Benefits:

Inpatient benefits

Any healthcare facility that has received PhilHealth accreditation may provide inpatient benefits to its members, and prior to discharge, the case rate amount will be subtracted from their overall bill.

Outpatient benefits

Assistance along with procedures and treatments that do not require hospitalization, such as day surgeries, radiotherapy, outpatient blood transfusions, and hemodialysis, is referred to as an outpatient benefit.

Z benefits

Members and those they depend on with serious illnesses that necessitate hospital stays and costly therapies—such as cancer, breast, prostate, kidney, and other transplants—are facilitated by the Z benefits coverage.

Maternity benefits

Maternity benefits are accessible to mothers who have updated contributions on file and are PhilHealth members. This might include any of the following:

·         Antenatal care package - Prenatal check-ups such as laboratory tests and ultrasounds are included in this coverage.

·         Normal spontaneous delivery package – This covers normal, low-risk vaginal deliveries, including postnatal check-ups from three to seven days post-delivery.

·         Other methods of delivery - PhilHealth also covers cesarean sections, breech extractions, vaginal deliveries following cesarean sections, and complex vaginal deliveries including those requiring an episiotomy or forceps.

·         Newborn care package - This includes the provision that are fundamental newborn care, such as early skin-to-skin contact, drying and weighing the baby, as well as newborn screening and hearing tests.

Members can avail of the benefits at any accredited hospital and non-hospital facilities.

Penalties:

·         Failure to Settle PhilHealth Contribution

   In December 2020, the state insurance agency made a statement clarifying that legal action would not be taken against individuals who miss their payments. Additionally, it was confirmed by Ricardo Morales, the former president and CEO of PhilHealth, that all Filipinos are covered by the Universal Health Care Act of 2019, also known as Republic Act No. 11223, regardless of their payment status. This means that even if premiums have not been paid, one can still benefit from PhilHealth coverage.

·         Liable for the Penalty of Late Payments of Premiums and the Exceptions:

- Employees who do not pay their premiums on time may face a penalty for late payments. However, there are some exceptions to this rule. If an employer is unable to remit the payment due to a PHIC down system delay or error, or if there are discrepancies in salary or payments for newly hired employees, these cases would not be subject to penalty.

·         Cost of Penalties for Late Payments

In accordance with PHIC Circular No. 2016-00343, the interest or surcharge for late PHIC remittances will be calculated at 2% of the total premium to be remitted or PHP 200, whichever is higher, compounded monthly. Note that even a partial month of delay will be considered as one full month.

Different types of PhilHealth medical benefits and how to claim them.

1. Inpatient benefits

The inpatient benefit may refer to any kind of diagnostic or therapeutic procedure where the patient needs to stay longer or be confined in a hospital. This covers the hospital charges (such as the ER, patient room, lab, medicines) and professional fees of the attending physician.

Where to avail:

Accredited health care institutions (HCI)

2. Outpatient benefits

An outpatient benefit refers to any hospital visits or medical assistance that are less than 24 hours and cases that do not need confinement. Procedures refer to:

●        Blood transfusion – a one-day transfusion of blood or blood products with the maximum covered amount of P3,640.

●        Day surgeries – refer to ambulatory, non-emergency, and outpatient surgeries

●        Hemodialysis – the maximum covered amount is P2,600 for both inpatient and outpatient dialysis procedures.

●        Radiotherapy – the maximum covered amount for a cobalt session is P2,000 and a linear accelerator session is P3,000.

●        Primary care benefit – inclusive of preventive services, diagnostic exams, drugs/medicines for indigent individuals, land-based OFWs, sponsored members, and organized groups.

●        Expanded primary care benefit – inclusive of initial and/or follow up consultation, diagnostic exams, medicines, and other essential services for medical conditions limited to asthma, acute gastroenteritis, pneumonia, upper respiratory tract infection, and UTI.

Where to avail:

Accredited ambulatory surgical clinics

(Read: How To Apply For A PhilHealth ID)

3. Z benefits

PhilHealth’s Z Benefits package refers to “financially and medically catastrophic illnesses” and provides coverage to conditions needing longer and/or expensive medical treatments, including, 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

(Read: Guide To Emergency Funds: 5 Ways To Prepare For A Financial Crisis)

4. SDG benefits

Part of the agency’s mandate is to set objectives in line with the United Nations Sustainable Development Goals (SDG). To make sure these objectives are met, PhilHealth has created medical packages for members with medical conditions or undergoing procedures of the following:

●        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 – Provided that the mother went to a minimum of four prenatal checkups, the mother will receive P1,500 worth of coverage. The last checkup should be in the third trimester of the pregnancy.

●        Normal spontaneous delivery package – Pertains to the post-partum period within the immediate 72 hours and the seven days after giving birth. The mother will have a coverage amounting to P5,000 for delivery at the hospital or P6,500 for delivery at maternity clinics/birthing homes.

●        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 – Essential health care worth P1,750 will be given to your baby. There’s no maximum number of births, but filing should be within 60 days after the childbirth.

6. Senior citizen benefits

Senior citizens (and retirees/pensioners) are automatic and lifetime members of PhilHealth granted that they meet the eligibility requirements. They can also be listed as dependents of principal members. Their benefits include inpatient, outpatient, Z health services, and TsekAp diagnostic exams that are appropriate to their conditions.

7. OFW benefits

OFWs and their dependents can avail of the same health care benefits in the Philippines. If they are confined outside the country, the expenses can be reimbursed by filing at any PhilHealth office. OFWs are also eligible to become lifetime members like that of retirees and pensioners.

PhilHealth Benefits And How To Avail Of Them (ecomparemo.com) 

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