philhealth

Agency's Mandate and Functions

Mandate
The National Health Insurance Program was established to provide health insurance coverage and
ensure affordable, acceptable, available and accessible health care services for all citizens of the
Philippines. It shall serve as the means for the healthy to help pay for the care of the sick and for
those who can afford medical care to subsidize those who cannot. It shall initially consist of
Programs I and II or Medicare and be expanded progressively to constitute one universal health
insurance program for the entire population. The program shall include a sustainable system of
funds constitution, collection, management and disbursement for financing the availment of a basic
minimum package and other supplementary packages of health insurance benefits by a
progressively expanding proportion of the population. The program shall be limited to paying for the
utilization of health services by covered beneficiaries. It shall be prohibited from providing health
care directly, from buying and dispensing drugs and pharmaceuticals, from employing physicians
and other professionals for the purpose of directly rendering care, and from owning or investing in
health care facilities. (Article III, Section 5 of RA 7875 as amended)

Powers and Functions

PhilHealth is a tax-exempt Government Corporation attached to the Department of Health for policy
coordination and guidance. (Article IV, Section 15 of RA 7875 as amended). It shall have the
following powers and functions (Article IV, Section 16 of RA 7875 as amended by RA 10606):
a) To administer the National Health Insurance Program;
b) To formulate and promulgate policies for the sound administration of the Program;
c) To supervise the provision of health benefits and to set standards, rules and regulations
necessary to ensure quality of care, appropriate utilization of services, fund viability, member
satisfaction, and overall accomplishment of Program objectives;
d) To formulate and implement guidelines on contributions and benefits; portability of benefits, cost
containment and quality assurance; and health care provider arrangements, payment, methods, and
referral systems;
e) To establish branch offices as mandated in Article V of this Act;
f) To receive and manage grants, donations, and other forms of assistance;
g) To sue and be sued in court;
h) To acquire property, real and personal, which may be necessary or expedient for the attainment of
the purposes of this Act;
i) To collect, deposit, invest, administer, and disburse the National Health Insurance Fund in
accordance with the provisions of this Act;

j) To negotiate and enter into contracts with health care institutions, professionals, and other
persons, juridical or natural, regarding the pricing, payment mechanisms, design and implementation
of administrative and operating systems and procedures, financing, and delivery of health services in
behalf of its members;
k) To authorize Local Health Insurance Offices to negotiate and enter into contracts in the name and
on behalf of the Corporation with any accredited government or private sector health provider
organization, including but not limited to health maintenance organizations, cooperatives and
medical foundations, for the provision of at least the minimum package of personal health services
prescribed by the Corporation;
l) To determine requirements and issue guidelines for the accreditation of health care providers for
the Program in accordance with this Act;
m) To visit, enter and inspect facilities of health care providers and employers during office hours,
unless there is reason to believe that inspection has to be done beyond office hours, and where
applicable, secure copies of their medical, financial, and other records and data pertinent to the
claims, accreditation, premium contribution, and that of their patients or employees, who are
members of the Program;
n) To organize its office, fix the compensation of and appoint personnel as may be deemed
necessary and upon the recommendation of the president of the Corporation;
o) To submit to the President of the Philippines and to both Houses of Congress its Annual Report
which shall contain the status of the National Health Insurance Fund, its total disbursements,
reserves, average costing to beneficiaries, any request for additional appropriation, and other data
pertinent to the implementation of the Program and publish a synopsis of such report in two (2)
newspapers of general circulation;
p) To keep records of the operations of the Corporation and investments of the National Health
Insurance Fund;
q) To establish and maintain an electronic database of all its members and ensure its security to
facilitate efficient and effective services;
r) To invest in the acceleration of the Corporations information technology systems;
s) To conduct information campaign on the principles of the NHIP to the public and to accredited
health care providers. This campaign must include the current benefit packages provided by the
Corporation, the mechanisms to avail of the current benefit packages, the list of accredited and
disaccredited health care providers, and the list of offices/branches where members can pay or
check the status of paid health premiums;
t) To conduct post audit on the quality of services rendered by health care providers;
u) To establish an office, or where it is not feasible, designate a focal person in every Philippine
Consular Office in all countries where there are Filipino citizens. The office or the focal person shall,
among others, process, review and pay the claims of the overseas Filipino workers (OFWs);
v) Notwithstanding the provisions of any law to the contrary, to impose interest and/or surcharges of
not exceeding three percent (3%) per month, as may be fixed by the Corporation, in case of any

