Philhealth: What You Need to Know about Philippine Health Insurance Corporation

In the midst of the COVID-19 pandemic health crisis, the Philippine Health Insurance Corporation, more frequently referred to as PhilHealth, has garnered significant media attention. They are required to provide all Filipinos with comprehensive health insurance coverage. Because of the mandatory deduction from our paychecks, some of us only utilize PhilHealth on a very infrequent basis, but we are nonetheless aware of its presence.

Also Read: List of PhilHealth Regional, Local, Satellite and Express Offices in the Philippines

Philhealth is, despite its somewhat tarnished reputation as of late, still one of the primary government institutions that provide relevant benefits to the majority of Filipinos, including abroad Filipino workers. This is despite the fact that Philhealth has been under considerable scrutiny recently by OFWs. Continue reading the following parts to find out more information if you are unclear about what it represents and the benefits it offers to members if you haven’t already done so.

Philhealth: What You Need to Know

What is the Meaning of Philhealth?

Philhealth stands for Philippine Health Insurance Corporation in the Philippines.

What is the Purpose of Philhealth?

The Philippine Health Insurance Corporation, or Philhealth, is a national health insurance programme for all Filipinos. The purpose of this organisation is to offer qualifying citizens with health insurance that allows them to get medical and hospital care from any recognised provider. Philhealth is often regarded as the Philippines’ universal health care system.

The history of Philhealth is critical to understanding what it does and what it means to you. In 1994, the Philippine government issued Republic Act 7875, which mandated the development of a social health insurance scheme. Philhealth was established as a legal body by RA 8243 in 1996. It was established “to promote and safeguard all Filipinos’ right to proper and affordable health care.” Previously, many Filipinos were unable to afford sufficient medical care due to the high cost of receiving treatment at a private clinic or hospital. As a result of PhilHealth’s coverage of these costs, a higher number of people can now receive appropriate medical care without financial concern. As a result, many people see Philhealth as one of the most helpful social projects that our country has undertaken in recent years.

Hospitalization (or inpatient care), professional fees (for outpatient therapy), and maternity benefits are all covered by Philhealth.

The Philippine Medical Association’s MARIA Project, launched in the early 1960s, was the impetus for the country’s universal health care system. Physicians were dispatched to outlying locations, particularly those with no physicians.

This was the reason for the Philippine Medical Care Act of 1969, which established a national policy “to gradually give whole medical treatment to our people by adopting and implementing a comprehensive and coordinated medical care programme based on known health care concepts.”

Its main goal was to offer medical care to all citizens within the country’s economic means and capabilities, to provide individuals with “practical means of assisting themselves in paying for adequate medical treatment,” and to establish the Philippine Medical Care Commission to monitor the implementation.

Representatives from the Social Security System, the Government Service Insurance System, the Philippine Medical Association, the Philippine Hospital Association, the Secretary of Health, and two appropriately licenced physicians comprise the Commission.

In response to public demand for more comprehensive health insurance, the National Health Insurance Act of 1995, which formed the Philippine Health Insurance Corporation, was enacted. This tax-exempt government organisation linked with the Department of Health performs a wide range of activities. To provide health insurance coverage and to ensure that health care services are affordable, acceptable, available, and accessible to all Filipino citizens.

List of Philhealth Programs and Services

The last thing you want to happen when you’re trying to sign up for health insurance is to feel overwhelmed by the application procedure. What’s the upbeat report? Philhealth, the largest health insurer in the country, offers a wide range of programmes and services that make it simpler to select a health coverage option that is suitable for an individual or a family’s needs.

The Philippine government collaborates with PhilHealth to advance efforts to provide access to quality medical care throughout the country. This effort will benefit all Filipinos. As of the beginning of the year 2020, PhilHealth will be contributing a higher amount to the premiums in order to facilitate a more rapid eligibility determination and improved service delivery.

Discover the various types of PhilHealth medical benefits and how to apply for them.

1. Inpatient benefits

The inpatient benefit may apply to any diagnostic or therapeutic procedure that necessitates a longer hospital stay or confinement. This covers hospital charges (such as the emergency department, patient room, lab, and drugs) as well as the professional fees of the attending physician.

Where to avail:

Accredited health care institutions (HCI)

2. Outpatient benefits

Outpatient benefits are hospital visits or medical services that are shorter than 24 hours long and do not require hospitalisation. Procedures are concerned with:

  • Blood transfusion – On a single day, the maximum amount covered for a transfusion of blood or blood products is P3,640.
  • Day surgeries – Non-emergency, outpatient, and ambulatory surgery
  • Hemodialysis – The highest sum covered for inpatient and outpatient dialysis operations is P2,600.
  • Radiotherapy – Cobalt treatments are covered up to a maximum of P2,000, while linear accelerator sessions are covered up to a maximum of P3,000.
  • Primary care benefit – Preventative care, diagnostic exams, and drugs/medicines are provided for the poor, land-based OFWs, sponsored members, and organised groups.
  • Expanded primary care benefit – Initial and/or follow-up consultations, diagnostic tests, drugs, and other critical treatments for asthma, acute gastroenteritis, pneumonia, upper respiratory infection, and UTI on their own.

