DR. NARISA J. SUGAYSenior Manager, Non Formal SectorMember Management Group

THE CHALLENGES AND WAYS FORWARD IN PROVIDING

UNIVERSAL HEALTH CARE

Vision:

Mission:

How to make health more inclusive?

The challenge…

No one should be left out…

Poor and near-poor familiesare subsidized by the National Government.

Formal and informal sector workersare mandatory members.

Lower income segments can be covered through cost-sharing scheme

Coverage as of December 2015(CorPlan Data)

2015 Projected Population: 101.4M

Sector Members Dependents Beneficiaries %

Members in the Formal Economy

13,869,211 14,449,551 28,318,762 30%

Members in the Informal Economy

3,424,526 5,033,910 8,458,436 9%

Indigents 15,288,583 30,118,509 45,407,092 49%

Sponsored Members

1,049,921 1,357,641 2,407,562 3%

Senior Citizens 5,868,005 1,255,025 7,123,030 8%

Lifetime Members

1,001,626 728,545 1,730,171 2%

TOTAL 40,501,872 52,943,181 93,445,053 100%

92%“the remaining 8% of the uncovered population is in the Informal Economy…”

A Situation Analysis

Mechanisms to Cover the Workers in the Informal

Economy

Target for CY 2016: Renewal of the 15.442M Listahanan/CCT/MCCT Families Enrolled in CY 2015

Legal Basis: 2016 GAA amounting to 37 Billion Pesos

A. INDIGENT PROGRAM

Workers in the Informal Economy who are included in the list of poor of the LISTAHANAN are automatically members of PhilHealth

B. SPONSORED PROGRAM

The following are qualified to be enrolled and covered as sponsoredmembers (Sec. 31, Rule VII):

Orphans, abandoned and abused minors, out-of-school youths,street children, persons with disability (PWD), senior citizens andbattered women under the care of the DSWD, or any of itsaccredited institutions run by NGOs or any nonprofit privateorganizations;

Barangay health workers, nutrition scholars, barangay tanods,and other barangay workers and volunteers;

Unenrolled women who are about to give birth; and

Members in the informal economy from the lower income segmentwho do not qualify under the means test rules of the DSWDthrough a cost sharing mechanism with the sponsor/s and themember.

• MEMBERSHIP– Identification of Hospital-Sponsored Members by Medical

Social Workers– Hospital to mandatorily enroll those classified as Class D

and C3– Validity: First day of the month of confinement until

December 31 of the same year– Cost: Php2,400 for the current Calendar Year

Point-Of-Care Enrollment Program

• BENEFITS– Immediate availment of members and hospital is entitled

to reimbursement– No Balance Billing– Faster Turn Around Time of Claims Reimbursements

SPONSORED PROGRAM

C. Informal Economy Program

Who may be covered? (Section 5b of the IRR)

Migrant Workers Informal Sector (workers) Self- Earning Individuals Filipinos With Dual Citizenship Naturalized Filipino Citizens Citizens of other countries Working and/or residing

in the Philippines

Informal Economy Program

Individually Paying Scheme Enrollment : Individual registration

Premium rate: 2-tiered premium scheme Php 2,400/ annum (for those with monthly family income of Php 25,000 and below);

Php 3,600/ annum (for those with monthly family income of above Php 25,000)

Payment of premium: LHIO – Initial;ACAs – succeeding payment

Eligibility: Contributions of 3/6 prior to the day of confinement

Benefits: Inpatient Hospital Package and Regular Hospital Outpatient Services

Requirements for availment: thru the portal

iGROUP PROGRAM

IPP- GROUP ENROLLMENT

Informal Economy Program

Partner organizations facilitates enrollment of members to PhilHealth and payment of premium contributions thru manual process.

Partner organized groups (OGs) facilitates coverage of members to PhilHealth using the eGroup Web-Based Application System;

OGs with at least 700 enrollees and committed to sustain the coverage for the entire year are entitled to premium discounts/ incentives.

Mandatory Coverage of Senior Citizens

Thus, RA 10645 provided coverage for FILIPINO SENIOR CITIZENS not currently covered by any membership program of the NHIP.

Republic Act 10645

“All senior citizens shall be covered by the national health insurance program of PhilHealth. Funds necessary to ensure the enrollment of all senior citizens not currently covered by any existing category shall be sourced from the National Health Insurance Fund of PhilHealth from proceeds of Republic Act No. 10351, in accordance with the pertinent laws and regulations"

INFORMATION DRIVE AND RELATED INTERVENTIONS

DISTRIBUTION AND ORIENTATION

ACTIVITIES

EXTENSION INFO

ANGELSIHCPS thru

PORTAL

Conduct of ALAGA KA Program

Conduct of FDS, LGU initiated orientations and

other similar activities

Upon hospitalization, online verification thru the HCP/CARES

Portal

Role of the LGU’s under RA10606

LGU Role as SHAPER of the NHIP

ROLE PARTICULARSponsor • Enrollment of the:

‐ Barangay workers and volunteers who are not members of the NHTS PR (eg. BHWs, BNS, Tanods etc.)

