Philhealth Benefits



This is a summary of the philhealth benefits and coverage given by Philhealth to its members and beneficiaries.  Although updates may be checked further at the website of: http://www.philhealth.gov.ph/

The said office enjoins all Filipinos to be a member. As such, the readers are encourage to learn more of the services offered by the company and the contribution to maintain it. 




Inpatient coverage:










Outpatient coverage:

    Day surgeries, dialysis and cancer treatment
    procedures such as chemotheraphy and radiotheraphy in accredited hospitals and free-standing clinics.

Special benefit packages:

  • Enhanced Outpatient Benefit Package
  • Coverage for up to the fourth normal delivery!
  • Newborn Care Package
  • TB treatment through DOTS
  • SARS and Avian Influenza Package
  • Influenza A (H1N1) Package

Exclusions/non-compensables

Coverage for normal spontaneous deliveries
PhilHealth provides compensation for uncomplicated normal spontaneous delivery or NSD of the first four births done either in hospital or non-hospital settings.
For deliveries in hospital facilities - subsidy shall be broken down as follows:
Services
Coverage
Hospital charges
Professional fees
Php 2,500
Php 2,000

Total

Php 4,500
For deliveries in non-hospital facilities a comprehensive package consisting of maternal and childcare services are offered under the Maternity Care Package.

Details of coverage:

Amount of coverage
Php 4,500
Services included
Prenatal to postnatal care including family planning services
Providers
Duly accredited birthing homes, maternity and lying-in clinics etc.
Eligibility
Confinement within validity period as stated in the Member Data Record
Exclusions
  • NSD of the fifth and subsequent births
  • Maternal age of less than 19 years
  • First pregnancy of patients aged 35 years and older
  • Multiple pregnancies
  • Ovarian abnormalities (ovarian cyst)
  • Uterine abnormalities (myoma uteri)
  • Placental abnormalities (placenta previa)
  • Abnormal fetal presentations (breech)
  • History of three or more miscarriages/abortions
  • History of one stillbirth
  • History of major obstetric and/or gynecologic operation (cesarian section, uterine myomectomy).
  • History of medical conditions such as hypertension, pre-eclampsia, eclampsia, heart disease, diabetes, thyroid disorder, morbid obesity, moderate to severe asthma, epilepsy, renal disease, bleeding disorders.
  • Other risk factors that may arise during present pregnancy (e.g. premature contractions and vaginal bleeding) that warrants a referral for further management.
Other conditions
Pregnancies resulting to abortion are not covered by the limitation of coverage of vaginal deliveries of the first four births.

Enhanced Outpatient Benefit Package

Enjoy a comprehensive package of benefits designed to ensure the health of our new heroes and their families.
A. Consultation
B. Diagnostic services
  • Complete blood count (CBC)
  • Routine urinalysis
  • Fecalysis
  • Fasting blood sugar
  • Blood typing
  • Hemoglobin/Hematocrit
  • Electrocardiogram (ECG)
  • Anti-streptolysin O (ASO-Titer)
  • Hepatitis B Screening Test
  • Treponema pallidum hemaglutination assay (TPHA)
  • Potassium hydroxide (KOH)
  • Erythrocyte sedimentation rate (ESR)
  • Pregnancy test
  • X-ray (Skull, Chest, Lower and Upper Extremities)
  • Sputum Microscopy
  • Pap Smear
C. Visual acuity examination
D. Psychological evaluation and debriefing
E. Promotive/preventive health services:
  • Visual acetic acid screening for cervical cancer
  • Periodic digital rectal examination
  • Periodic clinical breast examination (CBE)
  • Counseling for cessation on smoking
  • Lifestyle modification (regular blood pressure measurement and nutritional or dietary counseling)
  • Counseling for reproductive health particularly breastfeeding
  • Nutritional or dietary counseling
F. Auditory evaluation
G. Treatment of the following diseases based on PhilHealth-adopted clinical practice guidelines:
  • Urinary tract infection (UTI)
  • Upper respiratory tract infection (URTI)
  • Acute gastroenteritis (AGE)








Availment procedures

Here are two simple steps for you and your families to avail of the enhanced outpatient benefit package:
  1. Present clear copy of Member Data Record or MDR to the receiving clerk of the hospital.

