What is the full coverage of the PhilHealth benefits?
The Philippine Health Insurance Corporation, more commonly known as PhilHealth, is the country’s national health insurance program. As a government-owned and controlled corporation, PhilHealth provides financial assistance to eligible members for their medical care needs. Here are some of the frequently asked questions about PhilHealth benefits and coverage:
What are the benefits of PhilHealth (Philippine Health Insurance Corporation)?
PhilHealth provides a wide range of benefits to its eligible members. Furthermore, PhilHealth also offers financial assistance to its qualified dependents, such as senior citizens, pregnant women, and premature newborns. Here is a comprehensive list of the benefits provided by PhilHealth:
- Inpatient hospital care. PhilHealth covers hospitalization expenses, including room and board, medicines, laboratory tests, and professional fees. This includes confinement in hospitals due to illness or disease requiring hospitalization.
- Outpatient care. PhilHealth also covers outpatient services such as consultations, diagnostic tests, and minor procedures.
- Maternity care. PhilHealth provides prenatal and postnatal care, delivery, and newborn care benefits.
- Z Package. This is a special benefits package for catastrophic illnesses. Furthermore, this covers expensive treatments such as chemotherapy and organ transplantation.
- TB-DOTS. PhilHealth provides benefits for treating tuberculosis under the Directly Observed Treatment Short-Course (DOTS) strategy.
- Animal Bite Treatment. PhilHealth provides benefits for treating animal bites, including rabies vaccination and anti-rabies serum.
- Dialysis. PhilHealth provides benefits for hemodialysis and peritoneal dialysis treatments. This is especially helpful for patients with end-stage renal disease.
- Primary Care Benefit. PhilHealth provides benefits for primary care services such as check-ups, vaccinations, and health education.
- Mental Health. PhilHealth provides benefits for mental health services such as consultations and psychotherapy.
- Case-based payment system. PhilHealth uses a case-based payment system. As such, members receive a fixed amount of benefit for specific medical conditions or procedures, regardless of the actual cost of treatment.
How much can I claim in PhilHealth?
The amount that a member can claim from PhilHealth depends on the actual payments made for the medical care services rendered. The benefit payment notice or claim form will indicate the exact amount that can be claimed. However, there are also limits to the benefits that can be claimed for certain services. Also note that PhilHealth is not meant to cover your total bill, but only a portion of it.
When can I use my PhilHealth benefits?
An enrolled member of PhilHealth can use their benefits when they are admitted to a PhilHealth-accredited hospital or health care facility for a covered illness or medical condition requiring hospitalization. Outpatient services are also covered, such as dialysis, chemotherapy, and outpatient anti-tuberculosis treatment. PhilHealth can also be used for Z-benefits and other specialized medical care services.
What are the senior citizen PhilHealth benefits?
PhilHealth provides special benefits to senior citizens in the Philippines, aimed at reducing the cost of healthcare for the elderly. Here are some of the senior citizen benefits for PhilHealth:
- Lifetime membership. Once a senior citizen becomes a PhilHealth member, they are automatically enrolled as a lifetime member and no longer need to pay premiums.
- Expanded coverage. Senior citizens are entitled to expanded coverage, including benefits such as the Z Package (specialty package for catastrophic illnesses), tuberculosis (TB) treatment, and free influenza and pneumococcal disease vaccines.
- Higher case rate payments. PhilHealth provides higher case rate payments for senior citizens. In other words, they can receive higher reimbursements for certain medical procedures or treatments.
- No balance billing. Senior citizens also gets protection from balance billing. In effect, they will not get additional fees beyond what PhilHealth and other insurance policies cover.
- Special lane. PhilHealth has a special lane for senior citizens, ensuring they receive priority processing and faster service.
Furthermore, the premiums for the enrolled citizens are covered by the proceeds from the Sin Tax Law (Republic Act No. 10351).
Can I withdraw my PhilHealth contribution?
No, PhilHealth contributions cannot be withdrawn. The contributions made by employees and their employers are automatically deducted from their monthly salary. Voluntary members are required to pay their monthly premium directly to PhilHealth.
The contributions made are used to fund the health insurance program, and it entitles the member to avail of the benefits provided by PhilHealth. The PhilHealth contribution table determines how much each member has to pay in proportion to their salary.
What services are covered by PhilHealth?
PhilHealth covers a wide range of medical services, including hospitalization, outpatient services, Z-benefits, and other specialized medical care services. Hospitalization benefits include room and board, drugs and medicines, laboratory tests, and attending physicians’ fees.
Outpatient services include dialysis, chemotherapy, and outpatient anti-tuberculosis treatment. Z-benefits cover specialized medical care for certain illnesses, such as breast cancer and prostate cancer.
How much is covered by PhilHealth?
The amount of coverage that a member can avail of depends on the type of medical service required and the actual payments made for such services.
The benefit payment notice or claim form will indicate the exact amount that can be claimed. However, there are also limits to the amount of benefits that can be claimed for certain services.
