Kapanidungan sa Kalusugan
Social Health Insurance Program (KsK-SHIP)

Background

On April 28, 2003, the Local Government Units and Health Agencies of Batanes entered in to a memorandum of agreement with the Healthdev Institute (HDI) for a social health insurance program to be in place in Batanes. The partnership gave birth to Kapanidungan sa Kalusugan (or more popularly known as KsK), an innovative way to mobilize resources from the community to reduce the burden of expensive health care.

The social health insurance works by pooling the contributions from the community in to a common fund.  The common fund shall be used to pay for the health expenses of sick members of the community.  KsK therefore invokes the values of shared responsibility and social solidarity from the community as well as ownership of the program.

The Provincial Government of Batanes through its Provincial Health Office currently manages the KsK for and in behalf of the community.  It shall make use of the provincial health network to provide the necessary services.  KsK has undoubtedly redefined the delivery of healthcare in the province. More importantly, it has made healthcare more accessible while teaching Ivatans the value of foresight and taking care of each other.

Benefits Package

Members of good standing can avail of the following benefits as contained in their policies.

Hospitalization benefits.  For one policy contract, the member (and declared beneficiaries) is afforded up to P5,000 for hospitalization.  The benefit limit of P5,000 shall be exhausted to pay for expenses incurred during confinement for one year.  The benefit limit may be increased depending on the number of policies the member possesses.  Specific services that will be covered are as follows:

• Room and board
• Laboratory tests, x-rays and other indicated diagnostics
• Use of surgical or medical equipment and facilities, namely operating and recovery room, intensive care unit, dialysis and chemotherapy equipment
• Administration of anaesthesia and/or oxygen
• Transfusion of hospital-provided whole blood or plasma
• Dressing, plaster cast, and other medical supplies
• Prescribed drugs and other medication used in the hospital
• Normal spontaneous delivery not to exceed P1,000

Outpatient benefits.  For one policy contract, the member (and declared beneficiaries) is afforded up to P500 for outpatient services.  The benefit limit of P500 shall be exhausted to pay for the cost of outpatient services for one year.  The benefit limit may likewise be increased depending on the number of policies the member possesses.  Specific services that will be covered are as follows:

• Minor surgeries
• Prescribed medicines
• Laboratory tests, x-rays and other indicated diagnostics
• Dental procedures

Medicines purchased outside of the health service network of the Kapanidungan may be reimbursed up to the specified limit provided that it is prescribed by an accredited doctor and supported by official receipts.

Confinements outside of Batanes.  Costs incurred during hospitalization outside of Batanes may be reimbursed up to the benefit limit provided the member made use of the referral system (BHW-RHU-PHO/BGH/IDH)  which in effect will sanction referral to a higher facility outside Batanes. During reimbursement the member will need to present the following documents as proof of medical services and expenses incurred from health service provider:

• copy of referral form from referring facility
• copy of discharge summary
• official receipts
• letter of authority from KsK central office.

In case a member gets sick while outside  the province, he does not need to get a referral from Batanes General Hospital. During reimbursement, he will still need to present the following documents:

• Copy of discharge summary from facility
• Official receipts
• Letter of authority from KsK central office.

The above policy coverage will be binding provided the member is of good standing.

Charges in excess of the benefit limit.  In cases when the medical expenses exceed the benefit limit, the member shall pay the excess amount.  In such a case, the member can no longer make use of the policy until the benefit limit is reset but his membership to Kapanidungan shall remain until his membership’s anniversary is reached. The benefit limit will only be reset after purchase of a second policy and is within application and membership procedures.

Member’s reimbursement of claim subsequent to defaulted payment.   Should the member fail to continue or complete his/her contributions after availing the services of the program.  Kapanidungan shall charge the member the full amount of his/her availment.  This constitutes a breach of contract and therefore obligates the delinquent member to reimburse the amount that have been paid for by the program in his/her behalf.

Exclusions.  The benefit ceiling shall be exhausted to pay for expenses incurred in treating ailments except when it is proven that it is self-inflicted or that injury is a result of acts of irresponsibility.  Non-pathologic conditions namely procedures for cosmetic purposes, and circumcision are not covered. Normal spontaneous delivery shall be an outpatient benefit.  Likewise, professional fees of whatever nature cannot be charged to the Kapanidungan common health fund.

For more information, please contact:

The Provincial Health Office
Abad Street, Kayhuvokan
Basco, 3900 Batanes