Thursday, June 21, 2012

Philhealth Maternity Benefits

Philhealth will start implementing its Case Rates Payment system for maternity cases and certain other medical/surgical cases for patients admitted starting September 1, 2011.
For Normal Spontaneous Delivery (NSD) in Level 1hospitals and in lying-in facilities, maternity clinics, RHUs and birthing facilities, the total Philhealth payment will be 8,000 pesos (6,500 for the facility and health professional and 1,500 for prenatal care).
For NSD in Levels 2 to 4 hospitals, the total Philhealth payment will be 6,500 pesos (5,000 for the facility and health professional and 1,500 for prenatal care).
For delivery by Caesarian Section (CS) in accredited Levels 2 to 4 hospitals and performed by accredited health professionals, the Philhealth fixed payment will be 19,000 pesos.
The Newborn Care Package (NCP) has been increased from 1,000 to 1,750 pesos. NCP includes physical examination, eye prophylaxis, Vitamin K administration, BCG Vaccination, first dose of Hepatitis B immunization, newborn screening tests, and breastfeeding advice.
Several readers are asking about Philhealth maternity benefits.  Based on recent Philhealth circulars and advisories, here are some bits of info:
Q: How much is the total maternity benefit?
The total benefit is 6,500 pesos for normal delivery or normal childbirth. But usually, you enjoy only a deduction of 5,000 pesos from your total hospital/clinic bill. You’ll know why in the next questions. For admissions starting September 1, 2011, the benefit has been increased to 8,000 pesos in Level 1 hospitals and in lying-in and maternity clinics. It remains at 6,500 pesos, however, for normal deliveries at Levels 2 to 4 hospitals.
Q: Can I receive this maternity benefit for all my normal deliveries?
No.  Only the first 4 births are covered under the normal delivery package.
Q: Can I automatically receive the total benefit of 6,500 pesos or 8,000 pesos?
Not always.  The benefit of 8,000 pesos pays for the following:
- hospital costs
– for the attending doctor
– 1,500 pesos for prenatal care
For lying-in clinics or midwife-managed facilities:
6,500 pesos for midwife and facility services
1,500 pesos for prenatal care
So if you didn’t avail of prenatal care, you get only 5,000 pesos or 6,500 pesos, and if your doctor is not Philhealth-accredited, your benefit is reduced.
Q: If I’m one month pregnant now, can I apply for Philhealth membership so I can avail of the maternity benefits when I give birth?
No and yes. For Voluntary Members or Individually Paying Members, nine months of prior contributions is required for receiving the maternity benefit package. Count 9 months within the 12-month period prior to child delivery. Let’s say your expected delivery month is September 2011. For the period from September 2010 to August 2011, you should have paid 9 monthly contributions. If Philhealth allows you to pay for December 2010 so you can reach the 9-month total, then you can avail. This depends on your prior Philhealth membership, meaning if you have been a Philhealth member before.
If you’re an OFW or an OFW dependent, yes, you can avail of the benefit as long as your delivery date is within the time frame indicated in the receipt paid by the OFW member. The same condition for Sponsored Members.
For Employed Members, 3 months of payments within the 6-month period prior to delivery are required.
Q. If the hospital is Philhealth-accredited, can I be sure that I get the maximum hospital benefit?
No. You have to make sure that your doctor is also Philhealth-accredited.
Q: How do I get my pre-natal care benefit?
Keep your official receipts for paid prenatal consultation and care, and then submit them to your accredited hospital/clinic/lying-in/maternity facility, so the receipts will be included in the Philhealth claim.
Q: When should I file my claims?
Submit your documents to your accredited health facility before discharge so the 5,000 pesos or newborn test cost benefits will be deducted from your hospital/clinic bill. If you’re unable to submit your papers before discharge, file your claim within 60 days from date of discharge. Waiting for reimbursement can take months.
Q. What are the documents needed to enjoy maternity benefits?
1. Your Philhealth Member Data Record (MDR). Get this in advance from any Philhealth branch.
