Question & AnswerQ&A (PhilHealth Circular No. 006-2015)
The primary objective of PhilHealth Circular No. 006-2015 is to provide implementing guidelines and procedures for the mandatory PhilHealth coverage and entitlements of all senior citizens not currently covered under the National Health Insurance Program (NHIP).
A senior citizen or elderly is any Filipino citizen who is a resident of the Philippines and aged sixty (60) years or above, including dual citizens aged 60 years or above provided there is proof of Filipino citizenship and at least six (6) months residency in the Philippines.
It refers to a senior citizen who is not yet issued a PhilHealth Identification Number (PIN), is a member in formal or informal economy but without qualifying contributions, is not identified as indigent by NHTS-PR/Listahanan, not a sponsored member, not a lifetime member, and a qualified dependent of an NHIP member not declared in PhilHealth's membership database.
The Circular created a new membership category called 'Senior Citizen' for senior citizens who are not currently covered under the NHIP to ensure their health insurance coverage.
Senior Citizen members are primarily enrolled in coordination with the Office for Senior Citizens Affairs (OSCA) or any office designated by the Office of the Mayor in their locality, with submission of lists or PhilHealth Member Registration Forms (PMRFs) to the Local Health Insurance Office (LHIO). Senior citizens may also enroll directly with the LHIO.
Required documents include a duly accomplished PMRF, a recent 1x1 photo, and a Senior Citizen Identification Card issued by OSCA or any valid proof of senior citizen status such as passport, birth certificate, valid government-issued ID, or in some cases, certification or affidavits subject to PhilHealth validation.
Qualified dependents include legitimate spouses not enrolled under NHIP, legitimate or illegitimate unmarried children below 21 years old and unemployed, children 21 or older with a congenital or total disability, and foster children as defined under Republic Act 10165 (Foster Care Act of 2012).
Premium contributions for Senior Citizen members are sourced from the proceeds of Republic Act No. 10351, known as the Sin Tax Law.
Benefits include inpatient hospital care, day/ambulatory services, catastrophic case special benefits (Z-benefits), TB-DOTS package, animal bite package, malaria package, outpatient HIV/AIDS treatment, blood transfusion, maternity and newborn care, voluntary contraceptive surgery benefits, primary care benefit package (Tsekap), and the No Balance Billing policy at accredited government health care facilities.
Senior Citizen members are entitled to 45 days of confinement coverage per calendar year, and their qualified dependents collectively share another 45 days of confinement coverage in the same calendar year.
Enrollment may be done during confinement or after benefits are availed by submitting the required enrollment documents attached to the claims submitted by the healthcare provider.
PhilHealth Customer Assistance, Relations and Empowerment Staff (PhilHealth CARES) deployed in accredited hospitals assists senior citizens and their qualified dependents in availing NHIP benefits per Circular No. 12, series of 2012.
Yes, they can file direct benefit claims within sixty (60) calendar days from the circular's effectivity by submitting the required enrollment and claim documents to any PhilHealth office with jurisdiction over the facility where they were confined.
Yes, gainfully employed senior citizens with income above the poverty threshold in their locality continue to contribute to the NHIP according to existing rules applicable to formal or informal economy members.