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(NAR) VOL. 26 NO. 1/ JANUARY - MARCH 2015

[ PhilHealth Circular No. 033-2014, December 17, 2014 ]


Adopted: 17 December 2014
Date Filed: 05 January 2015

I. Rationale

Republic Act No. 10645 was signed into law by His Excellency, President Benigno S. Aquino III, on November 5, 2014 which provides for the mandatory PhilHealth coverage of all senior citizens. The Law amended Republic Act No. 9994, otherwise known as the “Expanded Senior Citizen Act of 2010”.

Section 5, sub-paragraph h (2) of Republic Act No. 7432, as amended, was further amended to read as follows:

(2) Mandatory PhilHealth Coverage

All senior citizens shall be covered by the national health insurance program of PhilHealth. Funds necessary to ensure the enrollment of all senior citizens not currently covered by any existing category shall be sourced from the National Health Insurance Fund of PhilHealth from proceeds of Republic Act No. 10351, in accordance with the pertinent laws and regulations.”

II. Objective

This Circular is being issued to provide the implementing guidelines and procedures for the coverage and entitlement of all senior citizens not currently covered under the National Health Insurance Program (NHIP).

III. Definition of Terms

  1. Senior citizen or elderly - refers to any Filipino citizen who is a resident of the Philippines, and aged sixty (60) years or above. The term may apply to dual citizens aged 60 years old or above provided there is proof of Filipino citizenship and have at least six (6) months of residency in the Philippines as provided in the Implementing Rules and Regulations of Republic Act No. 9994.

  2. Senior citizen who is not currently covered under the NHIP - refers to a senior citizen who is:

    1. not yet issued with a PhilHealth Identification Number or PIN;
    2. a member in the formal or informal economy but has no qualifying contributions to be entitled to the Program benefits;
    3. not an identified indigent under the National Household Targeting Systems for Poverty Reduction (NHTS-PR) or Listahan of the Department of Social Welfare and Development (DSWD);
    4. not currently a Sponsored Member; and
    5. not yet qualified as a Lifetime member; and
    6. a qualified dependent of an NHIP member who has been declared in PhilHealth’s membership database.

  3. Office for the Senior Citizens Affair or OSCA - refers to the office established in cities and municipalities under the Office of the Mayor headed by a senior citizen as defined in the Implementing Rules and Regulations of Republic Act No. 9994, also known as the “Expanded Senior Citizens Act of 2010.”

  4. Local Health Insurance Office or LHIO-refers to the office established by PhilHealth in every province or city, or whenever it is deemed practicable to bring its services closer to members of the Program 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.

IV. General Provisions

  1. A new membership category of “Senior Citizen” is hereby created for the purpose of providing coverage to senior citizens who are not currently covered under the NHIP.

  2. Qualified dependents of senior citizens who are also senior citizens themselves, e.g., a legal spouse who has already reached 60 years of age, shall be enrolled separately as a Senior Citizen member of the NHIP.

  3. Qualified dependents of other member categories of the Program, with or without coverage, who are senior citizens themselves, e.g. parents aged 60 years old and above, shall be enrolled separately as a Senior Citizen member of the NHIP.

  4. The PhilHealth LHIOs shall issue the PhilHealth Identification Card (PIC) and the Member Data Record (MDR) of the enrolled Senior Citizen member. A copy of the PIC is hereto attached as Annex A.

  5. Senior citizens who are gainfully employed or remains to have a regular source of income shall continue to contribute to the Program, subject to existing rules and regulations for those members in the formal or informal economy: Provided, that said income exceeds the poverty threshold of the province or city where the senior citizen resides. The poverty threshold level shall be based on the latest survey released by the Philippine Statistics Authority on poverty statistics.

V. Enrollment

  1. Senior Citizen members shall be primarily enrolled in coordination with the OSCA, or any office designated by the Office the Mayor, in the locality where they reside.

  2. The OSCA maintains and regularly updates on a quarterly basis the list of senior citizens of its locality as provided in Section 4(c), Rule VI of the Implementing Rules and Regulations of RA 9994. The OSCA may submit, on a quarterly basis, to the LHIO, who has operational jurisdiction over the locality, the list of senior citizens for enrollment to the NHIP as Senior Citizens.

