PhilHealth Benefits

First of all, is PhilHealth coverage mandatory for all Filipinos?

Yes, PhilHealth membership is compulsory. According to Republic Act 7875 Art. III, Sec. 6. Coverage - All citizens of the Philippines shall be covered by the National Health Insurance Program. In accordance with the principles of universality and compulsory coverage enunciated in Section 2 (b) and 2 (1) hereof, implementation of the Program shall, furthermore, be gradual and phased in over a period of not more than fifteen (15) years: Provided, That the Program shall not be made compulsory in certain provinces and cities until the Corporation shall be able to ensure that members in such localities shall have reasonable access to adequate and acceptable health care services.

R.A. 7875 and Its Implementing Rules and Regulations

Philhealth Main Objectives:

Provide all citizens of the Philippines with the mechanism to gain financial access to health services;

Create the National Health Insurance Program, hereinafter referred to as the Program, to serve as the means to help the people pay for health care services;

Prioritize and accelerate the provision of health services to all Filipinos, especially that segment of the population who cannot afford such services; and 

Establish the Philippine Health Insurance Corporation, hereinafter referred to as the Corporation, that will administer the Program at central and local levels.

Philhealth Member Category

Overseas Worker/ OFW

·         Who are qualified member

Active land-based Overseas Filipino Workers (OFWs) who underwent the normal process of registration as an OFW at Philippine Overseas Employment Administration (POEA) Offices.

OFWs who are currently abroad but are not yet registered with PhilHealth may also register under this category.

Note: Sea-based OFWs such as seafarers are considered locally Employed Members.

·         Member registration procedures

Submit duly accomplished PhilHealth Member Registration Form together with applicable for each qualified dependent declared.

Submit any of the following documents as proof of being an active OFW:

ü  Valid Overseas Employment Certificate (OEC) or E-receipt 

ü  Valid overseas employment contract or certificate of employment 

ü  Valid re-entry visa 

ü  Valid job contract 

Pay the annual premium amounting to P1,200.00. Premium payments covering the entire duration of contract (equivalent to the number of years provided for in your contract) is highly encouraged.

Individually Paying

·         Who are qualified member

Self-employed individuals - those who work for him/herself and is therefore both the employer and employee, including but not limited to the following:

ü  Self-earning professionals like doctors and lawyers 

ü  Business partners and single proprietors / proprietresses 

ü  Actors, actresses, directors, scriptwriters and news reporters who are not under an employer-employee relationship 

ü  Professional athletes, coaches, trainers and jockeys 

ü  Farmers and fisher folks 

ü  Workers in the informal sector such as ambulant vendors, watch-your-car boys, hospitality girls, tricycle drivers, etc. 

ü  Separated from employment - those who were previously formally employed (with employer-employee relationship) and are separated from employment. 

ü  Employees of international organizations and foreign governments based in the Philippines without agreement with PhilHealth for the coverage of their Filipino employees in the program. 

All other individuals not covered under the previous categories mentioned, including but are not limited to the following:

ü  Parents who are not qualified as legal dependents, indigents or retireess/pensioners 

ü  Retirees who did not meet the minimum of 120 monthly premium contributions to qualify as non-paying members 

ü  Children who are not qualified as legal dependents 

ü  Unemployed individuals who are not qualified as indigents 

·         Member registration procedures

ü  Fill out PhilHealth Member Registration Form (PMRF)

ü  Attach clear copy of supporting documents for qualified dependents to be declared

ü  Registrant will be issued his/her PhilHealth Identification Number or PIN and the PhilHealth Member

ü  Registration Form or PMRF and shall be asked to pay the required premiums to the PhilHealth Cashier.

ü  Succeeding premium payments may be made at any of PhilHealth’s accredited collecting banks. 

Employed Sector

·         Who are qualified member

ü  Government sector 

ü  Private sector 

ü  Foreign business organizations based abroad with agreement with PhilHealth to cover their Filipino employees 

ü  Sea-based OFWs 

ü  Household employees 

·         Member registration procedures

ü  Fill out PhilHealth Member Registration Form (PMRF) 

ü  Attach clear copy of supporting documents for qualified dependents declared 

ü  Submit to the HR Department for them to forward the above documents to PhilHealth together with ER2 Form (Report of Employee-Members). 

