PhilHealth adopts New Case Rates and No Balance Billing

 

Effective September 1, 2011, the Philippine Health Insurance Corporation (PhilHealth) will be adopting the case rate method to pay for selected medical and surgical cases.  Various considerations include: (1) developments are 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; (2) to empower PhilHealth members more by letting them know how much they can now avail themselves of for certain medical conditions and surgical procedures; (3) the case rate method means faster processing of claims and therefore faster reimbursement for the services the health care providers have provided to members.

These medical conditions that will be paid for using the case rate method are as follows:

MEDICAL CASES (11)		SURGICAL CASES (12)
Dengue I	P  8,000.00	Radiotherapy	P 3,000.00
Dengue II	P16,000.00	Hemodialysis	P 4,000.00
Pneumonia I	P15,000.00	Maternity Care Package	P 8,000.00
Pneumonia II	P32,000.00	Normal Spontaneous Delivery Package in Level 1 hospitals Normal Spontaneous Delivery Package in Levels 2 to 4 hospitals	P 8,000.00 P 6,500.00
Essential Hypertension	P  9,000.00	Caesarean Section	P19,000.00
Cerebral Infarction	P28,000.00	Appendectomy	P24,000.00
Cerebro-vascular accident with hemorrhage	P38,000.00	Cholecystectomy	P31,000.00
Acute gastroenteritis	P  6,000.00	Dilatation & Curretage	P11,000.00
Asthma	P  9,000.00	Thyroidectomy	P31,000.00
Typhoid Fever	P14,000.00	Herniorraphy	P21,000.00
Newborn care package in hospitals and lying-in clinics	P  1,750.00	Mastectomy	P22,000.00
		Hysterectomy	P30,000.00
		Cataract Surgery	P16,000.00

These new rates are applicable for all types of members, and these include those who are employed in the private and government sectors, the lifetime members, the overseas workers, the individually paying members and the sponsored program members.  They can avail these case rates in PhilHealth-accredited health care facilities nationwide.

However, for Sponsored Program members, those whose enrolment in PhilHealth are paid for by the National Government, by the Local Government Units or by private individual and corporate sponsors, they are entitled to the “No Balance Billing” (NBB) policy when they avail themselves of any of these case rates in accredited government hospitals. 

NBB simply means that no other fees or expenses shall be charged or paid for by the patient-member above and beyond the packaged rates.  The NBB policy also applies when the Sponsored Program members avail themselves of outpatient surgeries, hemodialysis and radiotherapy in accredited non-hospital facilities that included free-standing dialysis centers (FSDCs) and ambulatory surgical clinics (ASCs).  It also applies when they are availing themselves of the existing outpatient packages for TB-DOTS, Malaria and HIV/AIDS.

At the same time, all other member-types are entitled to the NBB policy when availing themselves of the Maternity Care Packages (MCP) and the Newborn Care Package (NCP) in accredited MCP (non-hospital) providers.

PhilHealth will continue to move towards options that will redound to better benefits for all members and plans to include more approaches to benefit payments and constantly improve on benefit delivery ratio to continuously strengthen the mark in the lives of Filipinos especially where their health care is concerned.