Where to avail:

Accredited ambulatory surgical clinics

3. Z benefits

The PhilHealth Z Benefits package refers to “financially and medically disastrous illnesses” and covers conditions that necessitate lengthy and/or costly medical treatment, such as, but not limited to:

  • Cancer – prostate cancer, breast, cervical, leukemia
  • Kidney failure, heart bypass surgery, congenital heart defects, Z Morph – risk level and criteria apply
  • Selected orthopedic implants

Where to avail:

Accredited HCIs specialized in the said service

4. SDG benefits

The agency’s mandate includes establishing goals that are aligned with the United Nations’ Sustainable Development Goals (SDG). To ensure that these objectives are met, PhilHealth has created medical packages for members suffering from or experiencing the following conditions or procedures:

  • Outpatient malaria
  • Outpatient HIV-AIDS
  • Anti-TB through DOTS course
  • Voluntary surgical contraception
  • Animal bite treatment

Where to avail:

Accredited primary care benefit provider you are scheduled to visit

5. Maternity benefits

PhilHealth provides four packages to women who are about to give birth. These include:

Antenatal care package – If the woman attends at least four prenatal appointments, she would earn P1,500 in coverage. The final examination should take place during the third trimester.

Normal spontaneous delivery package – The time period between 72 hours and seven days after childbirth. The mother would be covered up to P5,000 for a hospital delivery and P6,500 for a birthing clinic or birthing home.

Other methods of delivery – Cesarean (P19,000); complicated vaginal delivery (P9,700); breech extraction (P12,120); and vaginal delivery after a previous Cesarean method (P12,120)

Newborn care package – Your infant will receive basic medical care worth P1,750. There is no limit to the number of births, but the application must be filed within 60 days of the birth.

6. Senior citizen benefits

Senior citizens (as well as retirees and pensioners) who meet the eligibility requirements are automatically and permanently registered in PhilHealth. They can also be classified as primary members’ dependents. Their coverage includes appropriate inpatient, outpatient, Z health care, and TsekAp diagnostic examinations.

7. OFW benefits

OFWs and their family in the Philippines have access to the same health-care benefits. If they are hospitalised outside of the country, they can file a reimbursement claim at any PhilHealth clinic. OFWs are eligible for lifelong membership in addition to retirees and pensioners.

List of Philhealth Online Services

With the launch of online services, Philhealth members can now access their benefits and manage their personal information. They have access to their contributions, claims, and personal data.

PhilHealth’s enhanced capabilities make it easier for members to access their health insurance benefits.

  1. Case Rates Search. Information on PhilHealth’s benefit packages is provided to members.
  2. Claims Eligibility Checking. Providers can use this information to determine whether or not members are eligible for specific benefits.
  3. Electronic Group Enrollment System. It allows Organized Groups to register and get billed more easily.
  4. Electronic Collection Reporting System. Employers can now pay their premium contributions online.
  5. Health Care Institutions. The whole list of HCls is displayed, along with their accreditation status.
  6. Membership Portal. It allows members to check the accuracy of their membership information.

Video: ‎Need to Know: What is PhilHealth’s role in Filipinos?‎

PhilHealth is an essential government agency in the Philippines that offers medical coverage to the country’s population. It is essential to have an understanding of what PhilHealth is and what it does in order to make certain that you and your family have access to the highest level of medical protection possible. This video will provide an introduction to PhilHealth as well as an outline of its role in the delivery of medical services to Filipinos.

Frequently Asked Questions

1. What Do We Get from PhilHealth?

If you are admitted to a hospital, you will experience the vast majority of the practical benefits provided by PhilHealth. According to the homepage for PhilHealth Inpatient Benefits, the health insurance programme pays for a portion of a member’s total payment prior to the member being discharged from the hospital. This portion includes the professional fees of attending physicians. If you need medical attention, you should go to a reputable medical facility.

PhilHealth also pays some amount from the member’s total bill during outpatient procedures, such as day surgeries, radiotherapy (P2,000 per session for cobalt radiotherapy), hemodialysis (P2,600 per session), and outpatient blood transfusion (P3,640). There are also benefit packages for leukemia (P500,000), breast cancer (P100,000), prostate cancer (P100,000), end-stage renal disease (P600,000), coronary artery bypass graft surgery (P550,000), surgery for tetralogy of Fallot in children (P320,000), surgery for a ventricular septal defect in children (P250,000), cervical cancer (P120,000 to P175,000), Z-MORPH (P15,000 to P30,000), colon and rectum cancer (P150,000 to P400,000), and other critical diseases. However, there are strict conditions to avail of these benefits, including age restrictions and diagnosis.

