A New Lease on Sight: PhilHealth Expands Cataract Surgery Coverage

By SwiftClaims

Cataract remains one of the leading causes of visual impairment worldwide—and in the Philippines, it’s a significant reason for moderate and severe vision loss. Fortunately, the Philippine Health Insurance Corporation (PhilHealth) has taken another major step forward with a Benefits Package for Extracapsular Cataract Extraction (ECCE) with Intraocular Lens (IOL) insertion, along with policy refinements designed to protect Filipinos from undue financial burden. This means better coverage and clearer policies for patients needing this sight-restoring procedure.

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Why Cataract Surgery Matters

Blindness and poor vision rank among the Philippines’ top 20% most burdensome health conditions. Research indicates that 45% of people who are blind or visually impaired develop their condition because of cataracts. The 2018 Philippine National Survey on Blindness and Eye Diseases further identified cataract as the major cause of visual impairment in the country.

Cataract surgery—removing the cloudy lens and replacing it with a clear, artificial intraocular lens—remains the only effective treatment for this vision-stealing condition. Through improved PhilHealth coverage, more Filipinos can now afford this crucial intervention, helping them regain clear vision and a better quality of life.

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What’s New in PhilHealth’s Cataract Benefits

PhilHealth’s recent circulars build upon the transition from the All Case Rates (ACR) payment method to a more Diagnosis-Related Group (DRG)-oriented system. Essentially, this shift aims to:

1. Improve Financial Risk Protection – Ensure beneficiaries face minimal out-of-pocket expenses.
2. Ensure Quality Healthcare Delivery – Promote standardized, safe, and effective cataract surgical procedures by accredited healthcare facilities.

Key Features

• Expanded Case Coverage
  Covers Extracapsular Cataract Extraction with IOL insertion, recognized as an essential surgical approach for many cataract cases.

• Support for Accredited Health Facilities (HFs)
  Applies to Ambulatory Surgical Clinics (ASC) and Level 1 to 3 hospitals—both public and private—that have service capability for cataract surgery.

• Transparent Co-Payment Policies
  Helps reduce instances of balance billing, ensuring patients aren’t burdened by unexpected costs.

• Standardized Rate Adjustments
  In line with PhilHealth’s ACR Rationalization, the benefits are adjusted to support better reimbursements for legitimate cataract procedures.

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Important Definitions to Note

• Fixed Co-Payment
  A pre-determined, flat-rate out-of-pocket fee that remains the same regardless of the total cost of the procedure.

• Health Technology Assessment (HTA)
  A systematic evaluation of medical technologies, devices, procedures, and interventions to improve quality of care.

• Health Technology Assessment Council (HTAC)
  An independent advisory body guiding the Department of Health (DOH) and PhilHealth on prioritizing which health interventions and technologies should be funded.

• Intraocular Lens (IOL)
  A tiny, artificial lens that replaces the eye’s natural lens during cataract surgery.

• Monofocal IOL
  A lens with a single focal point, typically requiring patients to wear eyeglasses for near or distance work post-surgery.

• Multifocal IOL
  A lens offering both near and far focus, reducing the need for glasses but potentially at a higher cost.

• Toric IOL
  An IOL designed to correct astigmatism by addressing an uneven curvature of the cornea.

• Minimum Standards of Care
  Essential services and clinical practice guidelines that accredited facilities must provide as part of PhilHealth coverage.

• Non-Basic Accommodation
  Hospital amenities beyond minimum standards (e.g., upgraded rooms, choice of physician), often subject to co-payment or out-of-pocket fees.

• Published Case Rate
  A fixed, predetermined amount PhilHealth will reimburse for the condition, covering fees such as professional charges, diagnostics, room and board, medications, and more.

• Top-Down Costing
  A cost-accounting approach where PhilHealth estimates the overall budget for a facility, dividing it into service lines to manage resources efficiently.

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Key Policy Statements and Implementation Details

1. No Differentiation Between Facility and Professional Fees
   Under the Universal Health Care (UHC) Act, PhilHealth remits all payments to accredited private and public HFs, which are then responsible for distributing professional fees to attending physicians or health workers.

2. Cross-Subsidizing of Treatment
   Accredited HFs may use other fund sources, efficiency gains, or out-of-pocket (OOP) spending to cover costs that go beyond the published case rates for cataract surgery, if needed.

3. Following Clinical Practice Guidelines (CPGs)
   Medical professionals in accredited HFs must adhere to evidence-based protocols for cataract surgery.

