Law Summary
Coverage Objectives
- To provide implementing guidelines and procedures for enrolling senior citizens not currently covered under NHIP.
Key Definitions
- Senior Citizen/Elderly: Filipino citizens aged 60 or above, including dual citizens meeting residency and citizenship proof requirements.
- Senior Citizens not covered by NHIP include those without PhilHealth numbers, insufficient contributions, not indigents, not sponsored members, not lifetime members, or qualified dependents improperly registered.
- OSCA: Office for Senior Citizens Affairs in local government units.
- LHIO: Local Health Insurance Office of PhilHealth responsible for enrollment and service delivery.
General Provisions
- A new membership category “Senior Citizen” is created for unenrolled senior citizens.
- Senior citizens who are gainfully employed and earn above poverty threshold must contribute premiums.
- Qualified dependents who are senior citizens themselves must enroll separately.
Enrollment Procedures
- Enrollment coordinated primarily with OSCA or equivalent local office.
- OSCA to submit quarterly lists of senior citizens to LHIO.
- Required submission includes detailed personal and dependent information in electronic format.
- PMRFs (PhilHealth Member Registration Forms) should accompany enrollment lists.
- Enrollment may also proceed via national agencies, senior citizen organizations, or directly by seniors with required documents.
- Required documents include PMRF, recent 1x1 photo, and proof of senior citizen status (with a list of acceptable IDs and certifications).
- Unlawful registration by unauthorized persons is prohibited.
Qualified Dependents Declaration
- Members may declare:
- Legitimate spouse not enrolled in NHIP.
- Legitimate or illegitimate children under 21, unmarried and unemployed.
- Children above 21 with congenital disability totally dependent on member.
- Foster children as defined by Foster Care Act.
Premium Contributions
- Premiums paid from Sin Tax proceeds.
- PhilHealth bills the DBM through the DOH annually.
- Premium rate for senior citizens shall be no less than that for indigent members.
- PhilHealth retains discretion over sustainable premium rates.
Benefit Packages and Entitlements
- Benefits include inpatient care, ambulatory services, catastrophic case benefits (Z-benefits), TB-DOTS, animal bites, malaria, HIV/AIDS treatment, blood transfusion, maternity and newborn, contraceptive surgical procedures, and the Primary Care Benefit Package (Tsekap).
- No Balance Billing (NBB) policy applies in government facilities.
- Senior citizens entitled to 45 days confinement coverage annually; dependents share additional 45 days.
- Upon member's death, dependents retain benefits through calendar year-end, then must enroll as principals.
Availment of Benefits
- Presentation of PhilHealth Identification Card (PIC) or valid ID as proof of senior citizen status required.
- Enrollment can occur during or after confinement if not previously enrolled.
- For dependents, Benefit Eligibility Form or related membership proof required.
- PhilHealth CARES staff provide assistance in accredited hospitals.
Transitory Provisions for Claims
- Senior citizens confined since November 25, 2014, who missed automatic deduction can file claims within 60 days after Circular effectivity.
- Required submission includes PMRF, proof of status, claim forms, medical documents, waiver forms, and other supporting papers.
Repealing Clause
- All inconsistent prior PhilHealth issuances are repealed or amended accordingly.
Effectivity
- Circular effective 15 days after publication in two newspapers of general circulation.
- Circular to be filed with National Administrative Register at UP Law Complex.