[ PHILHEALTH CIRCULAR NO. 25, S. 2010, September 08, 2010 ]
NINE (9) MONTHS CONTRIBUTION AS A REQUIREMENT FOR BENEFIT AVAILMENT
Section 42. Entitlement to Benefits - A member whose premium contributions for at least three (3) months have been paid within the six (6) months prior to the first day of his or his dependents availment, shall be entitled to the benefits of the Program: Provided, that such member can show that he contributed thereto with sufficient regularity, as evidenced in their health insurance ID card: and Provided further, that he is not currently subject to legal penalties as provided for in ..this Act.
And in,
Title II - Definition of Terms of the RIRR - Sufficient Regularity of Premium Contribution - the Payment of premium contribution of at least nine (9) months within twelve-month period immediately prior to the month of availment.
the Corporation shall now require NINE (9) MONTHS OF CONTRIBUTION within 12 (twelve) months prior to the month of availment for all confinements including availment of outpatient benefit.
This requirement is based on the following conditions as stated above:
1. Three (3) months within six (6) months paid premium contributions prior to the first day of his or his dependents availment, and
2. Sufficient regularity of premium contribution and
3. No legal penalties as defined in RA 7875 amended by RA 9241.
To illustrate:
Example: A patient to be confined on March 15-16, 2011
A. For condition 1 - Paid premium contributions of three (3) months from September 2010-February 2011.
CY 2010 |
CY 2011 |
May |
Jun |
Jul |
Aug |
Sep |
Oct |
Nov |
Dec |
Jan |
Feb |
Mar |
Apr |
May |
Jun |
| 3 months premium contribution within 6 months prior to March 2011 (month of availment) |
Premium contribution shall be paid prior to confinement, thus, the reckoning date of payment contribution shall be the date of the last day prior to confinement. Any contribution payment paid within the confinement, allowed under previously defined policies (i.e., PhilHealth Circular Nos. 24 s-2003, 14 s-204 and 7 s-2006), shall no longer be considered for the present confinement but for future/prospective ones.
Example: A patient to be confined on March 15-16, 2011
a. Premium payment for January-March 2011 made on March 14, 2011 shall be considered.
March 2011 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
18 |
19 |
20 |
21 |
22 |
23 |
March 2011 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
18 |
19 |
20 |
21 |
22 |
23 |
x |
x |
x |
x |
x |
x |
x |
x |
x |
B. For condition 2 (Sufficient Regularity) - Paid contribution of nine (9) months from March 2010 - February 2011
CY 2010 |
CY 2011 |
| Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | Jan | Feb | Mar |
9 months paid premium contribution within the immediate 12 months preceding March 2011 (month of availment) |
Thus, for a confinement in March 15-16, 2011, the requirement shall be 9 months paid premium contribution from March 2010-February 2011. If in case February contribution is included in the 9 month requirement and is still unpaid, this shall be paid until the last day prior to confinement/availment, March 14, 2011. Payment made during or after the confinement shall not longer be considered for the present confinement but for future/prospective ones.
This requirement shall be for all types of members except those under the Sponsored Program, Lifetime (Non-Paying) Program and the Overseas Workers Programs (OWP).
This policy shall be effective for all reimbursements with admission/streatment (out-patient) date starting July 1, 2011.
All other provisions inconsistent herewith are hereby repealed/amended accordingly.
(SGD.) DR. REY B. AQUINO
President and CEO