Benefits

Inpatient Benefits

• Benefits for sickness or ailments that need confinement of not less than 24 hours.

Outpatient Benefits 

• Day surgeries and treatment procedures done in accredited hospitals and free-standing clinics that don’t require confinement.

Z-Benefits

• Benefits for illnesses perceived as medically and economically catastrophic.

SDG or Other Special Benefits 

• The existing PhilHealth benefit packages that aim to address certain disease conditions related to the Millenium Development Goals (MDG), namely malaria, tuberculosis, HIV/AIDS, and rabies, as it transitioned towards the current Sustainable Development Goals (SDG).

YAKAP (Yaman ng Kalusugan Program) 

• YAKAP is the improved and expanded Konsulta package. Its goal is to provide members with comprehensive healthcare through PhilHealth.

ALL CASE RATE

Payment method that reimburses to health care providers a PRE-DETERMINED FIXED RATE for each treated case or disease.

Patient benefits = final diagnosis and the amount will be based on the All Case Rate 

Cases covered under PhilHealth are the following (Inpatient and Outpatient benefits): 

• Medical cases

• Surgical cases

To determine whether a case is covered under the All Case Rate, each diagnosis or procedure is assigned a specific code that indicates the exact value of the benefit package. 

• Relative Value Scale (RVS) Code for procedure case rates

• International Classification of Diseases (ICD) 10 Code for medical case rates 

Note: Members who want to check the estimated benefit amount without a code may use the exact diagnosis or procedure description to determine the possible range from the lowest to the highest value.

Services covered: 

• Facility Fee

  • Room and board

  • Drugs and medicines during confinement

  • Laboratories and diagnostics

• Professional Fee

Computation of Benefits

• Medical Case Rate                           

Facility Fee: 70%
Professional Fee: 30% 

• Surgical Case Rate
    Facility Fee: 60%
    Professional Fee: 40% 

When a patient is admitted in a Primary Care Facilities (e.g., Infirmaries/Dispensaries), the health care provider shall be paid 70% of the case rate. The complete benefit schedule for primary care facilities is provided in Annex E and F of PC No. 2024-0037. 

When a patient has multiple conditions the health care provider may claim for two case rates relevant to the conditions of the patient:

• The First case rate shall be the medical condition or procedure that used the most resources.

• The Second case rate shall be the medical condition, or procedure with the second most resources used and will be paid 50% of the case rate amount.

Note: NOT all medical conditions or procedures may be claimed as second case rate

To confirm if a case qualifies for compensation under the second case rate either at 50% or 100% the member must provide the RVS/ICD 10 codes for all diagnoses. These must be listed among the case rates eligible as second case rate under PC No. 2024-0037, Annex D.

Z-BENEFITS

How to avail Z-Benefits? 

1. Submit a properly filled out Member Empowerment (ME) Form to any contracted facilities relevant to the Z-benefits package the member intends to avail.

2. A physician will assess whether the patient meets the eligibility requirements for the Z-benefit through a process called Pre-Authorization. 

List of contracted facilities can be accessed through the “Accredited Facilities” tab.

Benefit Packages

1. Acute Lymphocytic Leukemia

2. Breast Cancer

3. Cervical Cancer

4. Colon Cancer

5. Rectal Cancer

6. Kidney Transplantation

7. Peritoneal Dialysis (PD) First

8. Selected Orthopedic Implants

9. Prostate Cancer

10. ZMORPH

11. Expanded ZMORPH

12. Premature or Small Newborns

13. Z Benefits for Children with Mobility Impairment

14. Z Benefits for Children with Developmental Disabilities

15. Z Benefits for Children with Hearing Impairment

16. Z Benefits for Visual Disabilities

17. Z Benefits for Open Heart Surgeries

18. Z Benefits Package for Heart Valve Repair and/or Replacement for Valvular Heart Disease

Note: Foreign Nationals are not eligible to avail Z-Benefits. 

YAKAP BENEFITS

How to avail? 

Every PhilHealth member must register at an accredited YAKAP Clinic. Once registered, they may proceed to undergo the First Patient Encounter.

You may register for PhilHealth YAKAP through the following channels:

• eGovPH

• PhilHealth Member Portal https://memberinquiry.philhealth.gov.ph/member/

• PhilHealth offices nationwide

• YAKAP Clinics

PhilHealth YAKAP covers the following services:

• Free medical consultations at your chosen YAKAP Clinic

• Laboratory tests provided by the YAKAP Clinic

• Cancer screening tests 

• Medicines available at accredited pharmacies

Services will be provided based on the patient's needs and the doctor's recommendation.