    • If qualified dependent is not listed in the MDR - submit valid ID and proof of dependency
    • If MDR is not available - present also valid official receipt of premium payment

  2. After verification, you may now proceed to the doctor for consultation!
Note:
Availment of this package shall not be deducted from your 45-days allowance for room and board and from the separate 45-days allowance of your dependents.

TB treatment through DOTS

Treatment of new cases of pulmonary and extra-pulmonary tuberculosis in children and adults are covered through the Directly Observed Treatment Shortcourse or DOTS, the shortest and most effective internationally accepted treatment protocol for TB.

Details of coverage:

Amount of coverage
Php 4,000
Services included
Diagnostic work-up, consultation services and anti-TB drugs required in an outpatient set-up.
Providers
Duly accredited TB-DOTS Centers (available in the Philippines only)
Eligibility
New cases only, i.e., patient has never had treatment for TB or who has taken anti-TB drugs for less than one month.
Enrolment with TB-DOTS center falls within the validity period as stated in the Member Data Record.
Exclusions
Failure cases - a patient who, on previous treatment, is sputum smear positive at five months or later during the course of treatment.
Relapse case - a patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB.
Return after default (RAD) cases - a patient who returns to treatment with positive bacteriology (smear of culture) following interruption of treatment

SARS and Avian Influenza (Influenza Pandemic or Bird Flu) Package

Details of coverage:

Amount of coverage
For members and their qualified dependents - Php 50,000 per case.
For health care workers or HCW (forefront and high risk) - Php 100,000 per case.
Services included


  • Professional fees (Php 2,500 - pay to doctor)
  • Hospital charges (Php 42,500 - pay to hospital)
  • Official receipts amounting to Php 12,000 (Php 5,000 - pay to member)
Providers
Patients must be admitted only in accredited DOH-designated SARS or AI/IP hospitals.
Confinements abroad shall be paid compensated provided a certification from the attending physician is submitted.
Eligibility
Must be certified by the DOH as SARS or avian influenza/influenza pandemic patient.
Confinement within the validity period as stated in the Member Data Record.
Exclusions
SARS suspect cases.
Cases of acute respiratory illness where an alternative diagnosis can fully explain such illness.
Other conditions
Rule on single period of confinement and 45-days allowance for room and board per year applies.
Other conditions (for afflicted HCWs)


  • Must also be active PhilHealth members.
  • Contracted the disease while caring for a SARS or AI/IP patient (person to person transmission).
  • Renders service in DOH-designated hospital.
  • DOH attests that HCW contracted the disease while on official duty.


Special benefit packages

Influenza A (H1N1) Package

PhilHealth Coverage for Confirmed Cases of
Novel Influenza A (H1N1) in Humans

To mitigate the direct medical cost for the treatment of complicated human cases of novel Influenza A (H1N1) with complication or co-morbidities requiring hospitalization. The following shall be effective in all local and overseas confinements with admission dates starting May 1, 2009.

Details of coverage:

