National Employment Master Plan Law

The circular implements the benefit-entitlement rule under Republic Act No. 7875, as amended by Republic Act No. 9241 (National Health Insurance Act).
The benefit entitlement rule applies to members whose contributions meet both a minimum paid period and a regularity requirement, and who are not under legal penalties as defined by the Act.
The circular expressly ties its requirement to the implementing rules’ concepts of sufficient regularity and the timing of premium payments.
The circular establishes that PhilHealth will require NINE (9) MONTHS OF CONTRIBUTION within 12 (twelve) months prior to the month of availment.

A member’s eligibility to avail benefits is tied to contribution payment within the relevant look-back periods described by Section 42 of RA 7875, as amended by RA 9241.
The prior baseline entitlement concept remains that a member must have premium contributions for at least three (3) months paid within the six (6) months prior to the first day of the member’s (or dependents’) availment under Section 42.
The circular adds a higher requirement: nine (9) months paid within the immediate 12 months preceding the month of availment for the specific confinement and outpatient benefit coverage it governs.
The circular requires sufficient regularity of premium contribution and that the member is not currently subject to legal penalties as defined in RA 7875 as amended by RA 9241.

Premium contributions must be paid with a contribution “reckoning date” tied to the last day prior to confinement for purposes of counting toward the confinement’s eligibility window.
Premium payments made within the confinement are not counted for the present confinement but are counted for future/prospective confinements, consistent with the circular’s payment-timing rule.
When a contribution is paid before confinement, the payment is counted using the circular’s reckoning approach: the reckoning date is the date of the last day prior to confinement.
When the circular’s examples state a specific date, counting follows the rule that payment on March 14, 2011 is counted for confinement on March 15–16, 2011, while payment on March 15, 2011 is counted for future/prospective confinements instead.

The 9-month within 12 months requirement applies to all confinements, and it also covers availment of outpatient benefit.
The circular applies to all types of members except those under the Sponsored Program.
The circular applies to all types of members except those under the Lifetime (Non-Paying) Program.
The circular applies to all types of members except those under the Overseas Workers Programs (OWP).

To qualify for benefit availment under the circular’s conditions, a member must satisfy the three (3) months within six (6) months paid premium requirement, tied to the first day of availment under the Section 42 entitlement framework.
The member must also demonstrate sufficient regularity of premium contribution through payment patterns required by the circular’s definition of sufficient regularity.
The member must meet the circular’s core additional rule: paid contribution of nine (9) months from the month immediately preceding up to the month of availment, counted as part of the immediate 12 months preceding the month of availment.
The member must not be subject to legal penalties as defined in RA 7875, as amended by RA 9241.

For a confinement in a given month of availment (example used by the circular: March 15–16, 2011), the requirement is 9 months paid premium contribution from March 2010–February 2011.
If the circular’s “9-month requirement” includes a month (example: February) that is still unpaid, the unpaid portion must be paid until the last day prior to confinement/availment (example: March 14, 2011) to count for that confinement.
Payment made during or after the confinement is not counted for the present confinement and is counted for future/prospective confinements instead.
The circular’s “9-month” rule uses a look-back within the 12-month period immediately prior to the month of availment.

For confinement on March 15–16, 2011, premium contributions of three (3) months within six (6) months prior to March 2011 must be paid prior to confinement using the circular’s reckoning approach.
For that confinement example, premium payment made on March 14, 2011 for a coverage period (example: January–March 2011) is counted for the confinement.
For that confinement example, premium payment made on March 15, 2011 and thereafter is not considered for the confinement but may be considered for future confinements.
The circular provides payment-timing illustrations to show the cutoff: payments are counted only if made before the confinement begins, consistent with counting up to the last day prior to confinement.

The circular provides that all other provisions inconsistent with its 9-month within 12 months rule are repealed/amended accordingly.
The circular expressly states that previously allowed contributions paid during confinement (citing earlier circular numbers) shall no longer be considered for the present confinement but are still treated for future/prospective confinements under the new rule.
Previously cited rules for payment during confinement referenced in the circular are PhilHealth Circular Nos. 24 s-2003, 14 s-2004, and 7 s-2006.
The circular’s effective application is limited to reimbursements with admission/treatment (out-patient) date starting July 1, 2011.