Clarification in the Application of Qualifying Contributions to Ensure Entitlement to PhilHealth Benefits

December 10, 2014

PHILHEALTH CIRCULAR NO. 003-14

 

I. Rationale

Pursuant to Republic Act No. 7875 as amended by R.A. 10606 otherwise known as the National Health Insurance Act of 2013, this Circular is being issued for the consistent implementation of Section 12 on the Entitlement to Benefits, to wit:

"A member whose premium contributions for at least three (3) months have been paid within six (6) months prior to the first day of availment, including those of the dependents, shall be entitled to the benefits of the program"

II. Coverage

This Circular shall cover the paying PhilHealth members from the Formal Economy and Informal Economy sectors excluding the land based OFWs.

III. Premium Payment Required for Entitlement to Benefits

1. All members mentioned in this Circular shall be entitled to PhilHealth benefits, provided that premium contribution has been paid for at least three (3) months within the six (6) months prior to the first day of availment. The qualifying six months is inclusive of the confinement month; HEScID

2. Payments made on admission date or during confinement period or after discharge shall NOT be counted as qualifying contributions except otherwise declared by PhilHealth.

IV. Exemptions for Payment during Admission Period

The allowable deadline of payment within an applicable quarter is provided to give members longer time to pay their premium contribution. However, only applicable monthly payments made prior to the first day of availment shall be counted as compliance to the three (3) months within the six (6) months qualifying contributions for entitlement to benefits.

Payments made on admission date or during confinement period shall NOT be counted as qualifying contributions except for the following:

a. Dependents —

1. Children that just turned 21 years old who immediately enrolled under the Informal Sector and paid his/her premiums within the quarter of his/her birth month;

2. Spouse who opted to enroll as a Primary Member or previously declared dependent of a deceased primary member;

3. Dependent who are newly hired employees.

b. Sponsored Members whose sponsor has not signified its intention to continue the coverage of its enrollees in CY 2014 and paid the required 1st quarter contribution;

c. Members with seasonal employment whose employment have been recently terminated and paid the remaining unpaid months within the calendar quarter of separation period;

d. OFW whose payment coverage ends but will no longer work as an OFW and have paid their premium contribution within the calendar quarter following the date of last coverage. EcTCAD

V. Effectivity

This Circular shall take effect to all admissions starting January 1, 2015.

For information and guidance.

(SGD.) ALEXANDER A. PADILLAPresident and CEOPhilippine Health Insurance CorporationDate Signed: December 10, 2014