4. Referral to Higher-Level Facilities
   If a facility does not have the capacity to perform cataract surgery, it must properly coordinate and refer patients to a higher-level HF for safe and timely treatment.

5. Participation in Shadow Billing for DRGs
   Both public and private HFs are encouraged to join the “shadow billing” process under the upcoming transition to DRGs, as stipulated in PhilHealth Circular No. 2024-0006.

6. All Filipinos Are Eligible
   Under R.A. No. 11223, “Every Filipino citizen shall be automatically included in the NHIP.” Thus, anyone diagnosed with cataract can avail of the surgery benefits package.

7. Reflecting IOL Costs

   • The cost of IOLs should appear in the hospital billing. If the IOL is donated or provided by the patient, the HF may still claim the applicable package rate.
   • Ophthalmologists are discouraged from directly procuring or selling IOLs to patients.

8. Limits on Cataract Surgeries
   PhilHealth allows up to 200 approved cataract pre-surgery authorization (CPSA) requests per month, with no more than 10 scheduled cataract surgeries per day per PhilHealth-accredited eye surgeon.

9. Bilateral Cataract Surgery Interval
   For adult patients, there must be at least a two-day interval between operating on each eye, except in pediatric cases.

10. Prohibition Against Second Case Rate
    The case rate for cataract surgery cannot be claimed as a “second” case rate in combination with another case rate for the same confinement.

11. Accurate OOP/Co-Payment Recording
    Accredited HFs must accurately indicate the OOP and/or co-payment and any other funding sources in PhilHealth Claim Form 2 (CF2) Part III on Consumption of Benefits, as well as in the electronic Statement of Account (SOA).

12. Mandatory Filing Period
    All claims must be filed with PhilHealth within 60 calendar days. Direct filing by members or beneficiaries is discouraged and generally not allowed.

13. Late Filing Exceptions
    Late filing rules may apply in cases of natural calamities or other fortuitous events. PhilHealth has guidelines to extend privileges to those affected by such events.

14. Motion for Reconsideration (MR) and Appeal
    Accredited HFs can file an MR or appeal if their claims are denied by PhilHealth, following existing policies.

15. Cataract Surgeries Done Abroad
    If done outside the Philippines, PhilHealth may process and pay claims based on any remaining balance not covered by other insurance, up to the published local case rates.

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PhilHealth Benefits Packages: Adult Cataract Surgery

Below is the Package Code, Description, and Package Rate for adult cataract surgery:

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PhilHealth Benefits Packages: Pediatric Cataract Surgery

For pediatric cataract surgery, the table below outlines available package codes and rates:

Bilateral Pediatric Cataract Surgery

• If both eyes are operated on under PCSOU, the package rate covers additional sets of surgical instruments, drapes, viscoelastic, and other consumables.

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Procedure Codes for Cataract Surgery

The current procedure codes for cataract surgery, which accredited facilities must use for PhilHealth claims, are:

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Claims Filing Requirements

PhilHealth-accredited health facilities must carefully follow current policies on claims submission—using correct ICD-10 codes for the primary diagnosis/procedure, plus completing all required PhilHealth forms (CF), Statements of Account (SOA), and other relevant documentation.

For Adult Cataract Surgery

1. Claim Signature Form (CSF)
2. Claim Form 4 (CF4) documenting the patient’s clinical history, physical, and eye examinations
3. Scanned Pre- and Post-Op Refraction and BCVA (best corrected visual acuity) taken at least two weeks after surgery
4. Scanned Pre-Op Biometry Result
5. Scanned Operative Record with the IOL sticker attached (monofocal, multifocal, monofocal toric, or multifocal toric)

For Pediatric Cataract Surgery

1. Claim Signature Form (CSF)
2. CF4 documenting the patient’s clinical history, physical, and eye examinations
3. Scanned Pre-Op Biometry Result (except for infants younger than one year where no IOL is inserted)
4. Scanned Operative Record with the IOL sticker attached (if an IOL is included)
5. Scanned Anesthesia Record

Important:

• All claims must be filed within 60 calendar days after discharge.
• Facilities must observe all relevant laws regarding senior citizens (R.A. No. 9994), persons with disabilities (R.A. No. 10754), and indigent patients (Malasakit Centers Act), ensuring mandatory discounts are applied before PhilHealth benefits.
• Direct filing by members is discouraged; accredited HFs should facilitate the claims process.

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Additional Implementation and Payment Guidelines

1. No “Second” Case Rate
   The published cataract case rate cannot be claimed a second time for the same confinement.

2. Accurate Indication of OOP/Co-Payment
   Accredited HFs shall properly reflect the member’s out-of-pocket payments or co-payments in PhilHealth Claim Form 2 (CF2) Part III, as well as in the SOA.

