Benefits

Effective December 1999, PhilHealth is implementing a unified benefit package for all PhilHealth members.

What this is For:

This benefit package includes the following categories of personal health services:

Inpatient hospital care:

Room and board;

Services of health care professionals;

Diagnostic, laboratory, and other medical examination services;

Use of surgical or medical equipment and facilities;

Prescription drugs and biologicals, subject to the limitations stated in Section 37 of RA 7875; and

Inpatient education packages.

Outpatient care:

Services of health care professionals;

Diagnostic, laboratory, and other medical examination services;

Personal preventive services;

Prescription drugs and biologicals, subject to the limitations described in Section 37 of RA 7875; and

Emergency and transfer services

UNIFIED MEDICARE BENEFITS

For all Members and Dependents under the National Health Insurance Program

BENEFITS HOSPITAL CATEGORY

PRIMARY SECONDARY TERTIARY

ROOM AND BOARD 200 300 400

Not exceeding 45 days for each member & another 45 days to be shared by his dependents

DRUGS & MEDICINES 1,5002,5000 1,7004,0008,000 3,0009,00016,000

Per single period of confinement

a. Ordinary b. Intensive c. Catastrophic

X-RAY, LAB, ETC. 3507000 8502,0004,000 1,7004,00014,000

Per single period of confinement

a. Ordinary b. Intensive c. Catastrophic

PROFESSIONAL FEES P 150/day for General PractitionerP 250/day for Specialist

Per single period of confinement shall not exceed:

a. Ordinary General Practitioner Specialist 6001,000 6001,000 6001,000

b. Intensive General Practitioner Specialist 9001,500 9001,500 9001,500

b. Catastrophic General Practitioner Specialist 9001,500 9001,500 9002,500

OTHERS 38500 6701,1402,160 1,0601,3503,490

Operating Room

a. RVU of 30 and below b. RVU of 31 to 80 c. RVU of 81 and above

Surgeon Maximum of 16,000

Anesthesiologist Maximum of 5,000

Compensable Outpatient Services: Ambulatory surgeries and procedures including dialysis, radiotherapy and chemotherapy TB DOTS

Fig. 1 PhilHealth Benefits (Last Update: February 21, 2005)

Other Documentary Requirements:

Claims Processing

PhilHealth is about giving access to health services. In 2003, PhilHealth expanded its benefit package to cover services most needed by the members and would redound to better health services. As a result, PhilHealths benefit payments reached P10.9 billion in 2003.

A number of benefit enhancements were made in 2003 and these contributed to the phenomenal growth in benefit payments.

Increase in Room and Board Rates

PhilHealth started the year with an increase in room and board rates. Effective admissions on April 1, 2003, room and board rates for primary hospitals were increased from P150 to P200, secondary hospitals from P220 to P300 and tertiary hospitals to P400 per day of hospitalization.

TB Package

The Philippines has one of the highest incidence of tuberculosis in the world. In response to, this PhilHealth developed the TB-defined package which was made available starting April 1, 2003. The package follows the anit-TB treatment known as Directly-Observed Treatment Short-Course or DOTS which is reported to have a cure rate of as much 96%.

Normal Spontaneous Deliveries

Since Medicare started, normal deliveries were not being reimbursed. In a historic first, PhilHealth started to reimburse the first two Normal Spontaneous Deliveries (NSD) done in lying-in clinics, midwife-managed clinics, birthing homes, and rural health units (RHUs) effective May 1, 2003. The package which is paid with a case payment rate of P4,500 covers prenatal care, delivery care, newborn care and postpartum care to PhilHealth members and benificiaries.

Dialysis in Free Standing Clinics

Dialysis has long been reimbursed by PhilHealth but availment of such services are limited to hospital facilities. With the setting up of free standing dialysis centers offering services comparable to hospital- based facilities, PhilHealth saw the opportunity to expand PhilHealth services by reimbursing dialysis clinics effective April 1, 2003.

SARS Package

The global community grappled with a mysterious public health menace in 2003, the Severe Acute Respiratory Syndrome or SARS.

Members and their qualified dependents are given a maximum of P50,000 per case. This covers the payment for professional health services, drugs and medicines, radiographic services from the referring hospital to the DOH-designated hospital to the DOH-designated hospital for SARS. With our health workers facing greater risk of contracting the disease, their SARS benefit package was pegged at P100,000.

What You Need to Submit to Enjoy Your Benefits:

Fully-accomplished PhilHealth Claim Form I Claim Form 1 Members Data Record, Form II Claim Form 2 Hospital Data Record and Form III Claim Form 3 Patients Clinical Record.