PhilHealth is a government-administered health insurance program in the Philippines that provides access to quality and affordable healthcare for both Filipino citizens and those residing in the country. It is operated by the Philippine Health Insurance Corporation (PhilHealth), a statutory body corporate created under Republic Act No. 7875, otherwise known as The National Health Insurance Act of 1995.
Also Read: Pag-IBIG Fund Philippines
PhilHealth funds and supports member contributions, giving them access to services such as professional medical consultation, vaccinations, laboratory tests, hospitalization expenses, and limited dental services.
Membership is offered to all Filipinos living or working in the Philippines, including Overseas Filipino Workers (OFWs). PhilHealth also covers members’ dependents such as spouses and children up to 21 years old.
Various payments plans are available for members to choose from depending on their income levels and other factors. PhilHealth also covers emergency health care needs through its Interim Reimbursement Mechanism (IRM) program. This program reimburses eligible members with an emergency case at any public or private hospital approved by PhilHealth.
Are you ready for the unexpected? They say, “Mahirap magkasakit” and it’s true to all Filipinos. When it comes to illnesses, we all hope for the best, but sometimes things don’t go according to plan. That’s where PhilHealth comes in – the Philippine Health Insurance Corporation can help prepare for the unexpected, providing financial assistance for your medical needs.
It’s there to help you manage the costs of unexpected medical bills and provide you with peace of mind. But just like any safety net, PhilHealth has its challenges to overcome, including recent controversies. So, let’s take a closer look at the importance of PhilHealth, from its history to its current functions as well as membership and benefits, and learn how you can be prepared for whatever comes your way.
What is PhilHealth?
PhilHealth was established with the goal of providing universal health insurance coverage for all Filipinos, aiming to make healthcare more accessible, available, and affordable for everyone, particularly those who face challenges in accessing quality healthcare. This government agency employs a sustainable system of pooling, managing, and disbursing funds that are cross-subsidized across different districts.
In 1995, the National Health Insurance Act paved the way for the creation of PhilHealth, which inherited the responsibilities of its predecessor, the Medicare Program, PhilHealth was tasked to provide social health insurance coverage for Filipinos within a 15-year timeframe. Today, the agency has over 52 million members and 42 million dependents, including both direct and indirect contributors, registered in its system.
Different Types of Membership
PhilHealth membership is automatically provided to fully employed citizens, with their employers responsible for settling their membership and regular contributions. Meanwhile, there are other membership categories available, and anyone can manually register for PhilHealth through any branch or office, or via online registration.
1. Formal economy membership. This applies to all employed individuals who work for either government or private sector organizations with offices located within the country, including seafarers who agencies are based in the Philippines. For formal economy members, the monthly contribution payments begin at 3%, with the employer and employee each contributing half of the premium.
2. Informal economy membership. The informal economy category of PhilHealth membership covers those who are self-employed, unemployed, and engaged in informal work such as market vendors and small construction workers.
It also includes naturalized Filipinos and foreigners residing in the Philippines who are paying their premiums voluntarily and individually. Similar to formal economy members, voluntary contributors under this category are required to pay the same 3% rate, but they will have to cover the full premium amount.
3. Oveseas Filipino Workers. Land-Based and Sea-based OFWs are subject to the formal economy membership’s monthly contribution scheme, as they are covered by an employer-employee relationship. On the other hand, other members may choose to make their contributions every 3, 6, or 12 months.
4. Senior citizens. According to the Universal Health Care Law of 2019, Filipinos aged 60 and above who are not covered by any PhilHealth membership category are automatically enrolled in the program. Moreover, the national government is responsible for covering their annual premiums. To register as a member under this category, you can enroll through the Office for the Senior Citizens Affairs or the PhilHealth Local Health Insurance Office.
5. Lifetime membership. Lifetime membership are individuals who are at least 60 years old and have paid a minimum of 120 monthly premiums to PhilHealth and the previous Medicare Program. Once they reach the age of 60, their membership becomes free.
6. Sponsored membership. This pertains to members who have their contributions sponsored by a third-party, which can be a private individual, local government unit, government or private agency. Sponsored members may include low-income individuals who are not classified as indigent, such as barangay health workers, volunteers, nutrition scholars, Persons with Disabilities, unenrolled pregnant women, and other eligible beneficiaries.
7. Indigent membership. This membership category is intended for individuals who have no source of income or whose household income falls below the DSWD’s specific criteria. Once identified, indigents are eligible to register under the program.