2. Philhealth Claim Form. You can ask for this form from your employer, the hospital or from any Philhealth branch. Ask for two copies, the other is for your baby’s newborn care package.  If you’re employed, ask for a certificate of Philhealth premium payments.
3. Bring your ID, in case the hospital asks for identification.
4. If you’re voluntary or individually paying, or OFW dependent, bring original and copies of your Philhealth payment receipts.
5. If you’re a dependent of your husband, bring your marriage certificate, in case the hospital asks.
6. If you have pre-natal care receipts, bring them to the hospital/clinic and attach them to the claim forms. Pre-natal care benefit is 1,500 pesos.
Q. Are there other reasons why I can’t avail of Philhealth’s Normal Maternity Care Package (NCP) of benefits?
You CAN NOT avail of certain maternity-related care in non-hospital facilities such as lying-in and maternity clinics. Avail of these maternity services in hospitals.
Here are exclusions  (both hospital and non-hospital facilities):
- fifth normal delivery and subsequent deliveries
- normal delivery after 1 breech delivery and 3 normal deliveries
- normal delivery after 1 cesarean delivery and 3 normal deliveries
- normal delivery after 1 preterm delivery and 3 normal deliveries
- normal delivery after 1 stillbirth and 3 normal deliveries
- normal delivery after 1 normal delivery, 1 abortion and 3 normal deliveries
- normal delivery after 3 abortions and 4 normal deliveries
Exclusions in non-hospital facilities:
- you’re younger than 19
- you’re already 35 years old or older and this is your first time to give birth
- multiple pregnancy
- uterine or ovarian abnormalities, such as ovarian cysts and myoma uteri
- placental abnormality, such as placenta previa
- abnormal fetal presentation, such as breech
- history of 3 or more miscarriages or abortion
- history of 1 stillbirth
- history of cesarean section (CS), or uterine myomectomy, or other major gynecologic or obstetric operation
- history of hypertension, eclampsia, pre-eclampsia, diabetes, heart disease, asthma, epilepsy, bleeding disorders, renal diseases, thyroid disorder and morbid obesity
- risky conditions that may arise during pregnancy such as vaginal bleeding and premature contractions
Above exclusions are sourced from: Philhealth Circular signed by Philhealth President Rey Aquino on November 10, 2008.
Q:  If my child is delivered via Cesarean Section (CS), will Philhealth cover my expenses?
Philhealth will cover a portion of your expenses, using the chart ofPhilhealth benefits for regular surgeries.  A portion of the costs of your room, medicines, doctor’s fees, operating room and laboratory fees will be paid by Philhealth, and the balance will be paid by you.
Philhealth has announced that it will soon implement its Case-Rate-Basisprogram for CS and 21 other medical/surgical cases. If this is implemented, every delivery via CS will be paid by Philhealth at a fixed rate of 15,000 pesos, and you pay the balance. The amount is still a proposal, and it may change.
Update:  Philhealth has announced that the payment for CS is fixed at 19,000 pesos in Levels 2 to 4 hospitals, under the new Case Rates payment scheme, for admissions starting September 1, 2011.
Q: What is the Newborn Care Benefit?
This is a Philhealth benefit worth 1,000 pesos for your newborn baby:
- 250 pesos for umbilical cord care, eye prophylaxis, thermal care, Vitamin K, BCG vaccine administration, and newborn resuscitation
- 250 pesos for first dose of Hepatitis B immunization
- 500 pesos for newborn screening tests
- Available for all normal deliveries, even for fifth and succeeding deliveries
Ask your doctor about it beforehand because the newborn tests must be performed within 3 days of your child delivery in order for the tests to be paid by Philhealth.
This benefit has been increased to 1,750 pesos, for admissions starting September 1, 2011.
Q: What’s the best way to get the maximum Philhealth maternity benefits?
Find an obstetrics-gynecologist who is Philhealth-accredited, who works in a Philhealth-accredited hospital, and who is willing to help you get the maximum benefit starting from prenatal care up to newborn care.
Or find a midwife’s clinic or a lying-in clinic which is Philhealth accredited and willing  to help you get the maximum benefit starting from prenatal care up to newborn care. Make sure that your midwife is also Philhealth-accredited.