delay in the remittance of contributions which are due within the prescribed period by an employer,
whether public or private. Notwithstanding the provisions of any law to the contrary, the Corporation
may also compromise, waive or release, in whole or in part, such interest or surcharges imposed
upon employers regardless of the amount involved under such valid terms and conditions it may
prescribe;
w) To endeavour to support the use of technology in the delivery of health care services especially in
farflung areas such as, but not limited to, telemedicine, electronic health record, and the
establishment of a comprehensive health database;
x) To monitor compliance by the regulatory agencies with the requirements of this Act and to carry
out necessary actions to enforce compliance;
y) To mandate the national agencies and LGUs to require proof of PhilHealth membership before
doing business with a private individual or group;
z) To accredit independent pharmacies and retail drug outlets; and
aa) To perform such other acts as it may deem appropriate for the attainment of the objectives of the
Corporation and for the proper enforcement of the provisions of this Act.

Vision
"Bawat Pilipino, Miyembro,
Bawat Miyembro, Protektado,
Kalusugan Natin, Segurado"

Mission
"Sulit na Benepisyo sa Bawat Miyembro,
Dekalidad na Serbisyo para sa Lahat"

Core Values
Inobasyon
Serbisyong Dekalidad
Lubos na Integridad
Angkop na Benepisyo
Panlipunang Pagkakabuklod at
Ganap na Pagkalinga

Definition

National Health Plan is a long-term directional plan for health; the blueprint defining the countrys
health PROBLEMS, POLICY THRUSTS STRATEGIES, THRUSTS

Goal

to enable the Filipino population to achieve a level of health which will allow Filipino to lead a
socially and economically-productive life, with longer life expectancy, low infant mortality, low
maternal mortality and less disability through measures that will guarantee access of everyone to
essential health care

Objectives

promote equity in health status among all segments of society

address specific health problems of the population

upgrade the status and transform the HCDS into a responsive, dynamic and highly efficient, and
effective one in the provision of solutions to changing the health needs of the population

promote active and sustained peoples participation in health care

Matagal nang proposal ng Philippine Health Insurance Corp. (PHILHEALTH or PHIC) ang
pagbabayad ng 22 medical and surgical cases on a Case-Rate Basis, at hindi na on a Fee-forService basis. Ibig sabihin, magkakaroon nang fixed Philhealth payment for each of the 22
cases, kahit saang accredited hospital, kahit sinong accredited doctor, at kahit ilang araw ang
hospitalization or treatment.
Itong 22 cases ang pinakamadalas na binabayaran ng Philhealth for the past several years.
Almost 50 percent daw ng Philhealth claims ay itong mga 22 cases na ito.
Proposal pa lang ito, at pinag-uusapan pa ng Philhealth board. According to some press
releases, this Case-Rate-Basis will be implemented SOON.
UPDATE: Philhealth has already announced that it will start implementing the Case Rates
Payment scheme for hospital/clinic admissions starting September 1, 2011. Certain proposed
rates have been increased. The amounts in blue color are the final rates.
Another UPDATE: Philhealth announced that the Case Rates payments for surgical cases are
applied to hospitalizations in Levels 2, 3 and 4 hospitals only (bigger hospitals), except for certain
cases.
These are the surgical and medical cases, and the corresponding fixed rates or
payments/reimbursements by Philhealth.
Medical Cases:
1. Dengue Fever and DHF Grades 1 and 2 8,000 pesos
2. DHF Grades 3 and 4 16,000
3. Pneumonia 1 15,000
4. Pneumonia 2 32,000
5. Essential hypertension 9,000
6. Cerebral infarction (CVA I) 28,000
7. Cerebro-vascular accident hemorrhage (CVA II) 38,000
8. Acute gastroenteritis (AGE) 6,000

9. Asthma 9,000
10. Typhoid fever 14,000
11. Newborn care package (NCP) 1,000 increased to 1,750
Surgical Cases:
1. Radiotherapy 3,000 pesos
2. Hemodialysis 4,000
3. Normal delivery or maternity care package (MCP) in maternity or lying-in clinics 8,000
Normal spontaneous delivery (NSD) in Level 1 hospitals 8,000
Normal spontaneous delivery (NSD) Levels 2 to 4 hospitals 6,500
4. Delivery by caesarian section (CS) 15,000 increased to 19,000
5. Appendectomy 26,000 decreased to 24,000
6. Cholecystectomy 31,000

7. Hysterectomy 30,000
8. Dilatation and curettage 11,000
9. Thyroidectomy 31,000
10. Herniorrhapy 21,000
11. Mastectomy 22,000

* Note: For SURGERIES, the Case Rates payment will apply only to cases managed in Levels 2
to 4 hospitals, with certain exceptions.

