Legal basis and related laws
- Republic Act No. 10645 provides mandatory PhilHealth coverage for all senior citizens.
- Republic Act No. 10645 amends Republic Act No. 7432, as amended by Republic Act No. 9257, and further amended by Republic Act No. 9994.
- The circular implements the amendment to Section 5, sub-paragraph h(2) of Republic Act No. 7432, which mandates coverage by PhilHealth’s national health insurance program.
- PhilHealth premium contributions for the Senior Citizen category are funded from the proceeds of Republic Act No. 10351, commonly known as the Sin Tax Law.
- Foster child as a qualified dependent is tied to Republic Act No. 10165 (the Foster Care Act of 2012).
- Directly filed claims for the transitory period require use of forms and rules referenced in PhilHealth Circular No. 020, series of 2014.
- Claims handling assistance in accredited hospitals references PhilHealth Circular No. 12, series of 2012.
Purpose and policy intent
- The circular establishes implementing guidelines and procedures for the coverage and entitlement of all senior citizens not currently covered under the National Health Insurance Program (NHIP).
- The circular creates a dedicated PhilHealth membership category for Senior Citizen enrollment to cover senior citizens not yet enrolled under existing NHIP categories.
Core definitions and key offices
- A Senior citizen or elderly is any Filipino citizen who is a resident of the Philippines and is aged sixty (60) years or above.
- Dual citizens aged 60 years or above may fall within the term if they provide proof of Filipino citizenship and have at least six (6) months of residency in the Philippines, as provided in the Implementing Rules and Regulations of Republic Act No. 9994.
- A Senior citizen who is not currently covered under the NHIP includes a senior citizen who:
- has not yet been issued a PhilHealth Identification Number (PIN);
- is a member in the formal or informal economy but has no qualifying contributions to entitle the person to program benefits;
- is not identified as indigent under National Household Targeting Systems for Poverty Reduction (NHTS-PR) or Listahanan of the Department of Social Welfare and Development (DSWD);
- is not a Sponsored Member;
- is not yet qualified as a Lifetime member; and
- is not a qualified dependent of an NHIP member declared in PhilHealth’s membership database.
- The Office for the Senior Citizens Affairs (OSCA) is the office established in cities and municipalities under the Office of the Mayor headed by a senior citizen, as provided in the Implementing Rules and Regulations of Republic Act No. 9994.
- The Local Health Insurance Office (LHIO) is the office established by PhilHealth in every province or city, or wherever practicable to bring services closer to members, consistent with Section 22 of Republic Act No. 7875, as amended by Republic Act No. 9241, and further amended by Republic Act No. 10606.
Coverage rules and membership category
- The circular creates a new membership category: Senior Citizen, to provide coverage to senior citizens not currently covered under the NHIP.
- A senior citizen who is a qualified dependent and who is also a senior citizen (e.g., a spouse already aged 60 years or above) is enrolled separately as a Senior Citizen member.
- A senior citizen who is a qualified dependent and who is also a senior citizen (e.g., parents aged 60 years old and above) is enrolled separately as a Senior Citizen member.
- The LHIOs issue the PhilHealth Identification Card (PIC) and the Member Data Record (MDR) for enrolled Senior Citizen members.
- Senior citizens who are gainfully employed or have regular income must continue to contribute under existing rules for formal or informal economy members if their income exceeds the poverty threshold of the province or city where they reside.
- The poverty threshold used for this income test is based on the latest survey released by the Philippine Statistics Authority on poverty statistics.
Enrollment procedures and required documents
- Senior Citizen members are primarily enrolled in coordination with the OSCA or any office designated by the Office of the Mayor in the locality where the senior citizen resides.
- The OSCA maintains and regularly updates, on a quarterly basis, the list of senior citizens in its locality consistent with Section 4(c), Rule VI of the Implementing Rules and Regulations of Republic Act No. 9994.
- The OSCA submits, on a quarterly basis, the list of senior citizens for enrollment to the LHIO with operational jurisdiction over the locality.
- The OSCA’s list must include:
- full name (family, first, middle, including name extension if applicable);
- birthdate;
- sex;
- full name (family, first, middle, including name extension if applicable) of legal spouse and/or qualified dependents; and
- address with the breakdown covering unit/room/floor number, building name, lot/block/house/building number, street, subdivision/village, barangay (required field), city/municipality (required field), and province.
- To expedite enrollment, the OSCA submits the list to the LHIO in electronic format such as Microsoft Excel, Microsoft Access, text file, or any other format acceptable to PhilHealth.
- The electronic file must be password protected and submitted with:
- a transmittal letter from OSCA; and
- the printed alphabetical list of names of senior citizens.
- As much as practicable, a duly accomplished PhilHealth Member Registration Form (PMRF) is submitted together with the OSCA list.
- If OSCA cannot submit the list in electronic format, duly accomplished PMRFs may suffice, and they must be properly endorsed to the LHIO.
- LHIOs secure lists of senior citizens for enrollment under the care of the DSWD or accredited institutions run by non-government organizations or nonprofit private organizations, and may also tap other national government agencies and instrumentalities.
- Senior citizens organizations, duly registered with appropriate national government agency and/or recognized by the local government unit, may facilitate enrollment if they are oriented by the LHIO on enrollment guidelines and benefit availment procedures before submitting lists and PMRFs.
- Senior citizens may directly enroll with the LHIO in their locality.
- All senior citizens enrolling must submit to the LHIO in their locality:
- a duly accomplished PMRF;
- a 1 x 1 photo taken within the last six (6) months; and
- a Senior Citizen’s Identification Card issued by the OSCA in the city or municipality where the elderly resides or ANY of the listed documents proving senior status:
- Philippine passport;
- birth certificate;
- baptismal certificate;
- valid driver’s license;
- voter’s ID;
- SSS/GSIS ID;
- valid Professional Regulatory Commission (PRC) ID;
- postal ID;
- National Bureau of Investigation (NBI) clearance;
- Overseas Filipino Worker’s ID;
- valid identification cards issued by recognized government institutions/agencies/corporations specifying full name, sex, date of birth, address, and signature of owner.