  3. The list must contain the following information about the senior citizen:

    1. Full name (family, first, middle, including name extension if applicable);
    2. Birthdate;
    3. Sex; and
    4. Address with the following breakdown:

      1. Unit/Room/Floor No.;
      2. Building Name;
      3. Lot/ Block/House/Building No.;
      4. Street;
      5. Subdivision/Village;
      6. Barangay (required field); and
      7. City/Municipality (required field); and
      8. Province (required field).

  4. To expedite enrollment, processing and validation, the list shall be submitted to the LHIO in electronic format, i.e., Microsoft Excel, Microsoft Access, text file, or any other format acceptable to the Corporation. The file must be password protected. The list in electronic format shall be accompanied by transmittal letter from OSCA and the printed alphabetical list of the names of the senior citizens.

  5. As much as practicable, a duly accomplished PhilHealth Member Registration Form (PMRF) shall be submitted with the list of senior citizens from OSCA. In cases where the OSCA, or the office designated by the Office of the Mayor, cannot submit the list in electronic format, the duly accomplished PMRFs of the senior citizens may suffice. These PMRFs shall be properly endorsed to the LHIO who has operational jurisdiction over the locality.

  6. The LHIOs will likewise secure the list of senior citizen for enrollment under the care of the DSWD or any of its accredited institutions run by non- government organizations or any nonprofit private organizations. Other national government agencies and its instrumentalities may also be tapped to ensure coverage of senior citizens.

  7. Senior citizens organizations, duly registered with appropriate national government agency and/or recognized by their local government unit, may be tapped by the LHIOs to facilitate the enrollment of their member senior citizens to the Program: Provided, that said organizations have been oriented by the LHIO on the enrollment guidelines and procedures, the Program benefits and availment procedures prior to the submission of the list of their member senior citizens and corresponding PMRFs to the LHIO.

  8. Senior citizens may also directly enroll with the LHIO in their locality.

  9. All senior citizens who will enroll to the Program shall be required to submit the following documents to the LHIO in their locality:

    1. a duly accomplished PMRF;
    2. a 1 x 1 photo taken within the last six (6) months; and
    3. a Senior Citizens’ Identification Card issued by the OSCA in the city or municipality where the elderly resides or ANY of the following as proof of status as senior citizen:

      1. Philippine passport;
      2. Birth certificate;
      3. Baptismal Certificate;
      4. Valid Driver’s license;
      5. Voter’s ID;
      6. SSS/ GSIS ID;
      7. Valid Professional Regulatory Commission (PRC) ID;
      8. Postal ID;
      9. National Bureau of Investigation (NBI) Clearance;
      10. Overseas Filipino Worker’s ID;
      11. Valid identification cards issued by recognized government institutions/agencies/corporations that specify the full name, sex, date of birth, address and signature of owner; or
      12. In the absence of the abovementioned documents, the following may be accepted, 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.

  10. The LHIO shall not accept registration of senior citizens represented by individuals unauthorized, not identified or tapped by the Corporation, the DSWD or the LGUs that will facilitate enrolment of senior citizens to the Program.

VI. Declaration of Qualified Dependents

A Senior Citizen member may declare the following as qualified dependents in the PMRF:

  1. Legitimate spouse who is not enrolled under the NHIP;
  2. Children, legitimate or illegitimate below twenty-one (21) years of age, who is unmarried and unemployed;
  3. Child who is twenty-one (21) years of age or above but suffering from a congenital disability, either physical or mental, or any disability that renders him or her totally dependent to the member for support; and
  4. Foster child as defined in Republic Act 10165 otherwise known as the “ Foster Care Act of 2012.”

VII. Premium Contributions

  1. The premium contributions of Senior Citizen members shall be sourced from the proceeds of Republic Act No. 10351 or commonly known as the Sin Tax Law.
  2. PhilHealth will send to the Department of Budget and Management (DBM) thru the Department of Health (DOH) a billing statement for the payment of premium contributions of the enrolled senior citizens on an annual basis.
  3. The premium rate for the Senior Citizen category shall not be less than that prescribed for Indigent members of the NHIP: Provided, That PhilHealth shall reserve the right to determine the most actuarially feasible premium contribution rate to sustain the identified benefits.

