Legal basis and amended statute
- Republic Act No. 10645 mandates PhilHealth coverage of all senior citizens and amends Republic Act No. 9994 (Expanded Senior Citizen Act of 2010).
- Republic Act No. 10645 further amends Section 5, sub-paragraph h (2) of Republic Act No. 7432, as amended.
- The amended rule mandates that all senior citizens are covered by PhilHealth’s national health insurance program, with enrollment funds sourced from the National Health Insurance Fund of PhilHealth from proceeds of Republic Act No. 10351.
- This Circular creates the Senior Citizen membership category and sets the implementing enrollment, eligibility, contribution, benefits, and availment rules.
Policy and objective
- All senior citizens are enrolled for coverage under the NHIP through a new membership category called Senior Citizen.
- The Circular’s objective is to establish implementing guidelines and procedures for coverage and entitlement of senior citizens not currently covered under the NHIP.
- The Circular implements the mandate of Republic Act No. 10645 by defining who is eligible, how to enroll, and how to avail NHIP benefits.
Core definitions and offices
- Senior citizen or elderly refers to a Filipino citizen who is a resident of the Philippines and is aged sixty (60) years or above.
- A dual citizen aged 60 years or above may be treated as a senior citizen if there is proof of Filipino citizenship and at least six (6) months of residency in the Philippines as provided in the IRR of Republic Act No. 9994.
- Senior citizen who is not currently covered under the NHIP refers to a senior citizen who is:
- not yet issued with a PhilHealth Identification Number (PIN);
- a member in the formal or informal economy but has no qualifying contributions to entitle the person to Program benefits;
- not an identified indigent under NHTS-PR or Listahan of DSWD;
- not currently a Sponsored Member; and
- not yet qualified as a Lifetime member; and
- not a qualified dependent of an NHIP member already declared in PhilHealth’s membership database.
- Office for the Senior Citizens Affair (OSCA) is the office established in cities and municipalities under the Office of the Mayor headed by a senior citizen, as provided in the IRR of Republic Act No. 9994.
- Local Health Insurance Office (LHIO) is the PhilHealth office in every province or city, or wherever practicable to bring services closer to members, as provided in Section 22 of Republic Act No. 7875, as amended by Republic Act No. 9241 and further amended by Republic Act No. 10606.
Membership category, enrollment actors, continuity rule
- A new membership category called “Senior Citizen” is created to provide coverage to senior citizens not currently covered under the NHIP.
- A Senior Citizen member’s qualified dependents who are also senior citizens (e.g., a legal spouse aged 60 years or above) must be enrolled separately as Senior Citizen members.
- Qualified dependents of other NHIP member categories who are senior citizens must also be enrolled separately as Senior Citizen members.
- LHIOs issue the PhilHealth Identification Card (PIC) and the Member Data Record (MDR) for enrolled Senior Citizen members.
- A Senior Citizen who is gainfully employed or has a regular source of income must continue to contribute to the Program under existing rules for formal or informal economy members, provided that the income exceeds the poverty threshold of the province or city where the senior citizen resides; the poverty threshold is based on the latest survey released by the Philippine Statistics Authority.
Enrollment process and required documents
- Senior Citizen members must be primarily enrolled in coordination with the OSCA, or any office designated by the Office of the Mayor, in the locality where they reside.
- The OSCA maintains and regularly updates, on a quarterly basis, the list of senior citizens as provided in Section 4(c), Rule VI of the IRR of RA 9994.
- The OSCA may submit, on a quarterly basis, the senior citizen list for enrollment to the LHIO with operational jurisdiction over the locality.
- The OSCA list must include the senior citizen’s:
- full name (family, first, middle, including extension if applicable);
- birthdate;
- sex; and
- address with the breakdown: Unit/Room/Floor No.; Building Name; Lot/Block/House/Building No.; Street; Subdivision/Village; Barangay (required field); City/Municipality (required field); and Province (required field).
- To expedite enrollment, the OSCA list must be submitted in electronic format (e.g., Microsoft Excel, Microsoft Access, text file, or any other format acceptable), and the file must be password protected.
- The electronic list must be accompanied by a transmittal letter from OSCA and the printed alphabetical list of names.
- The OSCA list should be accompanied by duly accomplished PhilHealth Member Registration Form (PMRF); if OSCA cannot submit the electronic list, duly accomplished PMRFs may suffice, endorsed to the LHIO.
