippine Veterans Bank
• Planters Development Bank
• Premiere Development Bank
• Producer's Rural Banking Corp.
• Progressive Bank
• RCBC Savings Bank
• Rizal Commercial Banking Corp.
• Robinson's Savings Bank
• Rural Bank of Bambang (NV), Inc.
• Rural Bank of Jose Panganiban (CN), Inc.
• Rural Bank of Sta. Catalina (Negros Oriental), Inc.
• Security Bank
• United Coconut Planters Bank

NON-BANKS

• CIS Bayad Center (see Branch List)
• Philippine Postal Corporation (for Regions 2, 4A, 4B, V, VI, VIII, X, XI & XII)
• E-Soluzione (thru the Remittance By Air Project)
• MLhuillier Phils. Inc. (Region VI only)
• LBC Express Inc.
• Local Government Units
• SM Branches (Cubao, Megamall, South Mall, Makati, North Edsa, Fairview and MOA)

- Region IV-A

> Calauag, Quezon
> Catanauan, Quezon
> Guinayangan, Quezon
> Perez, Quezon
> San Narciso, Quezon

> Tagkawayan, Quezon

> Unisan, Quezon
- Region IV-B

> Taytay, Palawan

- Region VIII

> Bato, Leyte

> Laoang, Samar

> Leyte, Leyte

- Region X

> Calamba, Misamis Oriental

> Initao, Misamis Oriental

> Kibawe, Bukidnon

- Region XII

> Banicilan, Cotabato Province

OVERSEAS

• Development Bank of the Philippines (tie-ups)
• Philippine Veterans Bank (tie-ups)
• i-Remit, Inc. (branches/tie-ups)

For Employers under the Electronic Payment Schemes (ePAY) refer to the next post.