PhilHealth – Philippine Health Insurance Corporation – Purpose, Functions, and Responsibilities

PhilHealth is the national health insurance program of the Philippines. It is a social security institution that provides health insurance coverage to all Filipinos. PhilHealth also ensures that all citizens of the Philippines have access to affordable, acceptable, available, and accessible health care.

Also Read: What is OWWA Cares? #OWWAcares

PhilHealth is overseen by the Philippine government and is funded through taxes, premiums, and other contributions. One of the main objectives of PhilHealth is to ensure that all Filipinos have access to quality health care.

To achieve this, PhilHealth has put in place a number of programs and initiatives. These include the provision of health insurance coverage for indigent Filipinos, expansion of the coverage of pre-existing conditions, and establishment of a risk equalization fund.

Overview

The Philippine Medical Association developed the MARIA Project in the early 1960s, which prioritized help to towns in need of medical support. PhilHealth was established in 1995 to help the Philippines achieve universal health coverage.

This article will explain you how the Philippine Health Insurance Corporation, or PhilHealth, carries out its mission of providing health insurance coverage to all Filipino citizens of all ages and walks of life in order to protect them from financial disaster due to illness.

What is PhilHealth?

PhilHealth is a Philippine government-owned and controlled corporation (GOCC) that is affiliated with the Department of Health. This social insurance program allows the healthy to pay for the sick’s care, as well as those who can afford medical care to support those who cannot. The indigent are subsidized by both local and national governments.

What are the Benefits?

PhilHealth provides a wide selection of comprehensive health care services, ranging from basic primary care to catastrophic packages, to help members and their families understand their benefits and how to use them.

It comprises, among other things, qualifying criteria, coverage, basic rules for specific diseases, and selection criteria.

Vision

The following is the PhilHealth vision statement:

“Bawat Filipino, Miyembro,
Bawat Miyembro, Protektado,
Kalusugan ng Lahat, Segurado”

Mission

The PhilHealth mission statement for the coming years is as follows:

“Benepisyong Pangkalusugang Sapat at De-kalidad para sa Lahat”

Core Values

The following is the PhilHealth Core Values statement:

• Integridad
• Inobasyon
• Agarang Serbisyo
• Taos-Pusong Paglilingkod
• Pagmamalasakit
• Angkop na Benepisyo
• Panlipunang Pagkakabuklod

Mandate and Functions

Six major membership types cover practically the entire population of PhilHealth. Those who are counted as:

(1) Workers hired by public and commercial corporations, as well as other institutions, are considered “formal.”

(2) The national government subsidizes “indigents” (also known as “PhilHealth Ng Masa”) under the National Household Targeting System for Poverty Reduction.

(3) “Sponsored Members” receive funding from their local governments (LGU).

(4) “Lifetime” (non-paying) members are retirees and pensioners who have previously paid their membership dues for 120 months.

(5) Under the “Senior Citizen” (RA 10645) program, all Filipino nationals aged 60 and over are eligible for free PhilHealth coverage.

(6) Informal Sectors, Self-Earning Individuals, Organized Groups, Filipinos with Dual Citizenship, and Natural-Born Citizens make up the “Informal Economy.” The Overseas Filipino Workers (OFW) program, often known as Migrant Workers, is a part of the Informal Economy. Migrant workers are divided into two categories: land-based and sea-based (for seafarers).

Programs and Services

Philhealth provides programs and services to all Filipinos, both those who live in the Philippines and those who live overseas.

Only a small percentage of the population is aware of the PhilHealth’s programs and services. Take a look at this comprehensive list of programs and services available to all Filipinos for better guidance.

Inpatient Benefits

All Case Rates are used to pay impatient benefits to the authorized Health Care Institution (HCI). Prior to discharge, the HCI will subtract the case rate amount from the member’s overall payment, which will include professional fees from attending physicians.

Required documents:

• Copy of PhilHealth Benefit Eligibility Form (PBEF) or Member Data Record
• Completed PhilHealth Claim Form 1

Outpatient Benefits

1. Blood Transfusion for Outpatients

Outpatient blood transfusion has a case rate of P3,640 (one or more units). Drugs & Medicine, X-ray, Lab & Others, and Operating Room are all included. Only outpatient blood transfusions are covered. One session is equal to one day of transfusion of any blood or blood product, regardless of the number of bags. Second case rate (full case rate amount) is available. One session for each procedure deducts one day from the 45 days per year that are exempt from the SPC rule.

