QuestionsQuestions (PHILHEALTH CIRCULAR NO. 25, S. 2010)
It requires NINE (9) months of premium contribution within the twelve (12) months immediately prior to the month of availment (including confinements and outpatient benefit availments), as a condition for benefit entitlement.
It bases the new 9-month requirement on the entitlement framework in Section 42: a member must have at least three (3) months contributions paid within the six (6) months prior to the first day of availment, plus sufficient regularity of premium contribution as defined in the RIRR.
(1) At least three (3) months contributions paid within the six (6) months prior to the first day of availment; (2) Sufficient regularity—defined as at least nine (9) months paid within a twelve-month period immediately prior to the month of availment; and (3) No legal penalties as defined in RA 7875 as amended by RA 9241.
It defines sufficient regularity as the payment of premium contributions of at least nine (9) months within the twelve-month period immediately prior to the month of availment.
The circular states that premium contributions must be paid prior to confinement; thus, the reckoning date is the date of the last day prior to confinement. Payments made during confinement are not considered for that confinement.
It is the three (3) months paid premium contributions within the six (6) months prior to March 2011: September 2010 to February 2011.
Nine (9) months paid from March 2010 to February 2011 (the immediate 12 months preceding March 2011).
It must be paid until the last day prior to confinement/availment (e.g., March 14, 2011).
Contributions paid within the confinement are not considered for the present confinement/availment. They may only be considered for future/prospective confinements.
March 14, 2011 is the last day prior to confinement and is considered for the confinement; March 15, 2011 is already within the confinement period and is no longer considered for the present confinement (only for future ones).
Yes. It states the requirement applies to all confinements including availment of outpatient benefit. It is effective for all reimbursements with admission/treatment (outpatient) date starting July 1, 2011.
Those under the Sponsored Program, Lifetime (Non-Paying) Program, and Overseas Workers Program (OWP).
It extends beyond inpatient confinements; it explicitly includes the availment of outpatient benefits.
The circular provides that contributions paid within the confinement, previously allowed under those policies, shall no longer be considered for the present confinement but for future/prospective ones.
No. Payments made during or after the confinement/availment shall no longer be considered for the present confinement but may be considered for future/prospective ones.
It indicates that prior PhilHealth rules or circular provisions that conflict with the new 9-month rule and related implementation details are modified or superseded.