Risk Management

PhilHealth Benefits

May 15,2019 10:47 AM

Illness strike the moment you least expect it so having healthcare coverage from PhilHealth is a must. It helps you pay for hospital charges and professional fees in case you get hospitalized, which helps you save money on the hospital bills.

PhilHealth benefits is not just about inpatient. It can also curb the costs of outpatient services and critical illnesses. So Before you pay for the expensive bill, take a look at these PhilHealth benefits available to members and their dependents:

1. Inpatient Benefits
These benefits are paid to the accredited Health Care Institution (HCI) through All Case Rates. The case rate amount shall be deducted by the HCI from the member’s total bill, which shall include professional fees of attending physicians, prior to discharge. The case rate amount is inclusive of hospital charges and professional fees of attending physician

Availment condition: Member must have six (6) months contributions preceding the three months qualifying contributions within the 12-month period prior to the first day of confinement.

Documents needed: Copy of Member Data Record or PhilHealth Benefit Eligibility Form (PBEF) and duly accomplished PhilHealth Claim Form 1.

Where available: All accredited HCIs*

Different case rate amounts for selected medical conditions are being implemented when done in Primary Care facilities (PhilHealth Circular 14, s-2013).

Only admissible cases shall be reimbursed

2. Outpatient Benefits

a. Day Surgeries (Ambulatory Or Outpatient Surgeries)
Are Services That Include Elective (Non-Emergency) Surgical Procedures Ranging From Minor To Major Operations, Where Patients Are Safely Sent Home Within The Same Day For Post-Operative Care

• Payments for these procedures are made to the accredited facility through All Case Rates
• The case rate amount shall be deducted by the HCI from the member’s total bill, which shall include professional fees of attending physicians, prior to discharge
• The case rate amount is inclusive of hospital charges and professional fees of attending physician
• Availment condition: Member must have six (6) months contributions preceding the three months qualifying contributions within the 12-month period prior to the first day of confinement
• Documents needed: copy of Member Data Record and duly accomplished PhilHealth Claim Form 1
• Where available: Accredited Ambulatory Surgical Clinics (ASCs)

b. Radiotherapy
• The case rate for radiotherapy using cobalt is P2,000 per session and P3,000 per session for linear accelerator
• Includes radiation treatment delivery using cobalt and linear accelator
• Claims for multiple sessions may be filed using one (1) claim form for both inpatient and outpatient radiation therapy
• May be availed of even as second case rate (full case rate amount)
• 45 days benefit limit: One session is equivalent to one day deduction from the 45 allowable days per year
• If procedure is done during confinement, only the total number of confinement days shall be deducted
• Exempted from Single Period of Confinement (SPC) rule (admissions and re-admissions due to same illness or procedure within 90-calendar day period)
• Availment condition: Member must have six (6) months contributions preceding the three months qualifying contributions within the 12-month period prior to the first day of confinement
• Where available: Accredited HCIs including Primary Care Facilities that are accredited for the said service

c. Hemodialysis
• The Case Rate for hemodialysis is P2,600 per session
• Covers both inpatient and outpatient procedures including emergency dialysis procedures for acute renal failure
• Claims for multiple sessions may be filed using one (1) claim form for both inpatient and outpatient hemodialysis
• May be availed of even as second case rate (full case rate amount)
• 90 days benefit limit: One session is equivalent to one day deduction from the 90 allowable days per year
• If procedure is done during confinement, only the total number of confinement days shall be deducted
• The procedure is exempted from Single Period of Confinement rule (admissions and re-admissions due to same illness or procedure within 90-calendar day period)
• Availment condition: Member must have six (6) months contributions preceding the three months qualifying contributions within the 12-month period prior to the first day of confinement
• Where available: All Accredited HCIs – this benefit is no longer restricted to hospitals and free standing dialysis centers provided that the service is within their capability as provided for in the DOH license

d. Outpatient Blood Transfusion
• The case rate for outpatient blood transfusion is P3,640 (one or more units)
• Includes Drugs & Medicine, X-ray, Lab & Others, Operating Room
• Covers outpatient blood transfusion only
• One day of transfusion of any blood or blood product, regardless of the number of bags, is equivalent to one session
• May be availed of as second case rate (full case rate amount)
• 45 days benefit limit: One session for each procedure is equivalent to one day deduction from the 45 allowable days per year Exempted from the SPC rule
• Where to avail: All Accredited HCIs

e. Primary Care Benefit (PCB)
Coverage

• Indigent
• Sponsored Members
• Overseas Workers Program (Land-based)
• Organized Groups/iGroups

