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Philhealth Benefits You May Not Be Aware Of
PHOTO BY ofwcommunity.com
To read this story in Tagalog, click here.
  • The Philippine Health Insurance Corporation (PhilHealth) is the administrator of the country’s National Health Insurance Program (NHIP). Both were established in 1995 to provide financial assistance for every Filipino’s health care needs. “It’s an off-shoot of the Medicare [program], which catered to the employed in both private and public sectors. However, the government saw that there was a need for every Filipino to have health insurance, thus the NHIP was born, and PhilHealth was created as the authority to handle such program,” explains Israel Pargas M.D., vice president of the Corporate Marketing Department at PhilHealth.

    PhilHealth covers a wide range of medical cases based on a payment scheme known as the All Case Rates. What this means is, there’s a fixed amount paid for every illness (the PhilHealth website contains a search engine for these rates). According to Dr. Pargas, this is intended to be “an automatic deduction” from your medical bill. “That’s the intent: mabawasan yung babayaran mo, if there’s any, from the hospital. Or wala ka nang babayaran dapat.” But if, for any reason, you are unable to avail of this deduction upon discharge, you can file for a refund within 60 days after your discharge date.

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    These benefits are also portable: If you suddenly get confined or need to undergo a procedure abroad, you can refund your medical expenses upon your return, provided they are filed within 180 days upon discharge.

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    Inpatient benefits
    What it is: If a member is confined in a hospital for any illness or procedure, PhilHealth will subsidize part of the medical bill.

    Amount: This will depend on the member’s condition, which will have a corresponding amount based on the All Case Rates. But generally, 70% of that amount will pay for the hospital fee while 30% will cover professional fees.

    Qualifying conditions: You must have at least 3 months’ contributions within 6 months immediately prior to the month of confinement. Apart from that, you need to have been confined in a PhilHealth-accredited facility for no less than 24 hours.

    Z Benefits
    What it is: These are special case rates for severe illnesses like cancer and major procedures such as a heart bypass. Says Dr.Pargas, “These are cases which we know are financially and medically catastrophic, so we offer higher case rates for them.” The current list of Z Benefits includes kidney transplantion and several types of cancer.


    Amount: This will depend on the condition, procedure, or treatment that is administered on the member. As an example, the coverage for kidney transplantation is P600,000. Dr. Pargas says this is currently the highest case rate offered by PhilHealth.

    Qualifying conditions: Pre-authorization documents—accomplished by a doctor from a PhilHealth-accredited facility and who has assessed if you fulfill the selection criteria—submitted to and approved by PhilHealth.

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    Outpatient benefits
    What it is: PhilHealth also covers a number of outpatient procedures, from minor day surgeries to blood transfusion and chemotherapy.

    Amount: This will again depend on the procedure, which will have a corresponding amount based on PhilHealth’s case rates.

    Qualifying conditions: Same as inpatient benefits. The procedure must have been done at a PhilHealth-accredited facility.

    This excerpt originally appeared in an article on Good Housekeeping Philippines magazine December 2016 issue. Minor edits have been made by the Smartparenting.com.ph editors.

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