Ra 7875 amended by 9241 Benefit Coverage

Inpatient Coverage
PhilHealth provides subsidy for room and board, drugs and medicines, laboratories, operating room and professional fees for confinements of not less than 24 hours. Please refer to the table of rate ceilings/maximum allowances for inpatient coverage.

Revised Inpatient Care Benefits

The following are the maximum allowances or ceilings to be applied per single period of confinement** effective April 5, 2009 admissions onwards.
Level 1 Hospitals (Primary) Benefit Item Case Type A Room and Board (maximum of 45 days per year) 300 B 300

Drugs and Medicine 2,700 (per single period of confinement) X-ray, Laboratory and Others 1,600 (per single period of confinement) Operating Room Professional Fees a. Daily Visits General Practitioner (Groups 1, 5, & 6) 500

9,000

5,000

500

Per Day Maximum per confinement Specialist (Groups 2, 3, & 4) Per Day Maximum per confinement b. Surgery (for Case Type A and B)

300 1,200

400 2,400

500 2,000

600 3,600

Surgeon General Practitioner 1st Tier (Group 1) With Training 2nd Tier (Group 5 and 6) Diplomate/Fellow 3rd Tier (Group 2, 3 and 4) RVU x PCF 40=PF1

Anesthesiologist 40% of surgeon's fee (PF1)

RVU x PCF 48=PF2

48% of surgeon's fee (PF1)

RVU x PCF 56=PF3

56% of surgeon's fee (PF1)

Maximum of 2,000 per confinement

Maximum fee computed as percentage of 2,000

* Not to exceed 45 days for each calendar year. ** Refers to a confinement or series of confinements of the same illness not separated from each other by 90 days within a calendar year. In this case, a member or beneficiary is not entitled to another set of benefits until after 90 days. They can only avail of the unused portion of the benefits and the room and board fees until the 45 days allowance is exhausted. However, a member can avail of new set of benefits if succeeding confinements are of different illness or condition.
Level 2 Hospitals (Secondary) Benefit Item Case Type A Room and Board (maximum of 45 days per year) Drugs and Medicine (per single period of confinement) X-ray, Laboratory and Others 400 B 400 C 600

3,360

11,200

22,400

2,240

7,350

14,700

(per single period of confinement) Operating Room For procedures with RVU 30 and below = 750 For procedures with RVU 31 to 80 = 1,200 For procedures with RVU 81 to 600: RVU x PCF 15 (minimum = 2,200 and maximum = 7,500)

Professional Fees a. Daily Visits General Practitioner (Groups 1, 5, & 6) Per Day Maximum per confinement Specialist (Groups 2, 3, & 4) Per Day Maximum per confinement b. Surgery (for Case Type A, B and C) Surgeon General Practitioner 1st Tier (Group 1) With Training 2nd Tier (Group 5 and 6) Diplomate/Fellow 3rd Tier (Group 2, 3 and 4) RVU x PCF 40=PF1 maximum of 3,200 RVU x PCF 48=PF2 Anesthesiologist 40% of surgeon's fee (PF1) maximum of 1,280 48% of surgeon's fee (PF1) 500 2,000 600 3,600 700 5,600 300 1,200 400 2,400 500 4,000

RVU x PCF 56=PF3

56% of surgeon's fee (PF1)

* Not to exceed 45 days for each calendar year. ** Refers to a confinement or series of confinements of the same illness not separated from each other by 90 days within a calendar year. In this case, a member or beneficiary is not entitled to another set of benefits until after 90 days. They can only avail of the unused portion of the benefits and the room and board fees until the 45 days allowance is exhausted. However, a member can avail of new set of benefits if succeeding confinements are of different illness or condition.