How does PhilHealth coverage work?
PhilHealth coverage works by providing financial assistance to eligible members for their medical care needs.
When a member is admitted to a PhilHealth-accredited hospital or healthcare facility for a covered illness or medical condition requiring hospitalization, the hospital or attending physician will process the member’s PhilHealth requirements.
The member or their PhilHealth relative should submit the required documents, such as the PhilHealth ID, authorization letter, and valid ID, ready for direct filing or post claims.
How many days are covered by PhilHealth?
The number of days PhilHealth covers depends on the member’s eligibility requirements and the nature of the illness or medical condition. For example, a member is entitled to a 45-day allowance each year for each instance of hospitalization.
Furthermore, qualified dependents can also avail of the hospitalization benefit. However, the member and dependent must share 45 days allowance.
For those with a permanent disability, PhilHealth can provide additional benefits. Senior citizens can avail of additional benefits and services under the Senior Citizens Affairs program.
How to claim PhilHealth benefits?
Under the Universal Health Care Act, all Filipinos, regardless of their membership are eligible to avail PhilHealth benefits. Here are the following conditions and requirements to claim benefits:
1) Prepare the required documents.
- You need to have the following documents when you claim PhilHealth benefits:
- PhilHealth Member Data Record (MDR)
- Valid ID with photo Prescription or statement of account
- Hospital billing statement
- Claim form
2) Fill out the PhilHealth Claim Form 1.
This form is also called the PhilHealth Claim Form for Reimbursement. This is available on the PhilHealth website or at any PhilHealth office. You need to fill out this form with your personal and medical information, the hospital’s information, and the details of your medical expenses.
An employee only needs to submit this form’s original copy signed by the employer and the following:
- Certificate of Premium Payments and official receipt numbers
- PhilHealth ID
- Valid ID
3) Submit the documents and form to PhilHealth.
Once you have all the required documents and filled out the PhilHealth Claim Form 1, you can submit them to any PhilHealth office. You may also submit them online through the PhilHealth online portal.
If you cannot file the claim form personally, you may send a representative with an authorization letter and a Valid ID on your behalf.
4) Wait for the PhilHealth claim to be processed.
The processing time for PhilHealth claims may vary, depending on the complexity of the case. You can check your claim’s status by visiting the PhilHealth office where you submitted your documents.
5) Receive the PhilHealth benefit.
Once your claim has been processed and approved, PhilHealth will release the benefit directly to the hospital or reimburse the amount to you. Furthermore, PhilHealth will then send a benefit payment notice to the address declared on the MDR.
Furthermore, additional requirements or steps may vary depending on your specific case or the type of benefit claim. It is best to check with PhilHealth directly or consult a PhilHealth-accredited healthcare provider for further guidance.
Who are the qualified dependents?
PhilHealth considers the following as dependents:
- A legitimate non-member spouse
- Unmarried and unemployed children (regardless of their legitimacy) who are below 21 years old
- Children of members who are 21 years or older who are suffering from mental or physical congenital disabilities or any disability that renders them dependent on the member
- Foster child as defined by the Foster Care Act of 2012
- Parents that are 60 years or older, not enrolled members, and with income below the PhilHealth-determined amount
- Parents of any age with a permanent disability and dependent on the member
How to get a PhilHealth ID?
Getting a PhilHealth ID in the Philippines is a straightforward process. Follow these step-by-step instructions:
- Check if you are eligible. PhilHealth requires all Filipinos and foreign nationals residing in the Philippines for at least six months to enroll in the health insurance program. If you qualify, you can proceed with the application process.
- Prepare the requirements. To apply for a PhilHealth ID, you need to prepare the following documents:
- Two (2) 1×1 ID pictures
- PhilHealth Member Registration Form (PMRF) (you can download this from the PhilHealth website or get it from any PhilHealth office)
- A valid government-issued ID (e.g., passport, driver’s license, postal ID, etc.)
- Accomplish the PhilHealth Member Registration Form (PMRF). Fill out the PMRF entirely and accurately. Be sure to provide your complete name, address, and contact details.
- Submit the requirements. Once you have completed the PMRF and prepared the necessary documents, you can submit them to any PhilHealth office or accredited agent. You can find a list of PhilHealth offices on their website.
- Wait for your PhilHealth ID. After submitting your requirements, you will be given a PhilHealth number. You can use this number to access your PhilHealth benefits while waiting for your ID. Your PhilHealth ID will be mailed to you within a few weeks.
- Activate your PhilHealth account. Once you receive your PhilHealth ID, you need to activate your PhilHealth account. You can do this by visiting any PhilHealth office or through their online portal.
In conclusion, PhilHealth benefits and coverage can significantly assist its members in covering the cost of their medical care. PhilHealth contributions are automatically deducted from the monthly salary of enrolled members or directly paid by voluntary members. PhilHealth coverage can be used for hospitalization by the member. If a member’s dependent requires hospitalization, they can also avail of PhilHealth’s benefits.