2. Day Surgeries (Ambulatory or Outpatient Surgeries)

Day surgeries are elective (non-emergency) surgical procedures ranging from minor to major operations in which patients are safely sent home for post-operative care the same day.

All Case Rates are used to pay for these operations at the approved facility. Prior to discharge, the HCI will subtract the case rate amount from the member’s overall payment, which will include professional fees from attending physicians.

Required documents:

• Member Data Record Copies
• Completed PhilHealth Claim Form 1

3. Hemodialysis

Hemodialysis has a case rate of P2,600 per session. Inpatient and outpatient procedures are covered, as well as emergency dialysis for acute renal failure.

For inpatient and outpatient hemodialysis, a single claim form can be used to submit claims for several sessions. Even as a second case rate (full case rate amount) can be used. 90-day benefit limit: Each session deducts one day from the annual benefit maximum of 90 days. If the procedure is performed while in confinement, just the total number of days in confinement will be removed.

The process is excluded from the regulation of single confinement (admissions and re-admissions due to same illness or procedure within 90-calendar day period).

4. Radiotherapy

The case rate for cobalt radiation is P2,000 each session, whereas the linear accelerator case rate is P3,000 per session. For both inpatient and outpatient radiation therapy, claims for several sessions can be submitted on a single claim form.

It can be used as a second case rate (full case rate amount) as well. 45-day benefit limit: Each session deducts one day from the annual benefit maximum of 45 days. If the procedure is performed while in confinement, just the total number of days in confinement will be removed. Single Period of Confinement (SPC) rule exemption: admissions and re-admissions due to same illness or procedure within 90-calendar day period.

5. SDG Related

• Animal Bite Treatment Package – P3,000.00
• Outpatient Anti-Tuberculosis Treatment through Directly-Observed Treatment Short-course (DOTS) Package – P4,000
• Outpatient HIV-AIDS Package – P30,000.00 per year (P7,500/quarter)
• Outpatient Malaria Package – P600.00
• Voluntary Surgical Contraception Procedures – P4,000.00

