Updates on NHIP Utilization on NHIP

FP-MCH Benefits

November , 2013
Neoman R. Roxas

Context
Kalusugang Pangkalahatan or Universal Health Care identified the role of
NHIP as one of the three major strategies in insuring Universal Health Care
for All Filipinos.

Private Sector Mobilization for Family Health 2

SOCIAL HEALTH INSURANCE

A scheme for mobilizing and
utilizing resources through a RISK
POOLING & SHARING mechanism
to FINANCE the health care needs
of the members in a manner that
reflects the values of SOLIDARITY
and SHARED RESPONSIBILITY for
health care.

RA 7875 as amended by RA 9241

The National Health Insurance Law and RA 1066 2013

Philippine
Corporation

Health

Insurance

The Mandate of PhilHealth was founded on

Article 13, Section 11 of the 1987 Philippine
Constitution.
It stated : The State shall adopt an
integrated and comprehensive approach to
health development which shall endeavor to
make essential goods , health and other
social services available to all the people at

To attain universal coverage PhilHealth

has a program for .
Year

Salary
Cap

Max Total
Contribution
Per Month

2007

P 30,000

P 750.00

2006

P 25,000

P 625.00

2005

P 20,000

P 500.00

2004

P 15,000

P 375.00

2002

P 10,000

P 250.00

2001

P 7,500

P 187.50

2000

P 5,000

P 125.00

@ 2.5% of the
Salary

To attain universal coverage PhilHealth

has a program for .

To attain universal coverage PhilHealth

has a program for .

Individually Paying Program

P2,400 Annual Premium Contributions

To attain universal coverage PhilHealth

has a program for .

To attain universal coverage

PhilHealth has a program for .

Sponsored Program for the Poor

NHTS/ Sponsored= Per Family Performance
Rate

Challenges facing FP-MCH programs

Improve
FPMCH
outcomes

PublicHealthattainedthroughPPP
NHIPasaleversupportingPPPforFPMCH

NHIP FP-MCH Benefits

FP-MCH
Benefits

Type of Payment

Amount

MCP

Case Payment

P8,000

NSD

Case Payment

P6,500

NCP

Case Payment

P1,750

BTL

Case Payment

P4,000

NSV

Case Payment

P4,000

NSD with BTL

Case Payment

P10,500

IUD

Fee for Service

P1000 -2000 RVU

Scale

OPB/PCB

PFPR (per family

P500 per family
payment rate) Private Sector Mobilization for Family Health 2

Number of Claims
NSD, MCP and CS

Year

Amount Paid for NSD, MCP and CS

Facility Mapping (as of Apr. 2012)