ü  PhilHealth will send the PhilHealth Identification Card or PIC and a copy of the Member Data Record to the member, through the employer 

Lifetime Sector

·         Who are qualified member

Old-age retirees and pensioners of the GSIS, including uniformed and non-uniformed personnel of the AFP, PNP, BJMP and BFP who have reached the compulsory age of retirement before June 24, 1997.

·         Member registration procedures

ü  Submit the following to any PhilHealth Local Health Insurance Office (LHIO) nearest you: 

ü  Duly accomplished PhilHealth Membership Registration Form (PMRF) 

ü  Two (2) pieces of latest "1X1" ID picture 

ü  Photocopy of Birth Certificate or ANY two (2) valid IDs issued by a government official authority with birth date

Note: Please present original copy

• Senior Citizen ID 
• Passport 
• Driver’s License 
• Professional Regulation Commission (PRC) ID 
• National Bureau of Investigation (NBI) Clearance 
• Police Clearance 
• Postal ID 
• Voter's ID 
• Barangay Certification 
• Government Service Insurance System (GSIS) e-Card 
• Social Security System (SSS) Card 
• OFW ID 
• Seaman's Book 
• Overseas Workers Welfare Administration (OWWA) ID 
• Alien certification of Registration/ Immigrant Certification of Registration 
• Government Office and Government Owned and Controlled Corporation (GOCC) ID 
• Certificate from the National Council for the Welfare of the Disabled Persons (NCWDP) 
• Department of Social Welfare and Development (DSWD) Certification 
• Integrated Bar of the Philippines ID 
• Company ID issued by private entities or institutions registered with or supervised or regulated either by the Bangko Sentral ng Pilipinas (BSP), Securities and Exchange Commission (SEC) or Insurance Commission (IC). 

Benefit coverage

Inpatient coverage

Subsidies for hospital room and board fees, drugs and medicines, x-ray and other laboratory exams, operating room and professional fees for confinements of not less than 24 hours. Please refer to the table of rate ceilings/maximum allowances for inpatient coverage.

Outpatient coverage

Day surgeries, dialysis and cancer treatment procedures such as chemotherapy and radiotherapy.

Special Benefit Packages

• Case Rates
• TB Treatment through DOTS
• SARS and Avian Influenza
• Novel Influenza A(H1N1)

Exclusions

• 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 

Benefit availment conditions

• Eligibility Requirements 
• Payment of at least three (3) monthly premiums within six (6) months prior to the month of confinement. 
• Confinement in an accredited hospital for at least 24 hours (except when availing of outpatient care and special packages) due to illness or injury requiring hospitalization. 
• Attending physicians must also be PhilHealth-accredited. 
• The 45 days allowance for hospital room and board is not consumed yet. 

Post Availment Reminders

After the automatic deduction or reimbursement of your benefits, PhilHealth will send the Benefit Payment Notice or BPN to the address indicated in the member’s claim form. The BPN is a report of actual payments made by PhilHealth relative to member’s the confinement/availment.

Should there be discrepancies between the amounts reflected in the BPN and in the member’s final billing statement issued by the hospital, or if the member has other concerns pertaining to benefit availment, he may contact PhilHealth or the health care provider. The member must bring the BPN as reference document.

Availment procedures

Outright/automatic deduction of benefits

Submit the following to the billing section prior to hospital discharge: 

·         Duly accomplished PhilHealth Claim Form 1 

·         Clear copy of Member Data Record (MDR) 

For qualified dependent not listed in the MDR, submit clear copy of 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.

Direct Filing/reimbursement

Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days from the date of discharge:

1.    PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians) 

2.    Official receipts of payments made to the hospital and to the doctor's waiver 

3.    Operative record, if surgical procedures was performed 

Confinement abroad

Submit the following within180 days from the date of discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates and in the Philippine peso equivalent. Overseas confinements shall be paid based on Level 3 hospital benefit rates.

1.    PhilHealth Claim Form 1 

2.    MDR or supporting documents 

3.    Original official receipt or detailed statement of account (written in English) 

4.    Medical certificate (written in English) indicating the final diagnosis, confinement period and services rendered. 

Download - Philhealth Membership Registration Form

Disclaimer: This blog is not in any way authorized, commissioned, endorsed or sanctioned by the Philippine Health Insurance Corporation. The authors make no guarantees about the accuracy of the information presented in this blog, though every effort is exerted to ensure the correctness and accuracy of all explanations and procedures described in the posts.