According to Philhealth, the advantages of Case-Rate-Basis are the following:

Fixed payments regardless of hospital size and length of treatment
No more itemization of costs
Reduction in claim processing costs
Faster payment of claims
Lower financial risk for Philhealth
Reduction of fraud risk

This proposed Philhealth program is also called No Balance Bill Policy because it seeks to
cover the full costs of the medical and surgical procedures in accredited government hospitals.
Ang gusto nilang mangyari ay lalabas ang pasyente na walang babayaran sa government
hospital na Philhealth-accredited.

Example 1:

Diagnosis is Pneumonia (Moderate Risk).

The Philhealth benefit for this is 15,000 pesos

(10,500 pesos for hospital expenses, medicines and supplies and 4,500 pesos for doctors fees).

You bought 3,000 pesos worth of medicines and supplies outside the hospital.

Your hospital bill is 7,000 pesos. You were not asked to pay anythingbecause the 10,500
allocation is more than enough to pay this 7,000 pesos.

How about the 3,000 pesos you spent?

You still have available allocation (10,500 pesos 7,000 pesos = 3,500 pesos).

Keep your prescriptions, ORs, and your hospital bill, and when you receive your BPN, return to
the hospital and request for your refund.

ORs must be in the name of the patient. Xerox your documents.

But a member or his family does not need to be sick before they can experience PhilHealth with its
strengthened Primary Care Benefit Package which is now called by the name TSeKaP or Tamang
Serbisyong Kalusugang Pampamilya. TSeKaP aims to assign every entitled family to a primary care
doctor for annual consults, provide diagnostic tests (as needed) as well as preventive and promotive
services in rural health units.
Soon, medicines for diabetes, hypertension and dyslipidemia shall be included in the second wave
of expansion.
TSeKaP is initially available to sponsored and indigent members, land-based overseas workers and
iGroup Gold members and their qualified dependents. It is now being pilot tested with the
Department of Education for its teaching and non-teaching personnel nationwide. This will soon be
extended to the rest of NHIP membership in due time.
But beyond the usual questions on benefits, PhilHealth impresses a very important concept that
every responsible member should also learn by heart. This is the spirit of solidarity between
members wherever they are in the world. This spirit is realized by the coming together and pooling of
meager resources to a national health insurance fund, enabling sick members to avail of financial
help from the rest of the membership. In effect, members who at the moment are healthy and illnessfree are able to help others through their contributions to the fund indeed a classic case of
bayanihan system where everyone bears the weight of needy members.

Tamang Serbisyo Para sa Kalusugan ng Pamilya (TSeKaP)

i. Preventive Services
1. 1. Consultation
2. 2. Visual inspection with acetic acid
3. 3. Regular BP measurements
4. 4. Breastfeeding program education

5. 5. Periodic clinical breast examinations

6. 6. Counseling for lifestyle modification
7. 7. Counseling for smoking cessation
8. 8. Body measurements
9. 9. Digital rectal examination

ii. Diagnostic Examinations (as recommended by the doctor)

1. 1. Complete blood count
2. 2. Urinalysis
3. 3. Fecalysis
4. 4. Sputum microscopy
5. 5. Fasting blood sugar
6. 6. Lipid Profile
7. 7. Chest x-ray

iii. Drugs and Medicines

1. 1. Asthma including nebulisation services
2. 2. Acute Gastroenteritis (AGE) with no or mild dehydration
3. 3. Upper Respiratory Tract Infection (URTI)/Pneumonia (minimal and low risk)
4. 4. Urinary Tract Infection (UTI)

Payments for these services are made to the primary care provider through Per Family
Payment Rate (PFPR)

Availment condition: Indigent and Sponsored Members, as well as migrant workers and their
legal dependents should avail of these benefits within the effectivity of their coverage as indicated in
their PhilHealth ID cards or Member Data Records. iGroup (Gold) members may avail themselves of
these benefits within the validity of their group policy contracts, while DepEd personnel may avail
themselves of the benefits as long as they are still active members of PhilHealth

Documents needed: Copy of Member Data Record or PhilHealth ID

Where available: accredited rural health units, health centers or outpatient departments of
selected government hospitals where members are enlisted