998 Accredited MCP providers
607 municipalities out of 1646 municipalities and
cities have at least one MCP provider

Total no.
off Mun =
1646

44

131

81

130

100

109

114

133

132

143

71

93

49

49

73

119

75

w/ MCP

27

28

22

36

31

21

56

57

26

115

46

36

19

18

28

23

28

w/o MCP

17

103

59

94

69

88

58

76

106

28

25

57

30

31

45

96

47

The NHIP Value Chain for FP MCH

Processing

Enrolment
Accreditation
*Doctors, midwives
*Hospitals,
MCP,NCP

Utilization of FP (BTL, NSV,

IUD) and MCH (NSD, MCP,
NCP) benefits in accredited
facilities

Claims for FP
and MCH
packages
Claim
reimbursemen
t for FP and
MCH packages

Amoun
t of
benefit
payme
nt from
NHIP

PhilHeal
th
Benefits
delivere
d to FPMCH
clients

Financing
protection
for BTL,
NSV, IUD
Financing
protection
for NSD,
MCP, NCP

Private Sector Mobilization for Family Health 2

NHIP Enrolled Families in NCR

as of March 31, 2011

Processing
Enrolment

Accreditation
*Doctors, midwives
*Hospitals, MCP,NCP

Utilization of FP (BTL, NSV, IUD) and MCH

(NSD, MCP, NCP) benefits in accredited
facilities

Claims for FP and MCH

packages
Claim reimbursement
for FP and MCH
packages

Amount of
benefit
payment
from NHIP

PhilHealth
Benefits
delivered to
FP-MCH clients

Financing
protection for
BTL, NSV, IUD

Financing
protection for
NSD, MCP, NCP

Number of NHIP Accredited Facilities

as of March 31, 2011

Processing
Enrolment

Accreditation
*Doctors, midwives
*Hospitals, MCP,NCP

Utilization of FP (BTL, NSV, IUD) and MCH

(NSD, MCP, NCP) benefits in accredited
facilities

Claims for FP and MCH

packages
Claim reimbursement
for FP and MCH
packages

Amount of
benefit
payment
from NHIP

PhilHealth
Benefits
delivered to
FP-MCH clients

Financing
protection for
BTL, NSV, IUD

Financing
protection for
NSD, MCP, NCP

MCH Claims: Jan 2011- December 2011

Lo
w

*12.2% of deliveries

Pa
ym
ent

FP claims: Jan 2010 - March 2011

Potential NHIP FP Benefits in NCR

Number of unmet
need
Potential benefit from
BTL ([Number of
limiters/3] x P4,000
Potential benefit from
IUD
([Number of limiters/3]
x P300)
Potential benefit from
FP

Actual
Php 116.4 M

Php 1.4 M

8.7 M

27,261

125.1 M

1.4 M

Processing
Enrolment

Accreditation
*Doctors, midwives
*Hospitals, MCP,NCP

Utilization of FP (BTL, NSV, IUD) and

MCH (NSD, MCP, NCP) benefits in
accredited facilities

Claims for FP and MCH

packages
Claim reimbursement
for FP and MCH
packages

Amount of
benefit
payment
from NHIP

PhilHealth
Benefits
delivered to
FP-MCH clients

Financing
protection for
BTL, NSV, IUD

Financing
protection for
NSD, MCP, NCP

Losses in implementation and challenges

LGUcouldsecureadditional
financing
Usedbutdidnotclaim
Didnotorcouldnot
orreimburse
avail

MembersneedFPMCHservices
Didnotuse

Processing

Enrolment
Accreditation
*Doctors, midwives
*Hospitals,
MCP,NCP

Utilization of FP (BTL, NSV,

IUD) and MCH (NSD, MCP,
NCP) benefits in accredited
facilities

Didnotprovide

Claims for FP
and MCH
packages
Claim
reimbursemen
t for FP and
MCH packages

Providedbutdidnot
reimburseorwasnot
paid
Healthprofessionalsandinstitutions

areabletoprovideFPMCHservices

Amoun
t of
benefit
payme
nt from
NHIP

DOHneedto
increaseoutcomes
Minimal
influence
PhilHeal
th
Benefits
delivere
d to FPMCH
clients

Financing
protection
for BTL,
NSV, IUD
Financing
protection
for NSD,
MCP, NCP

Canonlypayclientsand
providersupon
compliancewith
procedures
PhilHealthiswillingandabletopay

UPDATES
New Engagement Process for Health Providers: PHIC
Circular: 13 ser. 2012
Features;
Automatic accreditation of government health facilities
health personnel
Development of new additional medical (33) and
surgical (19) case rates
Decentralize accreditation System (third party
accreditation )
Launching of enhanced MCP package (includes FP
benefit package, IUD as case payment)
Private Sector Mobilization for Family Health 2

MCP Summit
Objectives
Showcase good practices
Highlight efforts of each organization
Emphasis on cooperation and partnership towards a
common goal
Agreement to work together in the context of social
health insurance and Kalusugang Pangkalahatan

MCP Summit
Conference of organizations working for Maternal
and Child Health
Each organization will present their efforts and plans

Re Launching of MCP package

Declaration of Commitment towards MDG 4 and 5

MaramingSalamat!

