PhilHealth responds to members’ questions   

A reader said she was scheduled to undergo cataract surgery in a well-known eye clinic chain. But she was told that the procedure had to be done in another branch. 

She did not mind the change in venue, although the other clinic was farther from her home. However, she was told that she could not avail of her benefits as a member of the @Philippine Health Insurance Corporation (PhilHealth). She would have to pay the full amount of the surgery. 

The way she understood the explanation it was because the other clinic was in another location and, although it was part of one big chain, had not been accredited by PhilHealth.  

She could not understand how a clinic in Metro Manila that had been in existence for quite some time was still not accredited with PhilHealth and why, if that is the case, the clinic where she was a patient could not arrange for her to use her PhilHealth benefits even if the procedure was to be done in another place. 

 In response to this question, @Dr. Shirley B. Domingo, PhilHealth vice president, Corporate Affairs Group, explains that to participate in the National Health Insurance Program, health care facilities have to have a registration/license/certification from the Department of Health. 

If a health care facility has extension or branches, the branches have to apply for separate accreditation with PhilHealth. 

It seems that only one  branch of the eye clinic had been accredited by PhilHealth and the accreditation expired in 2020. 

Domingo adds that, for the member to avail of the cataract package, the following requirements should be met: 

A Cataract Pre-Surgery Authorization (CPSA) for the patient shall be secured by the facility from PhilHealth before the procedure is performed in PhilHealth-accredited health care facilities (hospitals and ambulatory surgical clinics) where the physician who will perform the operation  is affiliated, as declared in his/her accredited profile;  

The physician performing the cataract surgery must also be PhilHealth accredited. 

Existing guidelines require that the surgery has to be done in the same facility/clinic that applied for a patient’s CPSA.  

Member’s eligibility for benefits 

Another reader wanted to know how long he should be a PhilHealth member to be entitled to health care benefits.  

Domingo says, under the Universal Health Care (UHC) Law, all Filipinos shall be automatically PhilHealth members (Section 5. Population Coverage) and are granted immediate eligibility to health benefit packages under the Program (Section 9. Entitlement to Benefits). Members can automatically enjoy PhilHealth benefits the moment they are enrolled, with no waiting period unlike before. 

“The UHC Law also provides that failure to pay premiums shall not prevent the enjoyment of any Program benefits. Provided, further, that employers and self-employed direct contributors shall be required to pay all missed contributions with an interest, compounded monthly, of at least three percent (3 percent) for employers and not exceeding one and one-half percent (1.5 percent) for self-earning, professional practitioners, and migrant workers (Section 9. Entitlement to Benefits),” Domingo adds. 

 She also stresses that PhilHealth  benefits can be availed of anywhere in the country, regardless of where a person registered for membership, as long as the facility is PhilHealth-accredited. Confinements abroad are also being reimbursed based on existing rules and regulations. 

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