Title
PHIC Benefit Schedule for Indigent Members
Law
Phic Philhealth Circular No. 77-a
Decision Date
Jan 31, 2000
The upgraded benefit schedule for indigent members ensures equalized Medicare benefits across all sectors, providing comprehensive coverage for various medical services, including room and board, drugs, and professional fees.
indigent members
health insurance
benefit schedule

Why the benefit schedule was upgraded

  • The circular provides that indigent-sector benefits were upgraded in view of the equalization of medical care benefits for government and private sector employees and their dependents.
  • The circular requires the upgraded indigent benefits so that all members of the NHIP enjoy one Medicare benefit package.

Who is covered by the unified schedule

  • The circular applies to ALL members under the NHIP.
  • The circular’s unified schedule covers Government Indigent and Private Sector Members, including:
    • OWWA members, and
    • Individually Paying Members.
  • The circular includes dependents of covered members in the benefit package.

Benefit package structure and limits

  • The circular provides a unified benefit schedule with benefit item categories across PRIMARY, SECONDARY, and TERTIARY levels.
  • The circular limits Room and Board to not exceeding 45 days for each member and another 45 days to be shared by his dependents.
  • The circular applies the following “per single period of confinement” structure to the listed categories:
    • Drugs & Medicines, and
    • X-Ray, Lab, Etc.
  • The circular provides distinct caps by severity tier for the following categories (as applicable):
    • Ordinary, Intensive, and Catastrophic for Drugs & Medicines; and
    • Ordinary, Intensive, and Catastrophic for X-Ray, Lab, Etc.

Room and board benefit limits

  • The circular sets Room and Board caps of 120 (PRIMARY), 220 (SECONDARY), and 345 (TERTIARY).
  • The circular limits the eligible duration to not exceeding 45 days for each member.
  • The circular allows another 45 days to be shared by dependents.
  • The circular specifies that these room-and-board limits are applied within the covered duration described above.

Drugs, medicines, and confinement caps

  • The circular sets Drugs & Medicines caps per single period of confinement at:
    • Ordinary: 1,165 (PRIMARY), 1,595 (SECONDARY), 2,670 (TERTIARY).
    • Intensive: 2,430 (PRIMARY), 3,280 (SECONDARY), 7,660 (TERTIARY).
    • Catastrophic: 0 (PRIMARY), 6,575 (SECONDARY), 11,885 (TERTIARY).
  • The circular applies the caps as severity-dependent limits under the Primary/Secondary/Tertiary structure.

X-ray, laboratory, and related caps

  • The circular sets X-Ray, Lab, Etc. caps per single period of confinement at:
    • Ordinary: 305 (PRIMARY), 760 (SECONDARY), 1,625 (TERTIARY).
    • Intensive: 590 (PRIMARY), 1,680 (SECONDARY), 3,405 (TERTIARY).
    • Catastrophic: 0 (PRIMARY), 3,405 (SECONDARY), 9,810 (TERTIARY).
  • The circular applies these limits as severity-dependent caps consistent with the Primary/Secondary/Tertiary schedule.

Professional fees and daily limits

  • The circular provides that Professional Fees are subject to a per-day ceiling per single period of confinement.
  • The circular sets daily ceilings for professional fees at:
    • P105/day for General Practitioner, and
    • P150/day for Specialist.
  • The circular provides professional-fee package caps of:
    • General Practitioner: 540 (PRIMARY), 540 (SECONDARY), 540 (TERTIARY).
    • Specialist: 810 (PRIMARY), 810 (SECONDARY), 810 (TERTIARY).
    • Intensive/Catastrophic – General Practitioner: 810 (PRIMARY), 810 (SECONDARY), 810 (TERTIARY).
    • Intensive/Catastrophic – Specialist: 1,350 (PRIMARY), 1,350 (SECONDARY), 1,350 (TERTIARY).

“Others,” surgeon, and anesthesiologist caps

  • The circular sets Others – Hospital (OR) caps based on RUV bands:
    • RUV 5 & Below: 385 (PRIMARY), 670 (SECONDARY), 1,060 (TERTIARY).
    • RUV 1.5 to 10: 0 (PRIMARY), 1,140 (SECONDARY), 1,350 (TERTIARY).
    • RUV Above 10: 0 (PRIMARY), 2,160 (SECONDARY), 3,490 (TERTIARY).
  • The circular sets the Surgeon maximum at 15,390 @ 420/Relative Unit Value.
  • The circular sets the Anesthesiologist maximum at 4,785 @ 420/Relative Unit Value.

Outpatient benefits and named procedures

  • The circular provides Outpatient Benefits categories including:
    • Chemotherapy
    • Radiotherapy
    • Hemodialysis
    • Cataract extraction
    • Minor surgical procedure
  • The circular provides Surgical Family Planning Procedure outpatient benefits including:
    • Vasectomy: 900 (PRIMARY), 900 (SECONDARY), 900 (TERTIARY).
    • Tubal Ligation: 1,125 (PRIMARY), 1,125 (SECONDARY), 1,125 (TERTIARY).

Adoption and signature

  • The circular is marked “Adopted: 31 Jan. 2000”.
  • The circular is signed by (SGD.) ENRIQUE M. ZALAMEA, President and CEO.

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