‘BenepisyongPhilHealth, Alamin at Gamitin’

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The Philippine Health Insurance Corporation (PhilHealth) is marking its 19th year as a state-run agency mandated to administer the National Health Insurance Program (NHIP).

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It was on February 14, 1995 when then President Fidel V. Ramos signed into law Republic Act 7875 as amended, signaling the birth of a whole new program that caters not only to a few sectors but the entire Filipino population.

The mandate is clear: universality in the strictest terms because the law provides that “… the State shall provide comprehensive health care services to all Filipinos through socialized health insurance program…”.

Such gargantuan task is daunting but judging by the parade of successes and groundbreaking accomplishments in the past 19 years, PhilHealth has rightfully earned its place in the hearts and consciousness of the populace here and even beyond our shores. How can one ignore the fact that to date, eight of every ten Filipinos are already registered to the program? The latest count (December 2013) placed PhilHealth’s membership at 77 million which accounts for close to 80 percent of the total projected population of 97 million.

The promise is simple: it is providing Filipinos with the needed financial protection when illnesses arise in the family. People now equate PhilHealth with the first peso that substantially covers essential health care costs availed of in accredited government and private health care facilities. A Social Weather Stations survey in December 2012 validates such claim with net 82 percent of members expressing satisfaction with the support and protection they get from PhilHealth.

As PhilHealth marks this year with greater fervor and zeal, it takes a good steady look at what really matters, and that is making sure that its members are kept abreast of their benefits and privileges, able to use and maximize them when the need occurs.

Hence, the theme for this year’s anniversary celebration “BenepisyongPhilHealth: Alamin at Gamitin” which draws inspiration from our very members themselves.

Benepisyong PhilHealth, Alamin
Section 16s of the National Health Insurance Act of 2013 mandates PhilHealth to ensure that each and every member is aware and has adequate understanding of their benefit entitlements as well as how to avail of these.

It is a mandate that PhilHealth takes to heart because a member armed with correct and timely information is truly an empowered member. To effectively do this, we start off with the insights from our members themselves. We listen to and learn from them through the many channels that are now available, thanks to the power of information and communication technology. As mentioned earlier, feeling the public pulse is part of our feedback mechanisms in place.

Top most on our communication objectives is the empowering effect of correct, timely and steady stream of information about their benefits and entitlements, changes in membership and premium policies, and expansion in the provider front, access points, among others.

The key here is information that translates to working knowledge on various program features and this is best realized through our radio programs (which can now be heard and seen on TV too!) in leading networks, print advertising, TV appearances and the like.

Our action center (02 441-7442) is abuzz with around one thousand calls at any given business day from members, providers, employers, concerned citizens and the Press. Our website (www.philhealth.gov.ph) is taking on some 1.3 million page views per month, among the highest among government websites. These are proofs that demand for information is at its all-time high.

Recently, PhilHealth joined the social media bandwagon with its own Facebook (www.facebook.com/Philhealth), Twitter (teamphilhealth) and YouTube (philhealth channel) accounts where netizens get the latest about their PhilHealth.

Consistent with the information dissemination mandate, PhilHealth intensifies its communication on its benefits, being the core of the NHIP.

For example, the revolutionary shift in the way we are paying claims which took effect in January this year. For the longest time PhilHealth has been paying using the Fee-for-Service (FFS) where PhilHealth pays every unit of service dispensed by the hospital. Now we pay using the case-based or case-rate system where essential services are paid on a “bundled rate” or similar to the system where one pays a fixed amount for services that are already “all-in”.

This system bodes well with all the players in the health system. The fixed benefit per case is a boon for members (no more complicated computations as they can easily know the exact amount of coverage for a particular condition), health care providers (through substantially improved and quicker refunds as well) and PhilHealth too (for reduced documentations).

The shift covers more than 4,600 medical and surgical cases.

Then there’s special attention to catastrophic conditions which puts patients to a more awful and compromised situation, medically and financially. As a response, we introduced the Z Benefit Packages to help patients who are undergoing medically difficult and expensive treatments and procedures that can push families to poverty. Below are few examples of the Z Benefit Packages:

Procedure                               Coverage
Kidney Transplant                 P600,000
(low risk)
Coronary Artery Bypass       P550,000
Graft (standard risk)
Surgery of Tetralogy of         P320,000
Fallot (Blue Baby
Syndrome) in Children
Childhood Leukemia               P210,000
(standard risk)
Cervical Cancer                       P120,000
(early stage)
Cervical Cancer                       P175,000
(late stage)
Breast Cancer                          P100,000
(stage 0 – IIIA)
Prostate Cancer (low to    P100,000
intermediate risk)
External Lower                       P15,000
Limb Prosthesis

Also in support of the Millennium Development Goal (MDG) of maternal and child health, PhilHealth pays for Normal Spontaneous and Caesarian deliveries at P6,500 and P19,000, respectively, while its Maternity Care Package pays P8,000 covering pre-natal to post-natal, actual delivery and family planning services. For the elderly, our cataract package is now at P16,000 per eye and is available even in accredited ambulatory surgical clinics.