VIII. Benefits and Entitlements

  1. Upon the effectivity of Republic Act No. 10645, Senior Citizen members and their qualified dependents shall be entitled to the following benefit packages under the NHIP:

    1. Inpatient hospital care;
    2. Day/ambulatory services;
    3. Special benefits for catastrophic cases referred to as Z-benefits;
    4. Tuberculosis Directly Observed Treatment Short-course (TB-DOTS) package;
    5. Animal bite package;
    6. Malaria package;
    7. Outpatient HIV/ AIDS Treatment package;
    8. Blood transfusion package;
    9. Maternity and newborn care package;
    10. Normal spontaneous delivery package;
    11. Ante-natal care package; and
    12. Benefits for voluntary contraceptive surgical procedures.

  2. Health care services and benefit packages for the senior citizens under the Program shall be reviewed annually by the Corporation to determine its financial sustainability and relevance to health care innovations.
  3. In case of the Senior Citizen member’s death, the qualified dependents shall only be entitled to the Program benefits until the expiration of the validity or coverage period of the deceased principal member.

IX. Benefit Availment

  1. To avail of the Program benefits, Senior Citizen members shall present their PhilHealth Identification Card to any PhilHealth-accredited health care provider or in the absence thereof, any valid ID as proof of status as senior citizen.
  2. The absence of the PhilHealth Identification Card shall not prejudice the rights of a senior citizen or their qualified dependents to avail of the Program benefits or medical services under the Senior Citizen category: Provided, That a valid ID or document of the senior citizen as proof of identity and age is presented.
  3. In case a senior citizen was not able to enroll before the date of availment, enrollment to the Program shall be allowed during the confinement or after the benefits are availed provided that, the required documents for enrollment, as provided in Section V.9 hereof, are attached to the claims document that will be submitted to PhilHealth by the health care provider.
  4. For the benefit availment of a Senior Citizen member’s qualified dependent, a PhilHealth Benefit Eligibility Form (PBEF) indicating that said dependent is eligible to avail of the benefits must be attached to the standard claim documents:
    1. a copy of the MDR indicating that the dependent has been declared in PhilHealth’s membership database; or
    2. a duly accomplished PMRF declaring that the patient is a qualified dependent of the Senior Citizen.

  5. The PhilHealth Customer Assistance, Relationship and Empowerment Staff (PhilHealth CARES) deployed in accredited hospitals, as provided in PhilHealth Circular No. 12, series of 2012, shall extend utmost assistance needed to ensure that Senior Citizen members and their qualified dependents will be able to avail of the NHIP benefits.

X. Transitory Provisions

  1. Senior citizens and their qualified dependents who were confined from the effectivity date of Republic Act No. 10645 on November 25, 2014, until this Circular becomes effective but were unable to avail of the benefits thru automatic deduction are given sixty (60) calendar days from the effectivity of this Circular to directly file their benefit claims with any PhilHealth Office that has jurisdiction over the health care provider or hospital where they were confined.
  2. To directly file benefit claims, the senior citizen or their duly authorized representative should submit the following documents to any PhilHealth Office:

    1. For those senior citizens who are not yet issued a PIN, a duly accomplished PMRF AND any proof of status as a senior citizen as provided in Section V.9 hereof;
    2. Completely and properly filled-out Claim Forms 1 and 2;
    3. As may be necessary, a completely and properly filled-out Claim Form 3 (CF3) or in lieu of the CF 3, a photocopy of the chart, clinical abstract, or other similar documents etc;
    4. For Animal Bite Package, the treatment card/animal bite treatment record instead of CF 3;
    5. Other documents that provide details about the confinement such as but not limited to records of operative or surgical technique and anesthesia;
    6. A duly accomplished Waiver Form for Directly Filed Claims - Annex I of PhilHealth Circular No. 020, series of 2014; and
    7. Other requisite documents for directly filed benefit claims specified in PhilHealth Circular No. 020, series of 2014.

XI. Repealing Clause

All previous PhilHealth issuances inconsistent with the provisions of this Circular are hereby considered repealed and/or amended accordingly.

XII. Effectivity

This Circular shall take effect fifteen (15) days after its publication in at least two (2) newspapers of general circulation. It shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.

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