How to avail the additional medicines at accredited pharmacies? 

1. Both authorized physicians and GAMOT Facility shall have access to the GAMOT Application (GAMOT App) to prescribe and dispense medications under PhilHealth GAMOT.

2. The authorized physician shall prescribe medications through the GAMOT App, and each prescription shall contain the following information:

• Date of prescription;

• Unique Prescription Security Code (UPSC) generated by GAMOT App;

• Beneficiary Name (Surname, Given Name, Middle Name, Extension);

• Age, Sex, and Address;

• Medications: Generic name (in accordance with the RA 6675 or the Generics Act of 1988), dosage strength, dosage form, quantity, and directions for medication use;

• Follow-up Date (if applicable); and

• Physician’s Name, Physician’s signature, and license number

Note: All prescriptions must be generated through the GAMOT App. 

How to avail the cancer screening tests at accredited facilities? 

1. The patient must undergo a consultation with an accredited primary care physician from a YAKAP clinic.

2. The PhilHealth-accredited primary care physicians shall request needed screening test/s for their patients based on the clinical indications and health risks assessments.

3. The physician will fill out a request form (Screening Test Request Form) which the patient will then bring to the accredited cancer screening test providers.

Note: Cancer screening tests will only be recommended and provided based on the outcome of a medical consultation, not upon patient request.

SDG AND OTHER SPECIAL BENEFITS

Animal Bite Treatment Package

1. The ABT package shall be fixed at Php 5,850 per case. 

2. The package only covers outpatient cases and Post-exposure Prophylaxis (PEP) services: 

• Rabies vaccine

  • Purified Vero Cell Rabies Vaccine (PVRV) or                                                   

  • Purified Cruck Embryo Vaccine (PCECV)

• Rabies Immune Globulin (RIG)

  • Human Rabies Immune Globulin (HRIG) or

  • Purified Equine Rabies Immune Globulin (pERIG)

• Local wound care

• Tetanus toxoid and anti-tetanus serum (ATS)

• Antibiotics

• Supplies such as, but not limited to, syringes, cotton, alcohol and other antiseptics

3. Only category III and category II rabies exposure (head and neck) shall be covered.

Maternity Benefits

• Maternity Care Package (MCP) 

  • P15,600 Maternity Clinic or Lying-In Clinic (must have at least 4 prenatal check-up) 

  • P12,675 Hospital (must have at least 4 prenatal check-up) 

• Normal Spontaneous Delivery 

  • P12,675 Maternity Clinic or Lying-In Clinic (No prenatal check-up or prenatal check up is less than the required) 

  • P9,750 Hospital (No prenatal check-up or prenatal check-up is less than the required ) 

• Caesarean Section (Level 1-3 hospital) P37,050 

• Newborn Care Package- P5,752.50 

The following cases are not covered by maternity or lying-in clinics as they are classified as high-risk pregnancies.

1. maternal age under 19 years old                                                                                         

2. first pregnancy of patients aged 35 years and older                                                          

3. multiple pregnancy                                                                                                         

4. ovarian abnormality (ovarian cyst)       

5. uterine abnormality (myoma uteri)

6. placental abnormality (placenta previa) 

7. abnormal fetal presentations ( e.g., breech) 

8. history of three (3) or more miscarriages/ abortion

9. history of one (1) stillbirth 

10. history of major obstetric and/ or gynecologic operation (e.g., cesarean section, uterine myomectomy) 

11. history of medical conditions (e.g., hypertension, pre-eclampsia, eclampsia, heart disease, diabetes, thyroid disorder, morbid obesity, moderate to severe asthma, epilepsy, renal disease, bleeding disorders) 

12. Other risk factors that may arise during present pregnancy (e.g., premature contractions, vaginal bleeding) that warrants a referral for further management. 

High-risk pregnancies should be delivered in a hospital to avoid the need for patient transfer in case of complications and to prevent potential risks.

Note: Foreign Nationals are not eligible to avail Benefits for Women About to Give Birth. 

OUTPATIENT HIV/AIDS PACKAGE

• Package is now P9,750/quarter (before P7,500/quarter)

• Package can be availed under accredited Outpatient HIV-AIDS Treatment Package Providers