8. Qualified dependents. Dependents who are eligible for coverage are those whose contributions are declared and covered by a primary member. These include the member’s legally recognized spouse, children, or parents. In order to access the benefits, qualified dependents must be included in the primary member’s Member Data Record.
List of Benefits, Programs, and Services of PhilHealth
PhilHealth offers a range of medical benefits that aim to provide accessible healthcare to Filipinos. Here are some of the essential coverage that PhilHealth offers:
- Inpatient benefits. PhilHealth offers inpatient benefits that cover the cost of diagnostic and therapeutic procedures, as well as hospital charges such as patient rooms, medicines, and professional fees. These benefits are available to members who require hospitalization and can be accessed at any PhilHealth-accredited healthcare institution. The cost of the member’s treatment will be reduced by the amount covered by PhilHealth before they are discharged.
- Outpatient benefits. The outpatient benefits of PhilHealth pertain to medical procedures and treatments that do not require confinement, including but not limited to day surgeries, radiotherapy, outpatient blood transfusion, and hemodialysis. These benefits can be availed by members at any accredited ambulatory surgical clinic, healthcare institution, or primary care facility.
- Z benefits. PhilHealth’s Z benefit coverage provides comprehensive support for members and their dependents who have severe medical conditions that require hospitalization and expensive treatments, such as cancer, kidney transplant, and certain orthopedic implants.
- SDG-related benefits. PhilHealth has developed medical packages for members that are diagnosed with certain medical conditions or undergoing specific medical procedures, inline with the United Nations Sustainable Development Goals. These packages include outpatient malaria, outpatient HIV-AIDS, animal bite, and voluntary surgical contraception procedures.
- Maternity Benefits. PhilHealth members who are expectant mothers and have updated contributions can access maternity benefits. PhilHealth provides various benefit packages for pregnant women, which include:
- Newborn care package. This benefit covers the screening of newborns and hearing tests, as well as the provision of essential newborn care such as early skin-to-skin contact, drying the baby, and weighing the baby.
- Delivery options. PhilHealth provides coverage for different types of childbirth, including caesarean delivery, breech extraction, vaginal delivery after section, and complicated vaginal delivery that may require the use of forceps or episiotomy.
- Normal spontaneous delivery package. Included in this package are vaginal deliveries that are normal and low-risk, along with postnatal examinations spanning from three to seven days following delivery.
- Antenatal care package. This coverage encompasses prenatal check-ups, which consist of laboratory tests and ultrasounds.
Take note that the maternity benefits package provides coverage solely for the initial four regular deliveries of a member, and any succeeding births will not be covered by the insurance. Members may make sure of these benefits at any accredited hospital or non-hospital facilities.
For mental health services, PhilHealth is collaborating with the Department of Health to integrate mental health services into their range of primary care packages, particularly within the outpatient package.
Video: Things You Should Know for Your PhilHealth Registration
In this video, you will learn about PhilHealth benefit packages, direct and indirect contributors, who can register as a principal member, if student can register, and the minimum premium contribution. It also mentions about the Certificate of Indigency and who can perform the financial capacity to pay premiums.
Frequently Asked Questions
1. How can I claim my PhilHealth benefits?
Before a PhilHealth member can claim benefits, they must fulfill a certain set of requirements. One of which is having sufficient regularity of payment to qualify for the benefit. To be eligible for the assistance, a member must have completed a minimum of nine months’ worth of contributions within the 12 months preceding confinement.
2. What are the requirements to file and claim benefits?
The documents required for filing and claiming PhilHealth benefits include PhilHealth ID, another valid ID, PhilHealth Claim Form 1, Member Data Record Form, and proof of contribution payments.
3. What are requirements for Filipinos with dual citizenship?
The documents needed to file for benefits claim include accomplished PMRF, Certificate of Re-acquisition or Retention of Philippine Citizenship, and Identification Certificate issued by Bureau of Immigration or the Philippine Embassy or Philippine Consulate abroad.
4. How many times can I avail of PhilHealth benefits per year?
You can use your PhilHealth benefits anytime each year, but you need to fulfill your contribution requirements as well as benefit eligibility criteria.
5. How much can I get for medical coverage?
PhilHealth provides partial or full coverage of a member’s medical costs depending on their medical case.
PhilHealth provides accessible and affordable healthcare services to its members, including outpatient and inpatient care, as well as mental health services. Members must fulfill specific requirements to be eligible for PhilHealth benefits, such as completing a minimum number of contributions. It is crucial for eligible individuals to take advantage of PhilHealth’s benefits and maintain their contributions to support the country’s healthcare system.
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