6. Z Benefits

• “PD First” – for End-Stage Renal Disease Requiring Peritoneal Dialysis – P270,000 per year
• Acute Lymphocytic / Lymphoblastic Leukemia (standard risk) – P500,000
• Breast Cancer (stage 0 to IIIA) – P100,000
• 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
• Children with Developmental Disabilities
  The cost of examination and discharge ranges from P3,626.00 to P5,276.00.
  Sessions for Rehabilitation Therapy P5,000.00 per set
  **Eligible children with developmental disabilities are limited to nine different therapy. Each therapy package is limited to ten sessions.
• Children with Mobility Impairment
  Requiring assistive devices ranges from P13,110.00 – P163,540.00
  Requiring seating device, basic and intermediate wheelchair ranges from P12,730.00 – P29,450.00
  Yearly services and replacement of devices ranges from P1,590.00 – P13,690.00
• Children With Visual Disabilities (Package code and rates for initial assessment and intervention)
  Initial assessment and intervention (i.e. rehabilitation and training) for Category 1 Visual impairment – 25,920.00
  Initial assessment and intervention (i.e. electronic assistive device, rehabilitation and training) for Categories 2, 3, and 4 Visual impairment – 31,920.00
  Initial assessment and intervention (i.e. electronic assistive device, rehabilitation and training) for Category 5 Visual impairment – 9,070.00
  Optical Aid 1: Low Power Distance, Categories 1, 2, 3 and 4 visual impairment eyeglasses + low power optical device – 7,350.00
  Optical Aid 2: High power Distance, Categories 1, 2, 3 and 4 visual impairment progressive eyeglasses + high optical device – 13,820.00
  Optical Aid 3: Colored Filter, Categories 1, 2, 3 and 4 visual impairment – 2,940.00
  White cane, Category 5 visual impairment – 1,000.00
• Colon and Rectum Cancer
  Colon Cancer
  Stage I-II (low risk) – P150,000
  Stage II (high risk) – III – P300,00
  Rectum Cancer
  Stage I (clinical and pathologic) – P150,000
  Pre-operative clinical stage I but with post-operative pathologic
  Stage II-III
  – using linear accelerator as mode of radiotherapy) – P400,000
  – using cobalt as mode of radiotherapy – P320,000
  Clinical Stage II-III
  – using linear accelerator as mode of radiotherapy) – P400,000
  – using cobalt as mode of radiotherapy -P320,000
• Coronary Artery Bypass Graft Surgery (standard risk) – P550,000
• End-stage renal disease eligible for requiring kidney transplantation (low risk) – P600,000
• Preterm and Small Newborns (24 to < 32 weeks)
  1. Essential interventions for 24 to < 32 weeks – 35,000.00
  2. Essential intervention with minor ventilator support and Kangaroo Care for 24 weeks to < 32 weeks – 85,000.00
  3. Essential interventions with major ventilatory support and Kangaroo Care for 24 weeks to < 32 weeks – 135,000.00
• Preterm and Small Newborns (32 to < 37 weeks)
  1. Essential interventions for 32weeks to < 37 weeks – 24,000.00
  2. Essential interventions with mechanical ventilation and Kangaroo Care for 32 weeks to < 37 weeks – 71,000.00
• Premature and Small Newborn (Prevention of Preterm Delivery)
  1. Prevention of preterm delivery with severe pre-eclampsia/eclampsia – 3,000.00
  2. Prevention of preterm delivery, with preterm pre-labor rupture of membrane (pPROM) – 1,500.00
  3. Prevention of preterm delivery without pre-eclampsia/eclampsia or rupture of membranes but with labor or vaginal bleeding or multifetal pregnancy – 600.00
  4. With coordinated referral and transfer from a lower level of facility – 4,000.00
• Prostate Cancer (low to intermediate risk) – P100,000
• Surgery for Tetralogy of Fallot in Children – P320,000
• Surgery for Ventricular Septal Defect in Children – P250,000
• Z-MORPH (Mobility, Orthosis, Rehabilitation, Prosthesis Help)
  first right and/or left below the knee – P15,000
  both limbs – P30,000
• Expanded Z-MORPH
• Selected Orthopedic Implants
  1. Implants for Hip Arthroplasty
  – Implants Hip Prosthesis, cemented (66 years old and above) – P103,400
  – Total Hip Prosthesis, cementless (65 years and 364 days old and below) – P169,400
  – Partial Hip Prosthesis, bipolar – P73,180
  2. Implants for Hip Fixation
  – Multiple screw fixation (MSF) 6.5mm cannulated cancellous screws with washer – P61,500
  ***59 years and 364 days old and below (both displaced and undisplaced fracture); 60 years old and above (undisplaced fracture)
  3. Implants for Pertrochanteric Fracture
  – Compression Hip Screw Set (CHS) – P69,000
  – Proximal Femoral Locked Plate (PFLP) – P71,000
  4. Implants for Femoral Shaft Fracture
  – Intramedullary Nail with Interlocking Screws – P48,740
  – Locked Compression Plate (LCP) – Broad / Metaphyseal / Distal Femoral LC – P50,740

List of PhilHealth Offices in the Philippines

In every region in the Philippines, there is a dedicated PhilHealth office. Please check out the main branches of Philhealth and their locations below:

PhilHealth Region 1
Address: Akia Building, Old De Venecia Highway Dagupan City, Pangasinan
Telephone Number: (075) 515-1111
Email Address: region1@philhealth.gov.ph

PhilHealth Region 2
Address: The Builder’s Place, Del Rosario St. Tuguegarao City, Cagayan 3500
Telephone Number: (078) 255-1342
Email Address: info.pro2@philhealth.gov.ph

PhilHealth Region 3-A
Address: G/F PhilHealth Bldg., Lazatin Blvd., San Agustin, San Fernando City, Pampanga C-2000
Telephone Number: (045) 961-1977
Email Address: N/A

PhilHealth Region 3-B
Address: The Cabanas Mall of Malolos 2nd and 3rd floors N4 Bldg. Km. 44/45 MacArthur Highway Longos, Malolos City, Bulacan
Telephone Number: (044) 796-1559
Email Address: N/A

PhilHealth Region 4-A
Address: Lucena Grand Central Terminal, Brgy. Ilayang Dupay, Lucena City
Telephone Number: (042) 373-7554
Email Address: member.pro4a@philhealth.gov.ph

