PICPA 67th ANC

Government Sector Forum

PHILHEALTHS GAME
PLAN TOWARDS UHC
Balanghai Hotel, Butuan City
November 29, 2012

RENATO L. LIMSIACO, JR. CPA, DM

Head, Employed Segment, PhilHealth

PhilHealths Game Plan Towards UHC

STEPS TO UHC

THE GAME PLAN

Increasing
financing for
health care

Dominate the
market

Ensuring supply
side improvements
Using demand-side
approach by
health insurance
coverage

SHAPE market
behavior
towards greater
EFFICIENCY,
EQUITY and
SECURITY

UHC IN A
CAPSULE

BAWAT
PILIPINO,
MIYEMBRO
BAWAT
MIYEMBRO,
PROTEKTADO
KALUSUGAN
NATIN,
SEGURADO

PhilHealth Benefits Expansion Framework

COMPREHENSIVE

RESPONSIVE

RIGHTS-BASED

OPERATIONALIZATION

For the young and old alike

Covers preventive, primary to curative services
Covers the cheapest to the most expensive (A to Z)

Considers the burden of illness of the country

Non-transactional

Accessible, affordable, appropriate,

Ensures continuity of care

Easy to understand and empowering

Uses innovative payment schemes

PhilHealth BenefitsBenefits
HIGHLIGHTS HIGHLIGHTS
PhilHealth

Benefit Schedule

Case Rates
Medical Cases

Halaga ng
Benepisyo

Dengue I (dengue fever at dengue hemorrhagic fever Grades I & II)

P 8,000

Dengue II (dengue fever at dengue hemorrhagic fever Grades III & IV)

16,000

Pneumonia I o Pulmonya (moderate risk)

15,000

Pneumonia II o Pulmonya

32,000

(high risk)

Essential Hypertension

9,000

Cerebral Infarction (CVA I)

28,000

Cerebro-vascular Accident with Hemorrhage (CVA II)

38,000

Acute Gastroenteritis (AGE)

6,000

Asthma o Hika

9,000

Typhoid Fever o Tipus

Newborn Care Package
-Maari ring ma-avail sa mga accredited lying-in clinics

14,000
1,750
6

Case Rates
Surgical Procedures
Radiotherapy
Hemodialysis
Maternity Care Package (MCP)
Normal Spontaneous Delivery Package sa Level 1
Hospitals

Halaga ng
Benepisyo
P 3,000
4,000
8,000
8,000

(Panganganak ng Normal)

Normal Spontaneous Delivery Package sa Levels 2, 3,

& 4 Hospitals (Panganganak ng Normal)
Cesarean Section
Appendectomy
Cholecystectomy
Dilatation at Cutterage o Raspa
Thyroidectomy
Herniorrhaphy
Mastectomy
Hysterectomy

6,500
19,000
24,000
31,000
11,000
31,000
21,000
22,000
30,000

Case Rates
P11,000

coverage para sa
LEPTOSPIROSIS

P4,000

P600

coverage para sa TB-DOTS

na ina-admister ng mga
accredited TB-DOTS centers

coverage para sa malaria

treatment sa mga accredited
rural health units

P30,000/taon

coverage para sa outpatient

HIV/AIDS treatment bawat taon

PhilHealth Z Benefit Rates

Z condition

Proposed Rates

Acute lymphocytic leukemia

(children)

P 210 K
(for 3 years of treatment)

Breast Cancer
(Stage 0 to IIIA)

P 100 K

Prostate Cancer
(low to intermediate risk)

P 100 K

Kidney Transplant
(low risk)

P 600 K

GLOBAL BUDGET PAYMENT PROGRAM

Which means Next YEAR,

if your employees children need to
be confined in non-private rooms in
this hospital, and others like it
THEY WILL NOT HAVE
TO PAY
A SINGLE CENTAVO
UPON BEING DISCHARGED

PhilHealth Benefits Expansion

PRIMARY CARE
BENEFIT PACKAGE

Assignment of
members to a
Primary Care
Provider
Monitoring and
profiling of
members
(+incentive)
Submission of
timely and
complete data,
electronically

ACCESS BENEFIT

CASE TYPE Z
BENEFIT PACKAGE

Breast Cancer (St.