SSS - Maternity Benefit

What is the maternity benefit? 
The maternity benefit is a daily cash allowance granted to a female member who was unable to work due to childbirth or miscarriage.
What are the qualifications for entitlement to the maternity benefit?
  1. She has paid at least three monthly contributions within the 12-month period immediately preceding the semester of her childbirth or miscarriage.
  2. She has given the required notification of her pregnancy through her employer if employed, or to the SSS if separated, voluntary or self-employed member.

Is the voluntary or self-employed member also entitled to the maternity benefit? 
Yes, A voluntary or a self-employed member is entitled to the maternity benefit provided that she meets the qualifying conditions.
How much is the maternity benefit? 
The maternity benefit is equivalent to 100 per cent of the member’s average daily salary credit multiplied by 60 days for normal delivery or miscarriage, 78 days for caesarean section delivery.
How is the maternity benefit computed?
  • Exclude the semester of contingency (delivery or miscarriage).
       -  A semester refers to two consecutive quarters ending in the quarter of contingency.
       -  A quarter refers to three consecutive months ending March, June, September or December.
  • Count 12 months backwards starting from the month immediately before the semester of contingency.
  • Identify the six highest monthly salary credits within the 12-month period.

Monthly salary credit means the compensation base for contributions benefits related to the total earnings for the month. Please refer to the table below.

  • Add the six highest monthly salary credits to get the total monthly salary credit.
  • Divide the total monthly salary credit by 180 days to get the average daily salary credit. This is equivalent to the daily maternity allowance.
  • Multiply the daily maternity allowance by 60 (for normal delivery or miscarriage) or 78 days (for caesarean section delivery) to get the total amount of maternity benefit.

For example, let us say that an SSS member gives birth in December 2004. 

  1. The semester of contingency would be from July 2004 to December 2004
  2. The 12-month period before the semester of contingency would be from July 2003 to June 2004
  3. Let us assume that the six highest monthly salary credits are P15,000 each. Thus, the total monthly salary credit would be P90,000 (P15, 000 x 6).
  4. The daily maternity allowance would be P500 (P90,000/180).
  5. The total maternity benefit due would be P30, 000 (P500 x 60 days) for normal delivery or P39,000 (P500 x 78) for caesarian cases.

How many deliveries are covered under existing laws? 

The maternity benefit shall be paid only for the first four (4) deliveries or miscarriages starting May 24, 1997 when the Social Security Act of 1997 (RA8282) took effect.
Can a member apply for sickness benefit if she has been paid the maternity benefit? 
No. A female member cannot claim for sickness benefit for a period of 60 days for normal delivery or miscarriage or 78 days for caesarean delivery within which she has been paid the maternity benefit. As a rule, no member can be entitled to two benefits for the same period.
Is it necessary to notify the SSS of a member's pregnancy? 
Yes. As soon as a member becomes pregnant, she must immediately notify her employer (if employed) or the SSS (if separated/voluntary/self-employed) of such pregnancy and the probable date of her childbirth at least 60 days from the date of conception by accomplishing SSS FORM MAT-1 (Maternity Notification Form) and by submitting proof of pregnancy.

The employer must, in turn, notify the SSS through the submission of the maternity notification form and proof of pregnancy immediately after the receipt of the notification from the employee member.

Failure to observe the rule on notification may result to the denial of the maternity claim.
How would the claimant be paid the maternity benefit? 
For employed members - the benefit is advanced by the employer to the qualified employee, in full, within 30 days from the date of filing of the maternity leave application. The SSS, in turn, shall immediately reimburse the employer 100 percent of the amount of maternity benefit advanced to the female employee upon receipt of satisfactory proof of such payment and legality thereof.

If the employee member gives birth or suffers miscarriage without the required contributions having been remitted by the employer, or the employer fails to notify the SSS, the employer will be required to pay to the SSS damages equivalent to the benefits the employee would otherwise have been entitled to.

For separated/voluntary/self-employed members - the amount of benefit is paid directly to them by the SSS.
What are the forms and documents needed in filing for maternity benefit?
For employed members
  1. SSS Form MAT-1 (Maternity Notification) duly stamped and received by SSS;
  2. SSS Form MAT-2 (Maternity Reimbursement);
  3. Other documents:
  • Normal delivery - certified true or authenticated copy of duly registered birth certificate. In case the child dies or is a stillborn, duly registered death or fetal death certificate.
  • Caesarean delivery – certified or authenticated copy of duly registered birth certificate and certified true copy of operating room record/surgical memorandum.
  • Miscarriage or abortion - obstetrical history stating the number of pregnancy certified by the attending physician and dilatation and curettage (D&C) report for incomplete abortion, pregnancy test before and after abortion with age of gestation and hystopath report for complete abortion.
  • SSS digitized ID or E-6 acknowledgement stub with two valid IDs, one of which with recent photo.
  • To ensure receipt of benefits by members authorized company representatives who file maternity benefit claim shall present the members SSS digitized ID or E-6 acknowledgement stub with two valid IDs (at least one with photo). This requirement is in addition to the presentation by the company representative’s own SSS digitized ID and blue-card.

For separated members:
  • Items 1a to 1c of required documents for employed members.
  • Certification from last employer showing the effective date of separation from employment or notice of company’s closure/strike or certification from the Department of Labor and Employment that the employee or employer has a pending labor case.
  • Certification that no advance payment was granted (if confinement days applied for are within or prior to separation).
  • SSS digitized ID or E-6 acknowledgement stub with two valid IDs, one of which with recent photo.

For self-employed/voluntary members:
  • Items 1A to 1C of required documents for employed members.
  • SSS digitized ID or E-6 acknowledgement stub with two valid IDs, one of which with recent photo.

Where must the member file her application?
  1. For employed and separated members - applications may be filed at the SSS branch where the employer and employee records are based.
  2. For voluntary/self-employed members - application forms may be filed at any SSS branch nearest the members residence or where her record is based.