New Case Rate Packages from PhilHealth

New case rate packages for selected medical conditions and surgical procedures are now being implemented in institutional health care facilities accredited by the Philippine Health Insurance Corporation (PhilHealth). This is according to PhilHealth President and CEO Dr. Rey B. Aquino in a media statement during the CNEX Forum on New Case Rates held last August 22, 2011.

Full media statement follows..

Dr. Rey B. Aquino, PhilHealth President and CEO
Today we bring good news for our members: we are introducing a new method of paying for their medical care benefits through our partners in health care delivery. 
We are adopting the Case Rate method to pay for selected medical cases and surgical procedures. Why? There are various considerations. First, developments are taking place in the health care industry, most notable of which is the need to provide optimal financial risk protection especially to the most vulnerable groups, including the poorest of the poor.  We also want to empower our members more by letting them know exactly how much they can now avail themselves of for certain medical conditions and surgical procedures. Finally, for our partner-providers, the case rate method equates to faster processing of claims and therefore faster reimbursement for the services they have provided our members with.

The use of the case rate method in paying for health insurance benefits is nothing new. In fact, we have earlier used this for such conditions as the outpatient malaria treatment, HIV/AIDS, tuberculosis treatment, cataract surgery and a lot more. This time, we expanded the list to include the most common medical conditions that we pay for, meaning, these comprise about 49 percent of all claims that we received, processed and paid for over the last year.

What are these medical conditions that we will soon be paying for using the case rate method? Let me list them one-by-one:

                        MEDICAL CASES (11)
Dengue I
Dengue II
Pneumonia I
Pneumonia II
Essential hypertension
Cerebral infarction
Cerebro-vascular accident with hemorrhage
Acute gastroenteritis
Typhoid fever
Newborn care package in hospitals and lying-in clinics

            SURGICAL PROCEDURES (12)
Maternity Care Package
Normal Spontaneous Delivery Package in Level 1 hospitals
Normal Spontaneous Delivery Package in Levels 2 to 4 hospitals


Caesarean Section
Dilatation and curettage
Cataract surgery

These new rates are applicable for all types of members, and these include those who are  employed in the private and government sectors,  the lifetime members, the overseas workers, the individually paying members and the sponsored program members. They may avail themselves of these case rates in PhilHealth-accredited health care facilities nationwide.

One very important thing I would like to emphasize, however, is that for Sponsored Program members, meaning those whose enrolment into the National Health Insurance Program are paid for by the National Government, by the Local Government Units or by private individual and corporate sponsors, they are entitled to the ‘No Balance Billing’ policy when they avail themselves of any of these case rates in accredited government hospitals.

What does the NBB mean? It simply means that no other fees or expenses shall be charged or paid for by the patient-member above and beyond the packaged rates. Wala na ho silang babayaran para sa ospital man o sa duktor kung maaadmit sila dahil sa alinman sa mga nabanggit kong sakit kanina.

The NBB policy also applies when the Sponsored Program members avail themselves of outpatient surgeries, hemodialysis and radiotherapy in accredited non-hospital facilities that includes free-standing dialysis centers (FSDCs) and ambulatory surgical clinics (ASCs). It also applies when they are availing themselves of our existing outpatient packages for TB-DOTS, Malaria and HIV/AIDS.

At the same time, all other member-types are entitled to the NBB policy when availing themselves of the Maternity Care Package (MCP) and the Newborn Care Package (NCP) in accredited MCP (non-hospital) providers.

As the biggest purchaser of health care services in the country, your PhilHealth will continue to move towards options that will redound to better benefits for our members.  Our plans include more approaches to benefit payments and constantly improve on our benefit delivery ratio so that at the end of the day, we will be able to strengthen our mark in the lives of our fellow Filipinos, especially where their health care is concerned. 

We therefore seek your support to spread the good news to all our members and stakeholders. Maraming salamat po.

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