PhilHealth to revisit, amend policies ‘inconsistent’ with Universal Health Care law

State-run Philippine Health Insurance Corp. (PhilHealth) on Tuesday said it will review and amend its policies that are deemed inconsistent with the Universal Health Care (UHC) law.

The UHC law, signed in February 2019, provides that all Filipino citizens are automatically enrolled into the National Health Insurance Program as direct contributors or those who have the capacity to pay premiums, and indirect contributors sponsored by the government such as indigents and senior citizens.

The law ensures that all Filipinos are guaranteed equitable access to quality and affordable healthcare goods and services and protected against financial risks.

During the hearing of the House Committee on Health, Philippine Hospital Association (PHA) president Dr. Jaime Almora raised several policies of the PhilHealth that need to be revisited “to make it consistent with the Universal Healthcare law which provides that all Filipinos shall be qualified to Philhealth benefits.”

“One of the policies that need to be revisited is the less than 24 hours policy,” Almora said.

Under the PhilHealth Circular No. 31, series of 2010, if a patient stayed in the hospital for less than 24 hours, the patient shall not be covered.

“This is one of the policies that really denies PhilHealth coverage to the contributors as well as if the contributors are unable to pay the hospital for the less than 24 hour confinement it is the hospital that absorbs the loss,” Almora said.

The hospitals group also cited the single-period confinement policy, provided under Circular No. 0035, series of 2013, which means that admissions and re-admission due to same illness or procedure within a 90-day calendar period shall only by compensated within one case rate benefit.

Therefore, availment of benefit for the same illness or procedure that is not separated from each other by more than 90 calendar days shall not be provided with a new benefit, until after the 90-day period reckoned from the date of submission.

“For example, a [patient with] diarrhea or is amoebic is admitted and within the period of 90 days that patient is re-admitted, the other claims are not going to be paid because it is covered by the policy of single period confinement. It is a violation of single period of confinement,” Almora said.

“This violation is not within the control of hospitals, it is one reason of denial of claims,” he added.

The hospitals group also wants the policy on 45-day limit for room and board allowance benefit to be revisited.

Under PhilHealth Circular No. 21, series of 2006, members and dependents are entitled to a maximum of 45 days for room and board allowance per year.

Almora said this is one common cause of denied hospital claims since they have no access to record whether or not a patient has already fully availed of the 45-day limit.

In response, PhilHealth acting vice president and chief operating officer Eli Dino Santos said that the state health insurer “fully considers the recommendations of Dr. Almora.”

“My view is, there is really a need to revisit all the policies and revise them in accordance with the Universal Health Care law,” Santos said.

For her part, PhilHealth acting vice president for health finance policy sector Clementine Bautista said that during the COVID-19 pandemic, the single period of confinement and 45-day limit policies are waived.

“We are actually studying the potential revision of these policies in coordination with our actuarial department,” Bautista said. 

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