Coverage of Benefits
The benefit schedule applies to three hospitals classification levels: primary, secondary, and tertiary care facilities. Benefits cover:
- Room and board
- Drugs and medicines
- X-ray and laboratory services
- Professional fees
- Other hospital services (Operating Room and surgical fees)
- Outpatient benefits including chemotherapy, radiotherapy, hemodialysis, cataract extraction, and minor surgical procedures
- Surgical family planning procedures (vasectomy and tubal ligation)
Room and Board Benefits
- Coverage is provided up to a maximum of 45 days per member.
- Additional 45 days are allotted to be shared among the dependents of the member.
- The daily rates differ by hospital classification: PHP 120 (primary), PHP 220 (secondary), PHP 345 (tertiary).
Drugs and Medicines
- Divided into Ordinary, Intensive, and Catastrophic categories per single confinement period.
- Percentages of coverage increase with hospital level, with catastrophic cases covered only at secondary and tertiary levels.
- Maximum limits for each category per confinement period are specified, e.g., for tertiary hospitals: PHP 2,670 (ordinary), PHP 7,660 (intensive), PHP 11,885 (catastrophic).
X-ray, Laboratory, and Diagnostic Tests
- Coverage provided per single confinement period, distinguished by Ordinary, Intensive, and Catastrophic categories.
- Catastrophic cases are covered only at secondary and tertiary levels.
- Maximum allowances vary with hospital level, e.g., tertiary hospitals provide the highest benefit (e.g., PHP 9,810 for catastrophic cases).
Professional Fees
- Maximum daily professional fees are limited to:
- PHP 105/day for General Practitioners
- PHP 150/day for Specialists
- Per period of confinement ceilings are as follows:
- Ordinary cases: PHP 540 (GP), PHP 810 (Specialist)
- Intensive/Catastrophic cases: PHP 810 (GP), PHP 1,350 (Specialist)
- Fees apply uniformly across all hospital levels.
Other Hospital Services
- Operating Room (OR) fees are based on Relative Unit Value (RUV) classifications:
- RUV 5 and below
- RUV 1.5 to 10
- RUV above 10
- Maximum allowable fees increase with hospital level and RUV category.
- Surgeon fees have a maximum of PHP 15,390 at PHP 420/RUV.
- Anesthesiologist fees have a maximum of PHP 4,785 at PHP 420/RUV.
Outpatient Benefits
- Cover procedures such as chemotherapy, radiotherapy, hemodialysis, cataract extraction, and minor surgical procedures.
Surgical Family Planning Procedures
- Coverage includes vasectomy and tubal ligation, with fixed reimbursement rates:
- Vasectomy: PHP 900
- Tubal Ligation: PHP 1,125
Purpose and Implementation
- The benefit schedule aims to standardize and upgrade benefits for indigent sector members to match those given to government and private sector employees.
- This ensures equity and uniformity in the Medicare package provided under the NHIP.
Issuance and Authority
- The circular was adopted on January 31, 2000, under the authority of PHIC President and CEO Enrique M. Zalamea.