There are also packages for malaria (P600), tuberculosis (P4,000), and animal bite treatment (P3,000).

2. How Much Do We Pay for PhilHealth?

Employees who have regular employment are required to have a portion of their monthly basic income deducted to cover PhilHealth premiums. According to the “Premium Contribution Schedule in the National Health Insurance Program (Revision 1),” premiums will become more expensive beginning in the year 2022.

The information provided in this circular indicates that the premium rate for 2022 will be 4 percent, which is an increase of one full percentage point in comparison to the premium rates for 2020 and 2021. People who have already paid their payments at 3 percent for the months of January to May have until December 31 to settle the disparity with PhilHealth. This is according to the information provided by PhilHealth.

Those whose monthly earnings are P10,000 or less are required to pay a set premium of P400, while those whose monthly earnings are P80,000 or more are required to pay a fixed premium of $3,200. The employees whose monthly basic wages fall somewhere in the range of P10,000.01 to P79,999.99 have a range of P400 to P3,200—this simply accounts for the 4% difference.

In the event that you are not an employee but are classified as a “Direct Contributor,” you are still responsible for making your own payments at the modified premium rate.

3. Who Pays for PhilHealth?

The purpose of PhilHealth is to “provide as a mechanism for the healthy to aid pay for the treatment of the sick and for those who can afford medical care to subsidise those who cannot afford it.” There are “Direct Contributors,” who pay a premium for their participation in the health insurance programme (either through a payroll deduction or a voluntary payment), and there are “Indirect Contributors,” who do not pay anything but who can gain benefits from PhilHealth if they so choose.

Direct Contributors

  • Employees with formal employment
  • Kasambahays
  • Self-earning individuals; professional practitioners
  • Overseas Filipino Workers
  • Filipinos living abroad and those with dual citizenship
  • Lifetime members
  • All Filipinos aged 21 years and above with the capacity to pay

Indirect Contributors

  • Indigents identified by the Department of Social Welfare and Development
  • Beneficiaries of Pantawid Pamilyang Pilipino Program
  • Senior citizens
  • Persons with disability
  • Sangguniang Kabataan officials
  • Previously identified at point-of-service / sponsored by LGUs
  • Filipinos aged 21 years old and above without the capacity to pay premiums

In addition, PhilHealth is able to “receive and administer grants, contributions, and other types of aid” in order to bolster its financial resources.

4. Who is eligible for PhilHealth benefits?

A minimum of nine months’ worth of premium payments must have been made by the member before they are eligible to receive benefits or be hospitalized.

The total number of months must comprise at least three consecutive months of premium contributions (also known as qualifying contributions) before to hospitalization, as well as an accumulation of at least six months’ worth of premium contributions over the course of a year (called sufficient regularity). The qualified contributions period includes the confinement month as one of the months to contribute.

Benefits are also offered to qualifying dependents. They are required to have their declaration made by the primary member, which means that their name will be included on the member data record of the primary member (MDR). They are each eligible for individual coverage for up to 45 days each year, but those 45 days will be split equally between them. These things could be:

  • Legitimate spouse – inactive member or non-member
  • Children below 21 years old – single and unemployed (with birth certificate)
  • Children who are 21 years old and above – with grave disabilities
  • Foster children – recognized under Republic Act No. 10165
  • Parents who are 60 years old and above – non-member, with insufficient income
  • Parents, regardless of age – permanently disabled

Some members can be eligible for the benefits even without completing the 6-month Sufficient Regularity. These are:

  • Members with a period of validity – Indigent, sponsored members, Overseas Filipino Program members, and members tagged as out of service (both financially incapable and capable)
  • Members with automatic and lifetime coverage – Senior citizens and retirees/pensioners
  • Group enrollment members – Job order workers, contract of service, project-based personnel in the government
  • Kasambahays (house helpers)
  • Pregnant women nearing birth delivery

5. What are the PhilHealth documentary requirements?

These are the three ways you can avail of your PhilHealth benefits:

For automatic deduction on hospital/clinic bills:

  • PhilHealth ID or an updated copy of MDR. If you’re a dependent, make sure you are listed on the principal member’s MDR. If not registered in the MDR, submit proof that you’re a dependent of the member.
  • PhilHealth claim form 1, original and duly accomplished. If the member is an employee, the form must be signed by the employer. It can be acquired from the hospital, your employer, or downloadable file online.
  • Receipt/proof of premium payments with OR numbers (for employees only)
  • Valid government-issued ID

For reimbursement/direct filing:

  • Original copy of PhilHealth claim form 2. It should be filled out by the attending physician.
  • Official receipts from the hospital or waiver from the doctor
  • Record for surgeries, if the operative procedure is performed

Note: The documents for reimbursement should be submitted to PhilHealth or hospital earlier, or within 60 days after the discharge.