‐ Lowest segment of members in the informal economy thru cost sharing

‐ Critical poor thru Point-Of-Care (POC)- Women who are about to give birth

LGU Role as SHAPER of the NHIP

ROLE PARTICULAR

Health Care Provider • Primary health care services, provision of PCB (enlistment and health profiling) of the indigents and sponsored enrollees

• Manage the Per Family Payment Rate (PFPR )

• Hospital and other tertiary health care services with:‐ No Balance Billing (NBB) for the poor and

LGU enrollees‐ IHCP Portal connectivity

‐ Assist PhilHealth CARES

LGU Role as SHAPER of the NHIP

ROLE ParticularAdvocate • Promote the NHIP and enjoin constituents

to be enrolled to the Program

• Collaborate with DOH and DSWD on the establishment of Community Health Teams (CHTs) and Municipal Links (MLs), respectively

• Representation at the PhilHealth Board

Payor • Prompt and regular remittance of premiums of their employees and sponsored enrollees

• Option to become a PhilHealth Accredited Collecting Agent for PhilHealth premium contributions

LGU Role as SHAPER of the NHIP

ROLE ParticularEmployer • Ensure employees, including the job order

contractors and service providers (security, janitorial, among others) access to PhilHealth benefits

Regulator • MANDATORY require all applicants of business permits to show proof of payment of PhilHealth premium contributions- Joint Memorandum Circular No. 001 dated May 9, 2014 of DILG, DTI,PhilHealth, SSS, Pag-ibig, Leauge of Cities of the Phils. (LCP) and Leauge of Municipalities of the Phils. (LMP)

Investment in HEALTH is always an investment towards PROGRESS

Thank you . . .

CASE RATE PAYMENTSMedical Cases

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Dengue I P8,000 Stroke (CVA-I) P28,000

Dengue II P16,000 Stroke na may Pagdurugo (CVA-II) P38,000

Pulmonya I P15,000 Pagdudumi na may dehydration (AGE) P6,000

Pulmonya II (high risk) P32,000 Asthma o Hika P9,000

Alta Presyon P9,000 Tipus o Typhoid Fever P14,000

CASE RATE PAYMENTSSurgical Procedures

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Outpatient Radiotherapy P3,000 Raspa P11,000

Outpatient Hemodialysis P4,000 Pagtanggal ng

Thyroid P31,000

Panganganak ng Normal sa ospital at iba pang accredited na paanakan

P6,500(P8,000 sa L1)

Pagsasa-ayos ng Luslos P21,000

Panganganak ng Cesarean Section P19,000 Pagtanggal ng Suso P22,000

Pagtanggal ng Appendix P24,000 Pagtanggal ng Matris P30,000

Pagtanggal ng Apdo P31,000 Cataract Surgery P16,000

CASE RATE PAYMENTSOutpatient Services

NEWBORN CARE

NEWBORN CARE

P1,750

P4,000

P3,000

P75,000(non-health

workers)P150,000

Health workersP600

Catastrophic o Z Benefit Packages

Karamdaman/Operasyon Halaga ng Benepisyo

Acute Lymphocytic Leukemia (ALL)sa mga bata na may standard risk P210,000

Breast Cancerna nasa Stage 0 hanggang 3a pa lamang P100,000

Prostate Cancerna may low hanggang intermediate risk P100,000

Kidney transplantna may low risk P600,000

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Magagamit lamang sa mga piling levels 3 at 4 contracted hospitals na pag-aari ng pamahalaan

Additional Catastrophic o Z Benefit Packages

Karamdaman/Operasyon Halaga ng Benepisyo

Cervical Cancer with cobalt P120,000

Cervical Cancer with linear accelerator P175,000

Surgery for closure of ventricular septal defect P250,000

Surgery for total correction of tetralogy of fallot P320,000

Elective surgery for standard risk coronary artery bypass graft P550,000

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Magagamit lamang sa mga piling levels 3 at 4 contracted hospitals na pag-aari ng pamahalaan

PRIMARY CARE PACKAGE

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Pangunahing serbisyo para makaiwas sa sakit

• Konsultasyon sa duktor • Eksaminasyon ng kuwelyo ng matris para sa kanser • Regular na pagkuha ng presyon ng dugo • Edukasyon tungkol sa pagpapasuso ng sanggol• Regular na pagsusuri ng suso• Pagpapayo para sa malusog na pamumuhay• Pagpapayo para sa pagtigil ng paninigarilyo• Pagkuha ng taas, timbang at sukat ng baywang• Pagsusuri ng prostate

PRIMARY CARE PACKAGE

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Mga pagsusuri para matukoy ang sakit

• Kumpletong pagsusuri ng dugo o complete blood count• Pagsusuri ng ihi o urinalysis• Pagsusuri ng dumi o fecalysis• Pagsusuri ng plema o sputum microscopy • Pagsukat ng asukal sadugo o fasting blood sugar • Pagsukat ng kolesterol sa dugo o lipid profile • Chest X-ray

PRIMARY CARE PACKAGE

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Gamot at medisina para sa piling karamdaman

• Hika o asthma kasama ang nebulisasyon• Pagtatae o acute gastroenteritis na may bahagya o

walang pagkaubos ng tubig sa katawan• Ubo, sipon (Upper Respiratory Tract Infection)/Pulmonya

na minimal o low risk • Impeksyon sa daluyan ng ihi o Urinary Tract Infection

(UTI)

iGroup Program Features IPP-Group EnrollmentLetter of Intent, Certificate of Good Standing with affiliated Institutions (SEC, LGU) and Group Policy Contract

Documentary requirements for affiliation with PhilHealth

MOA (optional)

iGroup partner facilitates the enrollment thru the eGroup System

Registration Group partner facilitates enrollment thru manual submission of list enrollees

30 OG members Minimum Membership Required NoneQuarterly, Semi-Annual & Annual Mode of Payment/

RemittanceQuarterly, Semi-Annual, and Annual

premium discount rate ranging from 4%- 9.7% (Only for OGs with members of 700 and above)

Premium Discount Rate

None

Electronic via e-group Billing and Submission of Report Manual billing and reporting

In-patient & hospital outpatient benefits, & Primary Care Benefits,

Benefit Package and Availment of benefit

Inpatient & hospital outpatient benefits.

Automatic Availment within the validity period

Eligibility 3 mos. qualifying contribution within the 6 mos. Period prior to the day of confinement

Comparison of Group Enrollment Schemes