- LHIOs may secure lists for enrollment under care of the DSWD, including accredited institutions run by non-government organizations or nonprofit private organizations, and may also tap other national government agencies and instrumentalities to ensure coverage.
- Senior citizens organizations may be tapped by LHIOs to facilitate enrollment of their senior citizen members, provided the organizations are oriented by LHIO on enrollment guidelines and procedures, Program benefits, and availment procedures before submitting the list and PMRFs.
- Senior citizens may directly enroll with the LHIO in their locality.
- Senior citizens enrolling must submit to the LHIO in their locality:
- duly accomplished PMRF;
- a 1 x 1 photo taken within the last six (6) months; and
- a Senior Citizen’s Identification Card issued by OSCA in the city or municipality where the elderly resides, or any proof of senior citizen status from the following:
- Philippine passport;
- birth certificate;
- Baptismal Certificate;
- valid Driver’s license;
- voter’s ID;
- SSS/GSIS ID;
- valid 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;
- or, in the absence of the above documents and 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.
- The LHIO must not accept registration of senior citizens represented by individuals unauthorized or not identified or tapped by the Corporation, the DSWD, or the LGUs facilitating enrollment.
Qualified dependents and premium funding
- A Senior Citizen member may declare the following as qualified dependents in the PMRF:
- 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 that renders the child totally dependent on the member for support; and
- foster child as defined in Republic Act No. 10165 (Foster Care Act of 2012).
- Premium contributions of Senior Citizen members are sourced from proceeds of Republic Act No. 10351 (Sin Tax Law).
- PhilHealth must send to the Department of Budget and Management (DBM) through the Department of Health (DOH) a billing statement for annual payment of premium contributions of enrolled senior citizens.
- The premium rate for the Senior Citizen category must not be less than that 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.
Benefits, entitlements, and required proofs
- Upon effectivity of Republic Act No. 10645, Senior Citizen members and qualified dependents are entitled to NHIP benefit packages for:
- 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;
- ante-natal care package; and
- benefits for voluntary contraceptive surgical procedures.
- Health care services and benefit packages for senior citizens under the Program must be reviewed annually by the Corporation to determine financial sustainability and relevance to health care innovations.
- If a Senior Citizen member dies, qualified dependents are entitled to Program benefits only until the expiration of the deceased principal member’s validity or coverage period.
- To avail of Program benefits, Senior Citizen members must present the PhilHealth Identification Card (PIC) to any PhilHealth-accredited health care provider; in its absence, present any valid ID as proof of senior citizen status.
- Absence of the PhilHealth Identification Card does not prejudice rights of a senior citizen or qualified dependents to avail benefits, provided a valid ID or document proving identity and age is presented.
- If enrollment was not completed before the date of availment, enrollment is allowed during confinement or after benefits have been availed, provided required enrollment documents (under Section V) are attached to the claims document submitted by the health care provider.
- To avail benefits for a Senior Citizen qualified dependent, a PhilHealth Benefit Eligibility Form (PBEF) indicating the dependent’s eligibility must be attached to standard claim documents, together with 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 must extend the utmost assistance needed to ensure Senior Citizen members and qualified dependents can avail NHIP benefits, as provided in PhilHealth Circular No. 12 (series of 2012).
Transitory claims window after RA 10645 effectivity
- Senior citizens and their qualified dependents confined from November 25, 2014 (effectivity of Republic Act No. 10645) until the Circular’s effectivity who were unable to avail benefits through automatic deduction are granted sixty (60) calendar days from the Circular’s effectivity to directly file benefit claims with any PhilHealth Office having jurisdiction over the health care provider or hospital.
- For directly filed claims, the senior citizen or duly authorized representative must submit:
- for those not yet issued a PIN: duly accomplished PMRF and any proof of senior citizen status under Section V.9;
- completely and properly filled-out Claim Forms 1 and 2;
- if necessary: completely and properly filled-out Claim Form 3 (CF3) or, in lieu of CF3, a photocopy of the chart, clinical abstract, or similar documents;
- for the Animal Bite Package: the treatment card/animal bite treatment record instead of CF3;
- other documents giving details about confinement, including 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).
Repeal and mandatory conflict rule
- All previous PhilHealth issuances inconsistent with the Circular are repealed and/or amended accordingly.