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 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, a spirit that is concretized by coming together and by pooling their meager resources to a national health insurance fund. The fund enables sick members to access the fund, giving those that are healthy the opportunity to help others through their contributions to the fund. Indeed a classic case of our very own bayanihan system where everyone bears the weight of needy members.

Benepisyong PhilHealth, Gamitin
PhilHealth coverage is something a family seeks to insure themselves to have peace of mind so that in they are shielded from costly hospitalization come health contingencies happen. A member may be praying hard and doing everything to avoid health conditions that will necessitate the availment of insurance coverage.

However, the reality is that illnesses can strike any time. Therefore it is crucial that members are knowledgeable about their benefits and how and where to avail of these.

To date, there are some 1,800 hospitals that have been accredited by PhilHealth nationwide, making 9 in every ten DOH-licensed hospitals in the country as access points for quality services that are paid for by PhilHealth on behalf of its patients.

Information about one’s benefits and availment details should sufficiently empower them to make the right decision to seek treatment right away as the situation warrants it. Gone are the days when one hesitates to be treated because of financial difficulties. Your PhilHealth coverage now breaks such decision barriers because being a PhilHealth member now makes one a preferred patient in hospitals. So use your coverage, and here’s how:

A member should be aware that PhilHealth pays for compensable cases that are confined in accredited facilities for not less than 24 hours.

It is very easy to identify the accredited from the non-accredited ones. Just look for the lighted familiar yellow signage containing our corporate signature and you can be assured of quality care and ease of availment. Emergency cases brought to non-accredited facilities may also be paid provided that these are duly licensed by the DOH.

It is also very important that your updated premium payment receipts are kept safe and within easy reach especially during emergencies. You will definitely need them in asking the hospital billing section to deduct your benefits from your total charges.

Meanwhile, as soon as you have something to update in your membership profile such as additional dependents or change in civil status, promptly inform the nearest PhilHealth office so they can update your profile by just filling out the PhilHealth Membership Registration Form (PMRF).

The same also holds true with the enrollment of non-members because PhilHealth already waived the documentary requirements which are usually cumbersome and costly to obtain, thereby discouraging prospective members to enlist. By signing the PMRF, a member is under oath and legally bound for the accuracy of the entries in the form.

“My last payment was one year ago” one informal sector member once said. PhilHealth encourages members to religiously pay their contributions to be eligible to the benefits anytime.

Already armed with the essentials but still having concerns in the actual availment process? Members need not worry because it is working closely with its accredited providers to ensure ease in benefit claims at the point of availment. Come April this year, all accredited health care institutions should have been connected to PhilHealth through the enhanced Health Care Institution Portal or eHCIP. The eHCIP aims to streamline availment procedures at point-of-care, enabling hospitals to perform eligibility check online.

And to give more human touch to the process, PhilHealth even took the extra mile by being there in the very midst of the action with the deployment of some 530 Customer Assistance, Relations and Empowerment Staff (PhilHealth CARES) in various hospitals nationwide.

For two years now, the PhilHealth CARES have been providing onsite assistance to members and their families which include information service, guidance in the filling out of claim forms, among others. These registered nurses go out of their way to provide clients with personal and real time service, all in the name of public service.

Our solemn promise
As we look forward to the next 19 years, PhilHealth makes a solemn promise to continue giving the people excellent service and meaningful benefits that touches the core of a patient’s need for true social protection. We shall continue to work towards the fulfillment of a vision that encapsulates our mandate of universality and responsive financial protection — “Bawat Pilipino, Miyembro. BawatMiyembro, Protektado. KalusuganNatin, Segurado.”

In response to President Benigno Aquino 3rd’s call for Universal Health Care or KalusuganPangkalahatan, PhilHealth will enroll a total of 14.7 million poor families in the Department of Social Welfare and Development’s Listahanan this year, translating to some 59 million beneficiaries or more than half of the entire Philippine population.

We take pride in all that we have accomplished for the past 19 years, and we salute our partners, among them our members, employers, health care providers, local government units, collecting agents, development agencies, and the Press, for unceasingly believing and supporting us in this noble endeavor. (Rey T. Baleña and Amelita L. Buted, Corporate Communication Department)

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