PhilHealth Region 4-B
Address: Xentro Mall Batangas City, Diversion Road, Brgy. Alangilan, Batangas City, Batangas
Telephone Number: N/A
Email Address: region4b@philhealth.gov.ph

PhilHealth Region 5
Address: ANST IV Bldg., Benny S. Imperial Drive, Legazpi City, Albay
Telephone Number: (052) 481-5596
Email Address: N/A

PhilHealth Region 6
Address: Gaisano Capital Building, Luna Street, Lapaz, Iloilo City
Telephone Number: (033) 501-9160
Email Address: region6@philhealth.gov.ph

PhilHealth Region 7
Address: 7th and 8th Floor, Skytower, N. Escario Street corner Acacia Street, Cebu City 6000
Telephone Number: (032) 233-3287
Email Address: cebu.pro7@gmail.com

PhilHealth Region 8
Address: Brgy. 24, P. Burgos Street, Tacloban City, Leyte
Telephone Number: (053)325-3563
Email Address: info.pro8@philhealth.gov.ph

PhilHealth Region 9
Address: BGIDC Corporate Center, Gov. Lim Ave., Zamboanga City
Telephone Number: (062) 992-2739
Email Address: region9@philhealth.gov.ph

PhilHealth Region 10
Address: 8F Gateway Tower 2, Limketkai Center, C.M. Recto Avenue, Cagayan de Oro City
Telephone Number: (088) 859-0225
Email Address: region10@philhealth.gov.ph

PhilHealth Region 11
Address: Valgosons Building Bolton Extension, Poblacion, Davao City
Telephone Number: (082) 295-2133 / (0925) 7819987
Email Address: publicaffairs.pro11@gmail.com; info.pro11@philhealth.gov.ph

PhilHealth Region 12
Address: CSA I Building Cor. Zulueta Street, General Santos Drive, Koronadal City
Telephone Number: (083) 228-9731
Email Address: region12@philhealth.gov.ph; admin.pro12@philhealth.gov.ph

PhilHealth CARAGA
Address: Lynzee’s Building, 766 J. Rosales Avenue, Butuan City
Telephone Number: (085) 342-0900
Email Address: caraga@philhealth.gov.ph

PhilHealth Cordillera Administrative Region (CAR)
Address: SNOBT Inc. Bulding, No. 19 Leonard Wood Road Baguio City 2600
Telephone Number: (074) 444-5345
Email Address: car@philhealth.gov.ph

PhilHealth National Capital Region (NCR)
Address: VCP Building, Block 56, Lot 11, 68 Kalayaan Avenue Teacher’s Village West, Quezon City
Telephone Number: (02) 8441-5673
Email Address: N/A

PhilHealth Bangsamoro Autonomous Region in Muslim Mindanao (BARMM)
Address: Lynzee’s Building, 766 J. Rosales Avenue, Butuan City
Telephone Number: (0938) 212-9134/ (0905) 574-5492
Email Address: pro.armm@philhealth.gov.ph | phic_armm@yahoo.com

List of Philhealth Online Services

PhilHealth members can now enjoy the convenience of online services. With just a few clicks, members can check their contributions, update their personal information, and view availments and claims. Online services are available 24/7, so members can access them anytime, anywhere. With these new features, PhilHealth is making it easier for members to avail of their health insurance benefits.

1. Case Rates Search

Information on PhilHealth’s benefit packages is provided to members.

2. Claims Eligibility Checking

Providers can use this information to determine whether or not members are eligible for specific benefits.

3. Electronic Group Enrollment System

It allows Organized Groups to register and get billed more easily.

4. Electronic Collection Reporting System

Employers can now pay their premium contributions online.

5. Health Care Institutions

The whole list of HCIs is displayed, along with their accreditation status.

6. Membership Portal

It allows members to double-check the accuracy of their membership information.

Video: Frequently Asked Questions in Philhealth

Are you an OFW, or do you have a family member or relative that has a lot of questions about PhilHealth?

This video is ideal for you because it covers frequently asked questions (FAQs), requirements, qualifications, and the application process for PhilHealth membership:

Frequently Asked Questions

If you have any further questions regarding the PhilHealth, see the list of frequently asked questions and answers below.

1. What is PhilHealth?

PhilHealth is the organization that helps Filipinos gets financial aid and access to affordable health care. It pays for hospitalization, lodging and board, medicine, and professional services.