For confinement abroad

  • Original copy of PhilHealth claim form 1
  • Copy of MDR
  • Proof of premium payments with OR numbers (if applicable)
  • Original copy of the official receipt or detailed statement of account (should be in English)
  • Copy of medical certificate (should be in English)

Note: The aforementioned paperwork needs to be handed in no more than three months after the release. The hospital benefit rates applicable to Level 3 should be used to determine payment for overseas confinements.

6. How to claim PhilHealth benefits?

The following is a rundown of the steps you need to take in order to get your PhilHealth benefits:

Examine yourself to see if you meet all of the conditions (qualifying contributions and the sufficient regularity of the principal member; enlistment on MDR for the dependents). You can verify the information by either logging onto the online version of your PhilHealth account or getting in touch with the claims processing team at the hospital.

Gather the necessary documentation to prove your identity and membership in PhilHealth. It is needed that members provide either their PhilHealth ID or their MDR. Please display the MDR of the important member for whom you are enrolled as a dependent on their behalf. Fill out PhilHealth claim forms 1 and 2, as well as any other forms requested by the hospital.

Please bear in mind that if you present these documents to hospital staff prior to release, your benefits will be automatically paid to your account. It is possible that, depending on the total amount of your contributions, this will either cancel out your expenses or result in a reduction in the total amount that you are responsible for paying. Any excess not paid by your benefits will be your responsibility.

PhilHealth will send a benefit payment notice, or BPN, to the address indicated on your claim form once your benefits have been deducted/reimbursed. The amount that is written on the BPN can be compared to the deduction that is written on the statement of account for the hospital.

If you have any questions or concerns about the benefit payment notice, please get in touch with PhilHealth or your healthcare provider as soon as possible.

7. How will I know whether or not my PhilHealth is active?

Members of PhilHealth now have access to an improved function on the website of the corporation, which allows them to verify the accuracy of the data records that are kept on their respective accounts. You can make use of this service by navigating to the section of the website labelled “Member Inquiry.”

8. How can I keep contributing to PhilHealth online?

Even if you are a migratory worker or an individual, you are still eligible to pay your PhilHealth premium in the event that you are required to do so. However, before we can enable you to continue contributing, we would need that you ensure that the data record we have for you is up to current. Alterations to your personal information can be made after you have downloaded the PMRF form and opened it in your browser.

9. How many times per year can we use PhilHealth?

During the course of an entire year, members of PhilHealth are only allowed to be confined for a cumulative total of 45 days. Their eligible dependents are eligible for an extra 45 days of benefits, and it is up to them to figure out how to split this total sum among themselves.

10. Who is considered a dependent?

A child who was adopted or became a stepchild and is still under the age of 21 is regarded to be the child or children of a legitimate spouse. A person who is not a member of the home is considered to be a legitimate spouse.

Summary

Illnesses, in addition to having an impact on a person’s health, can also have a significant impact on a person’s ability to make ends meet financially. As a consequence of this, it is imperative for individuals to enroll in PhilHealth in order to obtain health insurance coverage. As a result of this, the organisation is able to produce high-quality medical treatments that are also not only affordable but also very easy to get a hold of for all Filipinos.

Membership in the Philippine Health Insurance Corporation (Philhealth) is among the most essential items for Overseas Filipino Workers (OFWs) to have. This is due to the fact that Philhealth is a health insurance program administered by the government that gives overseas Filipino workers access to high-quality medical treatment. There are a lot of advantages to having a Philhealth membership, such as being able to get discounts on inpatient and outpatient services and having access to a large network of hospitals and clinics all throughout the country.

In the Philippines, health insurance is provided through Philhealth, which is a government-owned and -operated organization. With more than 92 million customers, it is by far the largest health insurance provider in the country. It is the responsibility of the government to ensure that every Filipino is covered by Philhealth’s comprehensive medical services. It achieves this goal through giving patients in need with financial aid, as well as assistance to those who offer medical treatment. Philhealth also offers a wide range of health care services, such as preventive care, outpatient care, inpatient care, and dental care.

READ NEXT: How to Update Member Records in Philhealth Online

Contact Information

Address: Citystate Centre, 709 Shaw Boulevard 1603 Pasig City, Philippines
Telephone Numbers (trunkline): (02)441-7444 / (call center) / (02) 441-7442
Email: actioncenter@philhealth.gov.ph
Website: philhealth.gov.ph
Facebook Page: https://www.facebook.com/PhilHealthOfficial

Google Maps Location

Here’s the main office of Philhealth address:

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