- If the listed documents are unavailable, PhilHealth accepts substitutes subject to PhilHealth validation:
- certificate from the National Council for the Welfare of Disabled Persons (NCWDP);
- DSWD or Local DSWD certification;
- Barangay certification; and
- affidavit from two (2) disinterested persons certifying the age and identity of the elderly person.
- LHIO registration is not accepted for senior citizens represented by individuals who are unauthorized, not identified, or not tapped by the Corporation, the DSWD, or the LGUs facilitating enrollment.
Qualified dependents and declaration
- A Senior Citizen member declares qualified dependents in the PMRF consisting of:
- a legitimate spouse who is not enrolled under the NHIP;
- children, legitimate or illegitimate, below twenty-one (21) years of age, who are unmarried and unemployed;
- a child aged twenty-one (21) years or above suffering from a congenital disability (physical or mental) or any disability rendering the person totally dependent on the member for support; and
- a foster child as defined in Republic Act No. 10165 (Foster Care Act of 2012).
Premium funding and benefits entitlement
- Senior Citizen members’ premium contributions are sourced from proceeds of Republic Act No. 10351 (Sin Tax Law).
- PhilHealth sends the Department of Budget and Management (DBM) through the Department of Health (DOH) a billing statement for the annual payment of premium contributions for enrolled senior citizens.
- The Senior Citizen premium rate is not less than the rate prescribed for Indigent members of the NHIP.
- PhilHealth reserves the right to determine the most actuarially feasible premium contribution rate to sustain the identified benefits.
- Upon effectivity of Republic Act No. 10645, Senior Citizen members and their qualified dependents are entitled to benefit packages under the NHIP including:
- inpatient hospital care;
- day/ambulatory services;
- special benefits for catastrophic cases referred to as Z-benefits;
- TB-DOTS package;
- animal bite package;
- malaria package;
- outpatient HIV/AIDS Treatment package;
- blood transfusion package;
- maternity and newborn care package;
- normal spontaneous delivery package;
- pre-natal care package;
- benefits for voluntary contraceptive surgical procedures;
- starting January 2015, Primary Care Benefit Package: Tamang Serbisyo sa Kalusugan ng Pamilya (Tsekap) for Senior Citizen members, Lifetime Members, and Kasambahays aged 60 years old and above.
- Senior Citizen members, Lifetime Members, and Kasambahays aged 60 years old and above are entitled to the No Balance Billing Policy (NBB) of PhilHealth when confined in accredited government health care facilities, subject to applicable rules for NBB availment.
- PhilHealth annually reviews senior citizen services and benefit packages to determine financial sustainability and relevance to health care innovations.
- A Senior Citizen member is entitled to 45 days of confinement coverage every calendar year.
- Qualified dependents share among themselves an additional 45 days of confinement coverage every calendar year.
- If the Senior Citizen member dies, qualified dependents are entitled to program benefits only until the end of the calendar year.
- After the Senior Citizen member’s death, qualified dependents enroll as principal members.
How to avail and direct filing transitory period
- To avail benefits, a Senior Citizen member presents the PhilHealth Identification Card to any PhilHealth-accredited health care provider.
- If no PIC is available, a valid ID and proof of senior status may be used to avail benefits.
- Failure to enroll before the date of benefit availment does not bar availment when enrollment is allowed during confinement or after benefits are availed, provided that the required enrollment documents are attached to the claims document submitted by the health care provider.
- For a Senior Citizen member’s qualified dependent, a PhilHealth Benefit Eligibility Form (PBEF) indicating dependent eligibility must be attached to standard claim documents.
- If no PBEF is attached, standard claim documents must include either:
- a copy of the MDR showing the dependent has been declared in PhilHealth’s membership database; or
- a duly accomplished PMRF declaring the patient as a qualified dependent of the Senior Citizen.
- PhilHealth CARES, deployed in accredited hospitals under PhilHealth Circular No. 12, series of 2012, extends assistance needed for Senior Citizen members and qualified dependents to avail NHIP benefits.
- Transitory coverage applies to Senior citizens and qualified dependents confined from the effectivity of Republic Act No. 10645 on November 25, 2014 until this circular’s effectivity who were unable to avail benefits through automatic deduction.
- Qualified claimants in the transitory period have sixty (60) calendar days from the circular’s effectivity to directly file benefit claims with any PhilHealth office that has jurisdiction over the health care provider or hospital where confinement occurred.
- Directly filed claims require submission of documents, including:
- for senior citizens not yet issued a PIN: duly accomplished PMRF and any proof of senior status as provided under enrollment requirements;
- completely and properly filled-out Claim Forms 1 and 2;
- when necessary: completely and properly filled-out Claim Form 3 (CF 3) or, in lieu of CF 3, a photocopy of the chart, clinical abstract, or other similar documents;
- for Animal Bite Package: the treatment card/animal bite treatment record instead of CF 3;
- other documents detailing confinement such as operative or surgical technique and anesthesia records;
- a duly accomplished Waiver Form for Directly Filed Claims — Annex I of PhilHealth Circular No. 020, series of 2014; and
- other requisite documents for directly filed benefit claims specified in PhilHealth Circular No. 020, series of 2014.
- Directly filed claims are filed by the senior citizen or their duly authorized representative to the appropriate PhilHealth office.
Repeal and mandatory application
- All previous PhilHealth issuances inconsistent with this circular’s provisions are repealed and/or amended accordingly.