New Case Rate Packages from PhilHealth August 18, 2011

NEW case rate packages for selected medical conditions and surgical procedures will soon be
available in institutional health care facilities accredited by the Philippine Health Insurance
Corporation (PhilHealth).
According to PhilHealth President and CEO Dr. Rey B. Aquino, "the shift from fee-for-service to case
rates for these medical and surgical cases was prompted by developments taking place in the health
care industry, most notable of which is the need to provide optimal financial risk protection especially
to the most vulnerable groups, including the poorest of the poor." He added that better member
appreciation and faster reimbursement of fees to health care providers were also among the major
considerations for introducing this new type of provider payment scheme.
The use of case rates is an internationally accepted payment mechanism that serves to package
payment for health interventions. Through this mechanism, members will be able to predict how
much PhilHealth will be paying for each of the services provided. "Gone are the days when we could
not even give a definite amount of benefits for each of these common medical conditions and
surgical procedures," Aquino said, adding that "...now, the member is empowered with just the right
amount of information he needs for a particular disease or illness."
Among the medical cases and the corresponding package rates are Dengue I (P8,000.00), Dengue
II (P16,000.00), Pneumonia I (P15,000.00), Pneumonia II (P32,000.00), Essential Hypertension
(P9,000.00), Cerebral Infarction (CVA I, P28,000.00), Cerebro-vascular Accident with Hemorrhage
(CVA II, P38,000.00), Acute Gastroenteritis (P6,000.00), Asthma (P9,000.00), Typhoid Fever
(P14,000.00), and Newborn Care Package in Hospitals and Lying-in clinics (P1,750.00).
On the other hand, the surgical procedures include Radiotherapy (P3,000.00 per session),
Hemodialysis (P4,000.00 per session), Maternity Care Package (MCP, P8,000.00) coupled with the
Normal Spontaneous Delivery (NSD) Package in Level 1 (P8,000.00) and Levels 2-4 hospitals
(P6,500.00), Caesarian Section (P19,000.00), Appendectomy (P24,000.00), Cholecystectomy
(P31,000.00), Dilatation and Curettage (P11,000.00), Thyroidectomy (P31,000.00), Herniorrhaphy
(P21,000.00), Mastectomy (P22,000.00), Hysterectomy (P30,000.00) and Cataract Surgery
(P16,000.00).
Aquino said the new case rate packages are available for all member-types admitted in any of the
accredited institutional health care providers nationwide starting September 1. He, however,
emphasized that "...for our Sponsored Program members who are admitted in government hospitals,
the "No Balance Billing" (NBB) policy applies, meaning no other fees nor expenses shall be charged
to or paid for by the patient-member above and beyond the package rate."
The NBB policy shall also apply to any other member type such as the employed, individually paying
and overseas workers, who will avail themselves of the MCP and NCP in all accredited MCP nonhospital providers such as maternity clinics, and birthing homes.
"This policy was approved after a series of consultations with concerned medical societies and other
institutional partners. These conditions and procedures were also among the top 49 percent of total
claims we paid for over the previous years," the PhilHealth Chief noted. With all of these packages in
place, the government agency needs about P3 billion for the next six to 12 months once members
start availing themselves of the packages early next month. (END)
PhilHealth Benefit Packages - Case Payment Rates

This post contains a list of benefit packages, under the case payment scheme, that are
available to active PhilHealth members.
Name of Benefit Package

Case Rate (Php)

Maternity Care Package (MCP)

6,500.00

Normal Spontaneous Delivery (NSD) Package

6,500.00

TB-DOTS Package

4,000.00

SARS Package

50,000 - 100,000

Avian Influenza Package

50,000 - 100,000

New Born Care Package (NCP)

1,000.00

Bilateral Tubal Ligation (BTL) Package

4,000.00

Vasectomy Package

4,000.00

Malaria Package

600.00

Influenza A (H1N1) Package

75,000 - 100,000

NSD with BLT Package

10,500.00

Outpatient HIV / AIDS Treatment Package

30,000.00

Dengue I (dengue fever and DHF Grades I and II)*

8,000.00

Dengue II (dengue hermorrhagic fever grades III and IV)*

16,000.00

Pneumonia I (moderate risk)*

15,000.00

Pneumonia II (high risk)*

32,000.00

Essential Hypertension*

9,000.00

Cerebral Infarction (CVA I)*

28,000.00

Cerebro - vascular Accident with Hemorrhage (CVA II)*

38,000.00

Acute Gastroenteritis (AGE)*

6,000.00

Typhoid Fever*

14,000.00

Asthma*

9,000.00

Cesarian Section (CS)*

19,000.00

Dilatation and Curettage (D&C)*

11,000.00

Hysterectomy*

30,000.00

Mastectomy*

22,000.00

Appendectomy*

24,000.00

Cholecystectomy*

31,000.00

Herniorrhaphy*

21,000.00

Thyroidectomy*

31,000.00

Radiotherapy*

3,000.00

Hemodialysis*

4,000.00

Cataract Package*

16,000.00

* PhilHealth will be directly paying the health care facility inclusive of the professional fee,
hence, this is directly deducted to the bill of the eligible PhilHealth member.