2. Can I go directly to PhilHealth?

Yes, you can go to the PhilHealth office directly, which is open Monday through Friday from 8 a.m. to 5 p.m.

3. What is the purpose of PhilHealth?

PhilHealth provides comprehensive preventive and curative coverage packages to ensure that every member is covered. These benefits are focused on a person’s health needs rather than their financial ability to pay, and they are responsive to members’ health-care demands at all stages of life.

5. When will you be able to use your PhilHealth?

Members must have paid at least nine (9) months of premium contributions within the previous twelve (12) months to be eligible for PhilHealth benefits. The confinement month is included in the twelve (12)-month duration.

6. How will I know whether or not my PhilHealth is active?

MEMBERS of the Philippine Health Insurance Corporation (PhilHealth) can now use a new feature on the government corporation’s website to verify the authenticity of their member data records. On the homepage of www.philhealth.gov.ph, there is a Member Inquiry facility.

7. How can I keep contributing to PhilHealth online?

As a self-employed individual or migrant worker, you can continue to pay your contribution. But first, make sure your PhilHealth Member Data Record (MDR) is up to current. Download the PhilHealth Member Registration Form to update your information (PMRF).

8. How many times per year can we use PhilHealth?

Members of PhilHealth are allowed a maximum of 45 days of confinement per calendar year (1). Each calendar year, the member’s qualified dependents receive an additional 45 days of benefits. The 45-day allowance, however, will be shared among them.

9. Who is considered a dependent?

Adopted or stepchild or stepchildren under 21 years of age, unmarried, and unemployed; Legitimate spouse who is not a member; Child or children – legitimate, legitimated, acknowledged, and illegitimate (as shown on birth certificate).

10. What does the term “indigent” signify in PhilHealth?

Indigents are those who have no visible source of income or whose income is insufficient to support their families, as determined by the Department of Social Welfare and Development (DSWD) using defined criteria.

11. Can I use my PhilHealth benefits if I’m unemployed?

Even if you don’t have a job, you can register for PhilHealth voluntary membership as long as you can pay your monthly charges. If you’re unemployed, you don’t have to worry with PhilHealth requirements. Simply complete and submit the registration form with proper information.

12. In PhilHealth, what is considered informal?

Members of the informal economy include self-employed people, market sellers, street hawkers, tricycle drivers, and others; dual citizens and naturalized Filipino citizens; and migrant laborers, with the exception of land-based Overseas Filipino Workers.

13. What do lifetime members entail?

A lifetime member is a regular member who pays the whole amount due for lifetime membership as established by the National Board in one payment, provided that lifetime membership is only accepted from individuals who have practiced the profession for at least thirty years.

14. Can I re-register with PhilHealth?

Do not register again if you are an existing member who has to modify your membership category (for example, from employed to self-employed/voluntary). You only need to update your PhilHealth membership information.

15. What if I didn’t pay PhilHealth anymore?

PhilHealth provides up to three months of retroactive contribution payment if these two conditions are met: You must have paid nine consecutive monthly payments before the unpaid months. Pay the underpaid months back in full within one month.

16. Is it possible to use my husband’s PhilHealth for maternity leave?

Yes, as your husband’s legal dependents, you and your kid are eligible for PhilHealth maternity benefits.

17. If I’m married, how can I update my PhilHealth?

You should update your information. Below are the steps for updating your data:

Step 1: Download the Member Registration Form for PhilHealth or (PMRF).
Step 2: Fill out the PMRF as needed.
Step 3: Send the completed PMRF to the nearest PhilHealth office.
Step 4: Await the amended Member Data Record to be printed.

Summary

Illnesses affect not only one’s health but also one’s finances and the finances of their entire family. That is why Philhealth provides health insurance coverage to all Filipinos.

PhilHealth also ensures that all citizen of the Philippines have access to affordable, acceptable, available, and accessible health care.

Contact Information

Philhealth Main Office
Address: Citystate Centre, 709 Shaw Boulevard, Pasig City, Metro Manila, Philippines
E-mail address: actioncenter@philhealth.gov.ph / ofp@philhealth.gov.ph.
Telephone Number: (02) 637-9999 / +63 2 8441 7442
Website: http://www.philhealth.gov.ph
Facebook Page: https://www.facebook.com/PhilHealthOfficial

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