1-3a)
Childhood
Leukemia (ALL)
Prostate Cancer
requiring
Prostatectomy
Renal
Transplantation
(low risk)

SHIFT TO ALL
CASE RATES

Strengthen
implementation
of Zero CoPayment scheme

Global Benefit Payment Scheme to contracted hospitals

ACCREDITATION
INSTITUTIONAL Health Care Providers (IHCP)
As of June 30, 2012

Accredited
Hospitals

Center of
Safety
(COS)

Center of
Quality
(COQ)

Center of
Excellence (COE)

Provisional

Total

1,128

271

74

184

1,657

Primary Care
Benefit Package

Maternity Care
Package

DOTS Package

Number of Accredited
Outpatient Clinics

1,656

1,183

1,165

No. of cities & municipalities

with Accredited OP Clinics*

1,233

632

865

% to total cities &

municipalities

75%

39%

53%

ACCREDITATION
PROFESSIONAL Health Care Providers (PHCP)
As of June 30, 2012

Professional

Number

General Practitioner

11,669

Medical Specialist

13,624

Dentist

215

Midwife

648

Grand Total

26,156

Premium Schedule for Employed Sector

Item A. 1999-2006 1999-2012
Personal
Share (PS)
(PS = SB x
1.25%)

Employer
Share (ES)
ES = PS

P 50.00

P 50.00

125.00

62.50

62.50

6,000.00

150.00

75.00

75.00

7,000.00 to 7,999.99

7,000.00

175.00

87.50

87.50

8,000.00 to 8,999.99

8,000.00

200.00

100.00

100.00

9,000.00 to 9,999.99

9,000.00

225.00

112.50

112.50

10,000.00 to 10,999.99

10,000.00

250.00

125.00

125.00

11,000.00 to 11,999.99

11,000.00

275.00

137.50

137.50

12,000.00 to 12,999.99

12,000.00

300.00

150.00

150.00

10

13,000.00 to 13,999.99

13,000.00

325.00

162.50

162.50

11

14,000.00 to 14,999.99

14,000.00

350.00

175.00

175.00

12

15,000.00 to 15,999.99

15,000.00

375.00

187.50

187.50

13

16,000.00 to 16,999.99

16,000.00

400.00

200.00

200.00

14

17,000.00 to 17,999.99

17,000.00

425.00

212.50

212.50

15

18,000.00 to 18,999.99

18,000.00

450.00

225.00

225.00

16

19,000.00 to 19,999.99

19,000.00

475.00

237.50

237.50

Monthly
Salary
Bracket

Monthly Salary
Range

Salary Base
(SB)

P 4,999.99 and below

P 4,000.00

5,000.00 to 5,999.99

5,000.00

6,000.00 to 6,999.99

Total Monthly
Contribution
P 100.00

PhilHealth Circular No. 01, s-2005 dated 14 January 2005

Item B. Addl brackets for 2007-2012

Monthl
y
Salary
Bracket

Monthly Salary
Range

Salary Base
(SB)

Total Monthly
Contribution

Personal
Share (PS)
(PS = SB x
1.25%)

Employer
Share (ES)
ES = PS

17

20,000.00 to 20,999.99

20,000.00

500.00

250.00

250.00

18

21,000.00 to 21,999.99

21,000.00

525.00

262.50

262.50

19

22,000.00 to 22,999.99

22,000.00

550.00

275.00

275.00

20

23,000.00 to 23,999.99

23,000.00

575.00

287.50

287.50

21

24,000.00 to 24,999.99

24,000.00

600.00

300.00

300.00

22

25,000.00 to 25,999.99

25,000.00

625.00

312.50

312.50

23

26,000.00 to 26,999.99

26,000.00

650.00

325.00

325.00

24

27,000.00 to 27,999.99

27,000.00

675.00

337.50

337.50

25

28,000.00 to 28,999.99

28,000.00

700.00

350.00

350.00

26

29,000.00 to 29,999.99

29,000.00

725.00

362.50

362.50

27

30,000.00 and up

30,000.00

750.00

375.00

375.00

Implementation of the NEW Premium Rates for the Employed Sector

Effective January 1, 2013*

Monthly Salary Range

Php 7,000.00 and below

Php 7,000.00 up to
Php 50,000.00
Php 50,000.00 and above
* Deferred to 2014

Premium
Rate

Personal
Share

Employer
Share

210.00

105.00

105.00

3%

1.5%

1.5%

1,500.00

750.00

750.00

Why 3%
Effective January 1, 2013*
The vision of reducing the out-of-pocket expenses by
providing enhanced and higher benefits to the members and
their dependents.
The Sponsored program had already remitted and paid the
increased premium rate (from P100 P200 or from
P1,200.00 to P2,400.00 per year) since July 2012.
About time for the Employed Sector to have its premiumrates-schedule be increased from 2.5 to 3% of the basic
monthly salary in accordance with Section 28 paragraph (a)
& (c) of RA 7875.
N.B. Contributions made in behalf of indigent members shall
not exceed the minimum contributions set for employed
members (Sec 28 par. (c) of RA 7875)