FP Case rates included in the development of an enhanced

MCP Package

Case payment for IUD

Case Payment natural Family Planning
Case Payment for Injectables (still being
studied)

Potential MCH Benefits from NHIP in NCR

NHIP eligible 71.2
% (% of Births with
Birth order 4 and MCP-NSD Php
Below)
8,000

Number of
deliveries

NCP Php
1,750

CALOOCAN

28,005

19,938

159.5 M

34.8 M

MAKATI

10,278

7,318

62.2 M

7.3 M

MANDALUYONG

6,046

4,305

36.6 M

4.3 M

MARIKINA

6,366

4,533

38.5 M

4.5 M

PARANAQUE

11,444

8,148

69.3 M

8.1 M

QUEZON CITY

55,548

39,550

335 M

39.5 M

117,687

83,792

711.1 M

83.8 M

Total
ACTUAL

CS 25,546
MCP 6,417
NSD w/BTL 348
TOTAL 32,311

CS 111,712,676
MCP 32,606,815
NSD w BTL
2,552,087
TOTAL 146.8 M

20,727,551

Processing
Enrolment

Accreditation
*Doctors, midwives
*Hospitals, MCP,NCP

Utilization of FP (BTL, NSV, IUD) and

MCH (NSD, MCP, NCP) benefits in
accredited facilities

Claims for FP and MCH

packages
Claim reimbursement
for FP and MCH
packages

Amount of
benefit
payment
from NHIP

PhilHealth
Benefits
delivered to
FP-MCH clients

Financing
protection for
BTL, NSV, IUD

Financing
protection for
NSD, MCP, NCP

Luzon Health Technical Assistance for PhilHealth

FP-MCH Benefits:
Support in accreditation of MCP (Facility and
Providers)
Development of assessment tool to facilitate
accreditation.
Support in Accreditation of RHUs for PCB 1
(Facility and Providers)
Development of assessment tool to facilitate
accreditation.

Private Sector Mobilization for Family Health 2

PHILHEALTHS NORMAL
DELIVERY AND MATERNITY
CARE PACKAGES

Definition of Terms
MaternityCarePackage(MCP)
Packageapplicabletononhospitalfacilities/outpatient
providersthatcanprovideservicesrequiredofthem

NormalSpontaneousDeliveryPackage(NSD)
Packageapplicabletoaccreditedhospitalfacilities

Reimbursement Rules
Onlydulyaccreditedhospitaloroutpatientclinic
shallbereimbursed
Utilizesthecaserate(PC11s.2011)
o Level1andOutpatientclinicsPhp8,000
o Level2to4Php6,500

StrictenforcementofNoBalanceBill(NBB)policy
inallMCP/NCPproviders
o Forallofmembershiptypesandtheirdependents

Number of Accredited NSD and MCP

Providers

Accredited MCP Providers

Accredited MCP Providers (per PRO) as of

December 31, 2011

Standards for Accreditation of Professional

Providers

The provider for the MCP shall be Midwife or

Physician duly accredited by PhilHealth
1. Standards for Accreditation of Midwives as
Providers of the MCP
2. Standards for PhilHealth Accreditation of
Physicians as Providers of the MCP

The provider shall render the MC Package services

in a non-hospital facility accredited by PhilHealth
The Provider shall be allowed affiliation to a
maximum of three accredited facilities for the MCP

Standards for Accreditation of MCP

Providers (Clinic)
PhilHealth Circular No. 30 s. 2009
1. Service Capabilities
2. Technical Standards
2.1 General Infrastructure
2.2 Basic Consultation and Delivery Room
Equipment
2.3 Standard supplies
2.4 Records management
2.5 Available transport vehicle for emergency
cases
2.6 Human Resource
3. Quality Assurance Activities

1. Provide Services for:

Prenatal Care
Normal Delivery
Newborn Care Including Newborn
Screening (RA 9288)
Health Education
Materials for health education
Family Planning
Breastfeeding
Post Partum Care

2. Technical Standards

2.1 General Infrastructure

Delivery room which includes the following:
Birthing area
Area for cleaning baby/ instruments
Patient room/s
Adequate signage
Toilet (Minimum of 1 for 1 to 6 beds and additional
1 toilet for every 6 additional beds)

39

2.2 Basic Consultation and Delivery Room

Equipment
Non-mercurial thermometer and BP
apparatus
Neonatal or pediatric ambubag with neonatal
mask
NSD set (minimum of 2 sets)
Cord dressing set (minimum 2 sets)
Droplight