Amount of coverage
Maximum of Php 75,000 for non-health worker-members.
Maximum of Php 150,000 for health worker-members.
Services included
Members/ dependents
Room and board allowance of 1,500/day but up to 10,000 only
Drugs and medicines; X-ray, lab and others (including supplies and personal protective equipment and transfer services); and operating room fees – 50,000
Professional fees of 1,000/day but up to 15,000 only
HCWsRoom and board allowance of 1,500/day but up to 20,000 only
Drugs and medicines; X-ray, lab and others (including supplies and personal protective equipment and transfer services); operating room and other medically necessary care – 100,000
Professional fees of 1,000/day but up to 30,000 only
Providers
Hospitals designated by DOH as referral centers (national, sub-national and satellite) for Influenza A (H1N1) and other emerging and re-emerging diseases with the exception of confinements abroad.
Admissions in private hospitals may be covered if confirmatory tests were coordinated with or confirmed by the RITM, DOH-CHD or other DOH certified laboratories
Eligibility
Limited to members and health qualified workers with novel swine-origin influenza A (H1N1) virus infection confirmed by the Department of Health (DOH)
For qualified health care workers (HCWs):
  • Rendered service in a DOH-designated hospital for Influenza A (H1N1) and
  • Contracted the disease while performing their duties and or caring for an influenza A (H1N1) patient as certified or attested by DOH
  • Qualified dependents of HCWs who also contracted the disease shall be provided a maximum coverage of Php 75,000.
Premium payment of at least three months within the last six months prior to the month of confinement
Exclusions
Probable and case under observation*
Admissions in non-DOH designated hospitals*
Influenza-like illnesses (ILI)*
Other seasonal outbreaks of influenza by established flu virus (e.g., H1N2, H5N1)*
SARS**
Avian flu**
Other conditions
Reimbursement (to members) for drugs, medicines and supplies or laboratory procedures bought or performed in other facilities shall be based on the following:
  • Facility cannot provide necessary items and services covered by the benefit.
  • These items and services are used during confinement.
  • Official receipts and/or other purchase documents are submitted.
  • Reimbursement depends on actual cost of receipts submitted but not more than the difference between maximum benefit and reimbursement to facility.
  • Facility acknowledges that cost of benefits and services provided is less than the maximum benefit
Confinements abroad shall also be covered provided that a certification from their Ministry of Health (or its equivalent) confirming that case is due to A (H1N1) is submitted.
Availment of the package shall be charged against the 45-days annual limit and is covered by the rule on single period of confinement (only one Influenza A (H1N1) Package shall be paid within 90 days).
*Covered by regular hospitalization benefit
**Covered by SARS package
***Covered by Avian Flu package


Exclusions

The following are not being compensated yet except when, after actuarial studies, PhilHealth recommends their inclusion subject to approval of its Board of Directors:
  • Fifth and subsequent normal obstetrical deliveries
  • Non-prescription drugs and devices
  • Alcohol abuse or dependency treatment
  • Cosmetic surgery
  • Optometric services
  • Other cost-ineffective procedures as defined by PhilHealth

Availment conditions and procedures

Availment conditions

The following must first be met to avail of your PhilHealth benefits:
  • Availment must be within the validity period as stated in your Member data record or MDR or in the payment receipt.
  • The 45 days allowance for room and board of the member and the separate 45 days allowance shared among the dependents have not been consumed yet.

Benefit availment procedures

For outright/automatic deduction of benefits:

  • Submit to the billing section the following prior to discharge from the hospital:
    • Duly accomplished PhilHealth Claim Form 1 (original)
    • Clear copy of MDR.
      • If MDR is not available, submit official receipt of applicable premium payment
      • If qualified dependent is not listed in the MDR - submit applicable proof of dependency
  • Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit.
  • Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill.

For direct filing/reimbursement:

Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge:
  • PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians)
  • Official receipts or hospital and doctor's waiver
  • Operative record for surgical procedures performed

For confinements abroad:

Submit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates.
  • PhilHealth Claim Form 1
  • MDR or supporting documents
  • Proof of applicable premium payments
  • Original official receipt or detailed statement of account (written in English)
  • Medical certificate (written in English) indicating the final diagnosis, confinement period and services rendered.

Post availment reminders:

After the automatic deduction or reimbursement of your benefits, PhilHealth will send you (to the address you have indicated in your claim form) a benefit payment notice or BPN. The BPN is a report of actual payments made by PhilHealth relative to your confinement/availment.
Should there be discrepancies or if you have other concerns pertaining to your benefit availments, you may contact PhilHealth or your health care providers and bring the BPN as reference document.

Qualified Dependents

The following also enjoy PhilHealth coverage without additional premiums for each qualified dependent:
  • Legal spouse (non-member or membership is inactive)
  • Child/ren - legitimate, legitimated, acknowledged and illegitimate (as appearing in birth certificate) adopted or step below 21 years of age, unmarried and unemployed. Also covered are child/ren 21 years old or above but suffering from congenital disability, either physical or mental, or any disability acquired that renders them totally dependent on the member for support.
  • Parents (non-members or membership is inactive) who are 60 years old, including stepparents (biological parents already deceased) and adoptive parents (with adoption papers).
All of your qualified dependents shall be entitled to a separate coverage for up to 45 days per calendar year. However, their 45 days allowance will be shared among them.
Important:
Your dependents need to be declared and/or updated with PhilHealth to include them in your Member Data Record or MDR, your official membership profile with PhilHealth. Your updated MDR will make your benefit availments easier and convenient.

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