Where to avail
• Accredited rural health units,
• Accredited health center
• Accredited government hospitals

Disease Conditions:
• Asthma
• Acute Gastroenteritis (AGE) with no or mild dehydration
• Upper Respiratory Tract Infection (URTI)
• Pneumonia (minimal and low risk)
• Urinary Tract Infection (UTI)

Benefit Inclusions:
• Preventive Services
1. Consultation
2. Visual inspection with acetic acid
3. Regular BP measurements
4. Breastfeeding program education
5. Periodic clinical breast examinations
6. Counseling for lifestyle modification
7. Counseling for smoking cessation
8. Body measurements
9. Digital rectal examination

Diagnostic Examinations (as recommended by the doctor)
1. Complete blood count
2. Urinalysis
3. Fecalysis
4. Sputum microscopy
5. Fasting blood sugar
6. Lipid Profile
7. Chest x-ray

• Drugs and Medicines
1. Inhaled Corticosteroids (Fluticasone)
2. Short acting beta 2 agonists/Inhalation solution or metered dose inhaler (Salbutamol)
3. Oral or systemic corticosteroids (Prednisone)
4. Oral Rehydration Salts (ORS)
5. Amoxicillin
6. Macrolide (Erythromycin)
7. Beta Lactams with beta lactamase inhibitors (Cephalexin)
8. 2nd generation cephalosporins (Cefuroxime)
9. Oral fluoroquinolones (Ofloxacin)
10. Co-trimoxazole

How to avail:
1. Assignment thru Local Health Insurance Offices (only for Indigent and Sponsored Members)
2. Visit the PCB provider where you are assigned/enlisted

Expanded Primary Care Benefit (EPCB)
Coverage
• Formal Economy (Employed)
• Lifetime Members
• Senior Citizen

Where to avail:
• Accredited EPCB Health Care Institution to include the following:
- OPD of Level 1, 2 and 3 government and private hospital
- Ambulatory Surgical Clinic
- Infirmaries
- Private medical outpatient clinics

Disease Conditions:
• Asthma
•Acute Gastroenteritis (AGE) with no or mild dehydration
• Upper Respiratory Tract Infection (URTI)
• Pneumonia (minimal and low risk)
• Urinary Tract Infection (UTI)
• Hypertension
• Diabetes Mellitus Type II

Benefit Inclusions:
• Health screening and assessment/consultation
• Essential Services (based on the life stage as indicated in the AO 2017-0012: Guidelines on the Adoption of Baseline Primary Health Care Guarantees for All Filipinos )

3. Z Benefits

1. Acute Lymphocytic / Lymphoblastic Leukemia (standard risk) = P500,000

2. Breast Cancer (stage 0 to IIIA) = P100,000

3. Prostate Cancer (low to intermediate risk) = P100,000

4. End-stage renal disease eligible for requiring kidney transplantation (low risk) = P600,000

5. Coronary Artery Bypass Graft Surgery (standard risk) = P550,000

6. Surgery for Tetralogy of Fallot in Children = P320,000

7. Surgery for Ventricular Septal Defect in Children = P250,000

8. Cervical Cancer: Chemoradiation with Cobalt and Brachytherapy (low dose) or Primary surgery for Stage IA1, IA2 – IIA1 = P120,000.

Chemoradiation with Linear Accelerator and Brachytherapy (high dose) = P175,000

Z-MORPH (Mobility, Orthosis, Rehabilitation, Prosthesis Help) - first right and/or left below the knee = P15,000 - both limbs = P30,000

More information click here "Z-MORPH"

4. SDG Related

1. Outpatient Malaria Package = P600.00

2. Outpatient HIV-AIDS Package = P30,000.00 per year (P7,500/quarter)

3. Outpatient Anti-Tuberculosis Treatment through Directly-Observed Treatment Short-course (DOTS)
a. Package = P4,000
b. Intensive phase = P2,500
c. Maintenance Phase = P1,500

4. Voluntary Surgical Contraception Procedures = 4,000.00

5. Animal Bite Treatment Package = P3,000.00

*Data Updated as of March 31, 2019 by PhilHealth