Level 1 Hospitals (Primary) Benefit Item Case Type A Room and Board (maximum of 45 days per year) 300 B 300

Drugs and Medicine 2,700 (per single period of confinement) X-ray, Laboratory and Others 1,600 (per single period of confinement) Operating Room Professional Fees a. Daily Visits General Practitioner (Groups 1, 5, & 6) Per Day Maximum per confinement Specialist (Groups 2, 3, & 4) Per Day Maximum per confinement b. Surgery (for Case Type A and B) Surgeon General Practitioner 1st Tier (Group 1) With Training 2nd Tier (Group 5 and 6) Diplomate/Fellow 3rd Tier (Group 2, 3 and 4) RVU x PCF 40=PF1 500 2,000 300 1,200 500

9,000

5,000

500

400 2,400

600 3,600

Anesthesiologist 40% of surgeon's fee (PF1)

RVU x PCF 48=PF2

48% of surgeon's fee (PF1)

RVU x PCF 56=PF3

56% of surgeon's fee (PF1)

Maximum of 2,000 per confinement

Maximum fee computed as percentage of 2,000

Outpatient Coverage

Day surgeries, dialysis and cancer treatment procedures such as chemotheraphy and radiotheraphy in accredited hospitals and free-standing clinics.

Special Benefit Packages

Case Rates

Case Rates
Since September 1, 2011, the following medical cases and surgical procedures are being paid through case rate:

Medical Cases

1. Dengue I (Dengue fever, DHF grades I&II) 2. Dengue II (DHF grades III & IV) 3. Pneumonia I ( moderate risk) 4. Pneumonia II (high risk) 5. Essential Hypertension 6. Cerebral Infarction (CVA-I) 7. Cerebral Hemorrhage (CVA-II) 8. Acute Gastroenteritis (AGE) 9. Asthma

10. Typhoid Fever 11. Newborn Care Package in Hospitals and Lying in Clinics

Surgical Cases
3,000 4,000 8,000 8,000 6,500 19,000 24,000 31,000 11,000 31,000 21, 000 22,000

1. Radiotherapy 2. Hemodialysis 3. Maternity Care Package (MCP) 4. NSD Package in Level I Hospitals 5. NSD Package in Levels 2 to 4 Hospitals 6. Caesarean Section 7. Appendectomy 8. Cholecystectomy 9. Dilatation and Curettage 10. Thyroidectomy 11. Herniorrhaphy 12. Mastectomy

13. Hysterectomy 14. Cataract Surgery

30,000 16,000

TB Treatment through DOTS

Treatment of new cases of pulmonary and extra-pulmonary tuberculosis in children and adults are covered through the Directly Observed Treatment Shortcourse or DOTS, the shortest and most effective internationally accepted treatment protocol for tuberculosis (TB).

Inclusions
Amount of Coverage Services Providers Eligibility Php 4,000 Diagnostic work-up, consultation services and anti-TB drugs required in an outpatient set-up Duly accredited TB-DOTS Centers (available in the Philippines only) New cases only, i.e., patient has never had treatment for TB or who has taken anti-TB drugs for less than one month. Enrolment with TB-DOTS center falls within the validity period as stated in the Member Data Record.

Exclusions

Failure Cases - a patient who, on previous treatment, is sputum smear positive at five months or later during the course of treatment. Relapse Cases - a patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB. Return-After-Default (RAD) Cases - a patient who returns to treatment with positive bacteriology (smear of culture) following interruption of treatment for two months or more.

Other Conditions
Additional services rendered or extension of treatment shall not be covered.

SARS and Avian Influenza

Inclusions
Amount of Coverage Services For members and their qualified dependents - Php 50,000 per case For health care workers(forefront and high risk) - Php 100,000 per case Professional fees (Php 2,500 - pay to doctor) Hospital charges (Php 42,500 - pay to hospital) Official receipts amounting to Php 12,000 (Php 5,000 - pay to member) Patients must be admitted only in accredited DOH-designated SARS or AI/IP hospitals. Confinements abroad shall be paid compensated provided a certification from the attending physician is submitted Eligibility Must be certified by the DOH as SARS or avian influenza/influenza pandemic patient Confinement within the validity period as stated in the Member Data Record

Providers

Exclusions

SARS suspect cases Cases of acute respiratory illness where an alternative diagnosis can fully explain such illness.

