PhilHealth 101: Everything You Need to Know

As the saying goes, “Mahirap magkasakit.” This is true for many Filipinos, not only because of the challenges that come with getting sick but also the medical expenses. Even if you’re employed, you still need all the help you can get to cover unexpected costs as well as your own family’s medical needs.

Generally, the healthcare system in the country varies. Hospitals in major cities demonstrate high standards with more and better equipment than those in rural areas, which often lack infrastructure. As such, buying health insurance—although this can be expensive—is a must for Filipinos to prepare them in case of medical emergencies and financial shortcomings.

Thankfully, aside from a health maintenance organization or HMO plan that workers usually receive as part of their benefits from their employers, public healthcare is available.

PhilHealth, a government-owned organization, provides medical assistance and health benefits to Filipinos—regardless of social status—helping alleviate the medical financial burden.

Read on to learn more about PhilHealth functions, membership categories, and benefits.

What is PhilHealth?

The Philippine Health Insurance Corporation or PhilHealth was created to deliver universal health insurance coverage for all Filipinos, making healthcare more accessible, available, and affordable for many. This holds especially for those who do not have instant access to quality healthcare.

PhilHealth uses a sustainable fund pooling, management, and disbursement system cross-subsidized across districts.

The National Health Insurance Act of 1995 facilitated the establishment of PhilHealth, assuming the responsibilities of its precursor, the Medicare Program. PhilHealth was directed to provide social health insurance coverage to Filipinos within 15 years.

As of June 2021, there are 52,530,152 members and 42,265,302 dependents registered (direct and indirect contributors) in PhilHealth.

Types of PhilHealth Members

Fully employed citizens get automatic PhilHealth membership, as it is the employer’s responsibility to settle their membership and regular contributions. However, there are also other membership categories available. Anyone can register manually through a PhilHealth office or via online registration.

1. Formal economy members

This pertains to all employed individuals working in the government or private sectors with offices based in the country. This also covers seafarers, considering their agencies are in the Philippines.

The monthly contribution payments for formal economy members start at 3%. The employer and employee will each pay half of the premium.

2. Informal economy members

Members in the informal economy category include those who are unemployed, self-employed, informal workers (market vendors, small construction workers, etc.), naturalized Filipinos, and foreigners living in the Philippines who are voluntarily or individually paying their premiums. Like formal economy members, these voluntary contributors will follow the same 3% rate, but they will pay the full premium amount.

3. Overseas Filipino Workers (OFWs)

Sea-based OFWs follow the formal economy membership monthly contribution, as they are bound by the employer-employee relationship. For others, their contributions can be made every 3, 6, or 12 months.

4. Senior citizens

Filipinos aged 60 years and above who do not belong to any membership category are automatic members of PhilHealth as stated by the Universal Health Care Law of 2019. Furthermore, it is the national government that should cover their annual premiums.

To become a member under this category, you can enroll through Office for the Senior Citizens Affairs (OSCA) or PhilHealth Local Health Insurance Office (LHIO).

5. Lifetime members

Lifetime members are those aged 60 years and above and have paid a minimum of 120 monthly premiums with PhilHealth and the former Medicare Program. Their membership becomes free once they reach 60.

6. Sponsored members

This refers to members whose contributions are shouldered by a sponsor, which can be a private individual, the local government, or a government agency or private agency. Sponsored members can include low-earning citizens who are not indigents such as barangay health workers and volunteers, nutrition scholars, Persons with Disabilities (PWDs), and unenrolled pregnant women, among others.

7. Indigent members

This category pertains to members without a source of income or insufficient household income based on DSWD’s (Department of Social Welfare and Development) specific criteria. Once identified, indigents shall be registered under the program.

8. Qualified dependents

Qualified dependents are those whose contributions are declared and covered by a principal member. Those could be the member’s legitimate spouse, children, or parents. Qualified dependents must be listed in the PhilHealth contributor’s Member Data Record (MDR) to access the benefits.

Scope and Coverage of PhilHealth

PhilHealth provides various types of medical benefits to support and make healthcare available for Filipinos. Below is a list of PhilHealth’s benefit coverage you should know.