 Other Requirements:

Fire safety provision

Bassinet or newborn resuscitation
table
Properly labeled, colored garbage
containers
Separate receptacle for disposing
pointed or sharp objects
Sterilizer or its equivalent
Patients bed
Examining table

2.4 Records Management

2.4.1. Admission Register with
monthly summary
Cas Name Date of Addres
e no. of
birth
s
patient

Mem
bershi
p (NH
or NN)

Date
and
time of
admissi
on

Admi Date and

tting time of
diag Discharge
nosi
s

2011- Reyes,
001
Joan
Martin

NH

March
29, 2011
3:45 PM

G2P1 March 30,

PU
2011
39wks 1:30PM
in
labor

May 8,
2011
4AM

G56
May 8, 2011
38
11PM
wks in
labor

Oct. 1,
1985

2010- Santos, January

266
Josefina 10,
Ramos 1977

# 2 Don
Manuel
St., La
Loma ,
QC

89A 10th NN
Ave.,
Caloocan
City

2.6. Human Resource

PhilHealth accredited professional provider
Clinic Aide (full time or on-call)
On-call partner physician/s of professional
provider
Provider
Obstetrician-gynecologist
Pediatrician
Others (midwife, general
practitioner, internist, Family
Physician)

Partner MD/s
Physician for Pediatric
cases
Physician for obstetric cases
Physicians for obstetric
cases and Pediatric cases

 THE MIDWIFE:
Licensed practitioner.
Member in good standing of a PHIC recognized national
association of midwives.
Possesses competency on the expanded functions of
midwives.
Graduates from school year 1995 and onwards
- need not submit a certificate of training

Graduates before 1995 shall submit a training

certificate any of the following:

Training program accredited by the CPE Council of

the Board of Midwifery of the Professional
Regulation Commission (PRC); or
DOH-recognized training program

Shall have one partner MD for Ob cases and one for

pedia cases

The midwife shall have two (2) PARTNER

PHYSICIANS, one for obstetric cases and
one for newborn cases
A Diplomate or Fellow of the POGS/ PPS/
PAFP; or
Graduate of POGS/ PPS/PAFP accredited ObGyne / Pediatrics /Family Medicine residency
training program; or
Physician who completed at least a six
months in-service training in OB-GYNE (for
government physician) or Training on
BEmONC or CEmONC

In lieu of the MOA with the partner physicians,

the following may also be submitted:

MOA with PhilHealth accredited hospital (at

least level two)

ILHZ MOA which allows sharing of

resources (municipalities or cities with
existing ILHZ)
MOA with DOH-certified BEmONCCEmoNC network

The Newborn Care Package

(PC no. 11 s. 2011)
GENERAL RULES:
Providers:
Currently accredited as a Non-hospital facility
Certified NSF by NSRC of the NIH or by DOH
Reimbursement scheme: Case payment
Applicable to NB of qualified mothers who complied with
PHIC requirements
NBS should be performed after the 24th hr of life but not
later than 3 days from birth of non-problematic babies or
within 7 days from birth of NB in the NICU

Newborn Care Package

DESCRIPTIVE TERMS
Provision of essential newborn care to include
the following: cord clamping, drying of the
newborn, immediate skin-to-skin contact,
washing, breast feeding, weighing of the
newborn,
eye
prophylaxis,
Vit.
K
administration, BCG vaccination, Hepatitis B
immunization (1st dose)
Professional fee (for physical examination and
breastfeeding advice)
Newborn Screening Test (NBS)
Newborn Hearing Screening Test
TOTAL

PROPOSE
D

500

500
550
200
1,750

Newborn Care Package

(PC 15 s.2011)
In cases of incomplete provision of services, the
corresponding amount shall be deducted for the
following services:
SERVICES NOT GVEN

AMOUNT TO BE
DEDUCTED FORM
CASE RATE

Newborn Screening Test (NBS)

P 550

Newborn Hearing Screening Test

Only

P200

Both NBS and Newborn hearing

Screening Test)

P750