Other Conditions
Rule on single period of confinement and 45-days allowance for room and board per year applies. For afflicted health care workers:

Must also be active PhilHealth members.

Contracted the disease while caring for a SARS or AI/IP patient (person to person transmission). Renders service in DOH-designated hospital. DOH attests that HCW contracted the disease while on official duty.

Novel Influenza A(H1N1)

To mitigate the direct medical cost for the treatment of complicated human cases of novel Influenza A (H1N1) with complication or co-morbidities requiring hospitalization. The following shall be effective in all local and overseas confinements with admission dates starting May 1, 2009.

Inclusions
Amount of Coverage Services Maximum of Php 75,000 for non-health worker-members Maximum of Php 150,000 for health worker-members For Members/Dependents: - Room and board allowance of 1,500/day but up to 10,000 only - Drugs and medicines; X-ray, lab and others (including supplies and personal protective equipment and transfer services) and operating room fees 50,000 - Professional fees of 1,000/day but up to 15,000 only For Health Care Workers: - Room and board allowance of 1,500/day but up to 20,000 only - Drugs and medicines; X-ray, lab and others (including supplies and personal protective equipment and transfer services) ; operating room and other medically necessary care 100,000 - Professional fees of 1,000/day but up to 30,000 only Providers Hospitals designated by DOH as referral centers (national, subnational and satellite) for Influenza A (H1N1) and other emerging and re-emerging diseases with the exception of confinements abroad. Admissions in private hospitals may be covered if confirmatory tests were coordinated with or confirmed by the RITM, DOH-CHD or other DOH certified laboratories. Eligibility Limited to members and health qualified workers with novel swine-

origin influenza A (H1N1) virus infection confirmed by the Department of Health (DOH) Confinement within the validity period as stated in the Member Data Record For qualified health care workers (HCWs): - Rendered service in a DOH-designated hospital for Influenza A (H1N1) and contracted the disease while performing their duties and or caring for an influenza A (H1N1) patient as certified or attested by DOH. - Qualified dependents of HCWs who also contracted the disease shall be provided a maximum coverage of Php 75,000. .

Eligibility
Limited to members and health qualified workers with novel swine-origin influenza A (H1N1) virus infection confirmed by the Department of Health (DOH) For qualified health care workers (HCWs):

Rendered service in a DOH-designated hospital for Influenza A (H1N1) and contracted the disease while performing their duties and or caring for an influenza A (H1N1) patient as certified or attested by DOH Qualified dependents of HCWs who also contracted the disease shall be provided a maximum coverage of Php 75,000.

Confinement within the validity period as stated in the Member Data Record.

Exclusions

Probable and case under observation* Admissions in non-DOH designated hospitals* Influenza-like illnesses (ILI*) Other seasonal outbreaks of influenza by established flu virus (e.g., H1N2, H5N1*, SARS**, Avian flu***)

Other Conditions
Reimbursement (to members) for drugs, medicines and supplies or laboratory procedures bought or performed in other facilities shall be based on the following:

Facility cannot provide necessary items and services covered by the benefit. These items and services are used during confinement. Official receipts and/or other purchase documents are submitted. Reimbursement depends on actual cost of receipts submitted but not more than the difference between maximum benefit and reimbursement to facility. Facility acknowledges that cost of benefits and services provided is less than the maximum benefit

Confinements abroad shall also be covered provided that a certification from their Ministry of Health (or its equivalent) confirming that case is due to A (H1N1) is submitted. Availment of the package shall be charged against the 45days annual limit and is covered by the rule on single period of confinement (only one Influenza A (H1N1) Package shall be paid within 90 days). *Covered by regular hospitalization benefit **Covered by SARS package ***Covered by Avian Flu package

Exclusions / Non-Compensables
The following shall not be covered except when, after actuarial studies, PhilHealth recommends their inclusion subject to approval of its Board of Directors:

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