• Inpatient benefits
  1. Inpatient benefits cover any kind of diagnostic or therapeutic procedure, as well as hospital charges (patient room, medicines, professional fees, etc.) for individuals who may need confinement in a hospital. Members can avail of inpatient benefits at any PhilHealth accredited healthcare institution (HCI), and the case rate amount shall be deducted from the member’s total bill before discharge.
• Outpatient benefits
  1. Outpatient benefits refer to assistance in procedures and treatments that do not require confinement, such as day surgeries, radiotherapy, outpatient blood transfusion, and hemodialysis. Members can utilize the benefits at accredited ambulatory surgical clinics (AASC), HCIs, and primary care facilities.
• Z benefits
  1. The Z benefits coverage assists members and dependents with severe conditions requiring hospitalization and expensive treatments, including but not limited to cancer (prostate, breast, cervical), kidney transplant, and selected orthopedic implants.
• SDG-related benefits
  1. Following the United Nations Sustainable Development Goals (SDG), PhilHealth has established medical packages for members diagnosed with or undergoing procedures such as outpatient malaria, outpatient HIV-AIDS, animal bite, and voluntary surgical contraception procedures.
• Maternity benefits
  1. Expectant mothers who are PhilHealth members with updated contributions can take advantage of maternity benefits. PhilHealth offers a range of benefit packages for pregnant women, including:
     
     1. Antenatal care package - Prenatal check-ups such as laboratory tests and ultrasounds are included in this coverage.
     2. Normal spontaneous delivery package – This covers normal, low-risk vaginal deliveries, including postnatal check-ups from three to seven days post-delivery.
     3. Other methods of delivery - Cesarean, breech extraction, vaginal delivery after cesarean section, and complicated vaginal delivery (with or without forceps or episiotomy) are also insured by PhilHealth.
     4. Newborn care package - This covers newborn screening and hearing tests and provisions of essential newborn care, including early skin-to-skin contact, drying of the baby, weighing of the baby, etc.
     5. Note that this benefits package covers only the first four normal deliveries of a member, and any subsequent childbirths will no longer be insured. Members can avail of the benefits at any accredited hospital and non-hospital facilities.
        
• Mental health services
  1. PhilHealth is working with the Department of Health (DOH) to include mental health services in their roster of primary care packages, particularly the outpatient package. You can visit this link for a more thorough list of PhilHealth’s benefit packages and amounts.

PhilHealth Contribution Table

The monthly or quarterly contribution rate of PhilHealth members depends on their salary range. Take a look at the PhilHealth contribution table below, which illustrates the premium rate increase for the years 2022-2025.

For 2021, note that the contribution remains at 3% following PhilHealth’s suspension of contribution hike.

To calculate your contribution amount, you need to check where your salary fits in the salary range. For example, suppose you earn a monthly salary of ₱15,000. Based on the table above, your monthly premium will be ₱450. This will then be shared by the employee and employer, amounting to ₱225 each.

How to Claim PhilHealth Benefits

A PhilHealth member must meet a set of requirements first before they can claim benefits. For one, sufficient regularity of payment (SRP) will be required to avail the benefit. A member should have completed at least nine months’ worth of contribution within 12 months before confinement to be eligible for the assistance.

Below are the documents members need to accomplish when filing to claim benefits.

• Your PhilHealth ID and another valid ID.
• An original copy of PhilHealth Claim Form 1 signed by your employer.
• A clear and updated copy of your Member Data Record Form (MDR). This may be skipped if the hospital has a My PhilHealth Portal account.
• Proof of contribution payments with official receipts if the information is not included on the MDR.

Members can get copies of the necessary documents from the hospital or healthcare facility or download the required forms through the PhilHealth website.

Know and Maximize Your Benefits for Better Health

It helps to be informed and know what benefits the government provides for you. Government agencies like PhilHealth make it possible for Filipinos of all backgrounds to have social and financial safety nets. Being a PhilHealth member can assist you during tough times of emergencies for you and your family’s medical needs.

If you want to learn more about medical insurance and how it can protect you from unexpected costs, experts at Kwik.insure can help you determine which coverage would best match your needs. Reach out to Kwik.insure today to get all your insurance-related concerns answered or to get a free consultation.