3. Motion for Reconsideration (MR) and Appeals
   HFs may file an MR or an appeal if claims are denied. This must follow existing policies on claim disputes.

4. Late Filing and Natural Calamities
   Delays caused by force majeure events like natural disasters may be allowed under specific PhilHealth guidelines.

5. Cataract Surgery Abroad
   PhilHealth may reimburse costs for surgeries done overseas up to the published local case rates, considering other insurance coverage and out-of-pocket expenses.

6. Claims Evaluation and Payment

   • Service Capability: Only HFs accredited with the capability for cataract surgery are eligible for the published case rates.
   • Review Process: PhilHealth may review or audit claims before or after payment.
   • All Case Rates (PC No. 35, s. 2013) apply for percentage allocation between health facilities and professionals.
   • Return to Sender (RTS) Policy: Incomplete documents or discrepancies in claim forms can lead to returned claims, requiring re-filing within the prescribed period.

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Monitoring, Marketing, and Policy Review

1. Performance Monitoring
   PhilHealth will actively monitor accredited HFs to ensure compliance with the Benefits Package for cataract surgery, curbing any non-compliance or adverse provider behaviors (e.g., unwarranted fee increases).

2. Feedback from Beneficiaries
   Members are encouraged to report any concerns about the implementation of the policy or issues with service quality. They can contact PhilHealth’s Corporate Action Center (CAC) via hotline ((02) 8862-2588) or email ([email protected]).

3. Marketing and Promotion
   PhilHealth plans communication and social marketing campaigns with experts and stakeholders to increase awareness of cataract surgery case rates and coverage.

4. Policy Review

   • PhilHealth may adjust payment rates to reflect efficiency and service quality in accredited facilities.
   • A formal policy review will be conducted as PhilHealth transitions further to a DRG-based payment system.

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Penalty Clause

Violations of this PhilHealth Circular will be penalized in accordance with R.A. No. 7875 (as amended by R.A. Nos. 9241 and 10606), R.A. No. 11223, and related implementing rules and regulations. The PhilHealth Rules on Administrative Cases (PROAC) also apply.

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Transitory Clause

• Claims for cataract surgeries covered by this package but performed prior to its effectivity will be processed based on existing guidelines.
• Cataract procedures not covered in this package remain subject to current rules.

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Separability, Repealing, and Date of Effectivity

• Separability: If any part of this circular is declared invalid by a court, the remaining provisions stay in force.
• Repealing: Any prior PhilHealth issuances or parts thereof inconsistent with this Circular are repealed or modified accordingly.
• Date of Effectivity: This Circular takes effect 15 days after publication in the Official Gazette or any newspaper of general circulation, and after three (3) certified copies are filed with the Office of the National Administrative Register (ONAR), University of the Philippines Law Center.

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How Does This Help You?

• Reduced Out-of-Pocket Costs
  Rationalized case rates and clear coverage rules mean lower out-of-pocket expenses. Eligible members in basic or ward accommodation should pay little to no co-payment.

• Greater Access to Quality Care
  Accredited facilities must meet minimum standards of care and maintain essential stock of intraocular lenses, medications, and supplies, ensuring safe, timely, and efficient procedures.

• Choice of IOLs
  Patients can opt for monofocal, multifocal, or toric IOLs. Additional costs, if any, should be discussed transparently, and no physician should push specific products for profit.

• Streamlined Claims Process
  By following the outlined documentation and guidelines (including correct procedure codes), health facilities can expedite PhilHealth reimbursement.

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Final Thoughts: Keeping Sight on the Future

By focusing on cataract surgery—a leading cause of preventable blindness—PhilHealth underscores its commitment to universal health care. These comprehensive guidelines, updated package rates, and strict quality standards create a clearer path for Filipinos to regain their vision without fear of overwhelming medical bills.

Quick Tip: If you or a loved one experiences cloudy or blurred vision, consult a medical professional for an eye examination. Early detection is key to preventing severe complications.

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Looking Ahead

With the refined PhilHealth Benefits Package for Extracapsular Cataract Extraction with IOL, the agency continues to push for affordability, quality, and transparency. Whether you choose a monofocal, multifocal, or toric lens, rest assured that PhilHealth has policies in place to help you see more clearly—both literally and financially.

Have questions about eligibility or want to learn more about your benefits? Visit the official PhilHealth website or inquire at your local PhilHealth office for detailed guidelines and a list of accredited healthcare facilities.