Premium Increase
Deferment

Premium Schedule for Employed Sector

2013

Monthly
Salary
Bracket

Monthly Salary
Range

Salary Base
(SB)

Total Monthly
Contribution

Personal
Share (PS)
(PS = SB x
1.25%)

Employer
Share (ES)
ES = PS

7,000.00 and below

7,000.00

175.00

87.50

87.50

8,000.00 to 8,999.99

8,000.00

200.00

100.00

100.00

9,000.00 to 9,999.99

9,000.00

225.00

112.50

112.50

10,000.00 to 10,999.99

10,000.00

250.00

125.00

125.00

11,000.00 to 11,999.99

11,000.00

275.00

137.50

137.50

12,000.00 to 12,999.99

12,000.00

300.00

150.00

150.00

13,000.00 to 13,999.99

13,000.00

325.00

162.50

162.50

14,000.00 to 14,999.99

14,000.00

350.00

175.00

175.00

15,000.00 to 15,999.99

15,000.00

375.00

187.50

187.50

10

16,000.00 to 16,999.99

16,000.00

400.00

200.00

200.00

11

17,000.00 to 17,999.99

17,000.00

425.00

212.50

212.50

12

18,000.00 to 18,999.99

18,000.00

450.00

225.00

225.00

13

19,000.00 to 19,999.99

19,000.00

475.00

237.50

237.50

Personal Share
(PS)
Total Monthly
Contribution
(PS = SB x
1.25%)

Employer
Share (ES)

Monthly Salary

Salary Base

Range

(SB)

14

20,000.00 to 20,999.99

20,000.00

500

250

250

15

21,000.00 to 21,999.99

21,000.00

525

262.5

262.5

16

22,000.00 to 22,999.99

22,000.00

550

275

275

18

23,000.00 to 23,999.99

23,000.00

575

287.5

287.5

19

24,000.00 to 24,999.99

24,000.00

600

300

300

20

25,000.00 to 25,999.99

25,000.00

625

312.5

312.5

21

26,000.00 to 26,999.99

26,000.00

650

325

325

22

27,000.00 to 27,999.99

27,000.00

675

337.5

337.5

23

28,000.00 to 28,999.99

28,000.00

700

350

350

24

29,000.00 to 29,999.99

29,000.00

725

362.5

362.5

25

30,000.00 to 30,999.99

30,000.00

750

375

375

26

31,000.00 to 31,999.99

31,000.00

775

387.5

387.5

27

32,000.00 to 32,999.99

32,000.00

800

400

400

28

33,000.00 to 33,999.99

33,000.00

825

412.5

412.5

29

34,000.00 to 34,999.99

34,000.00

850

425

425

30

35,000.00 and up

35,000.00

875

437.5

437.5

Monthly Salary
Bracket

ES = PS

Strengthening
Organizational Efficiency
and Service Delivery

PhilHealth Employed Segment Initiatives

PHILHEALTH ACCOUNTS MANAGEMENT STRATEGY
(PAMS)
1.
2.
3.
4.

Assignment of a PhilHealth-AIMS (Account Officer) to a particular Employer

Provide services such as enrollment/updating of membership, remittance and
reporting
Empowerment of PhilHealth Employers Engagement Representatives (PEER)
Conduct of members empowerment activity.

ELECTRONIC PREMIUM REPORTING SYSTEM

(EPRS)
1. Provides the Employer access to PhilHealth Database
2. Allows Employer to generate Statement of Account prior to Payment;
3. Allows Employer to pay electronically through accredited banks;
4. Allows automatic posting of premium payments into the collections database;
5. Does away with MDR, adopt Electronic Claim Forms (eCF 1) for benefit
availment.

PhilHealth AIMS

P-AIMS is tasked to build a strong,

lasting and meaningful relationship
with the employers.

22

PhilHealth Employers Engagement Representatives

(PEERs)
A person identified and authorized by an
employer to be given acess to EPRS.

An employee of the
represented
employer
Primary contact
person of the PAIMS

Enrollment

Collection

17
LOCAL

OFFICES
Health Care
Provider
Engagement

Claims
Processing

REGIONAL
OFFICES

106

5000

OFFICERS

STAF F

FILIPINOS

100,000,000

Marketing Initiatives
Increase
convenience &
improve service
delivery
Reaching out to
new markets &
audiences

Alone we can do so
little;
together we can do
so much.
Helen Keller

Thank You!

Renato L. Limsiaco, Jr.

Cel no. 09173065138, email ad: rllimsiacojr@yahoo.com