What are the benefits provided by PhilHealth?

To maximize your PhilHealth membership, it is important for you to know the benefits that you are entitled to, as well as the requirements you need to procure to allow you and your beneficiaries to fully enjoy your entitlements.

First things to know are these basic items:

• You as a member and your qualified dependents are entitled to benefits for medical expenses for every sickness or operation.
• Both, you as a member and your legal dependents, can get equal benefits.
• Every year, there is an allocated 45 days hospitalization allowance for the member and 45 days to be divided to all qualified dependents. Hospitalization days in excess of 45 days will not be covered by PhilHealth.

Secondly, these benefits can be used by you as a member and your qualified dependents, provided that:

• You, as a member, have updated contributions (except Lifetime and Senior Citizen Members) or valid PhilHealth coverage (for Sponsored, Indigent, and OFWs).
• That the hospital or clinic that you went to is PhilHealth-accredited.
• And that the allocated 45 days in a year has not yet been consumed (except for other PhilHealth benefits such as hemodialysis)

How much can you claim on PhilHealth?

The benefits will be paid by PhilHealth in terms of Case Rates whereas every illness or operation has price allotment to be divided into the hospital and the doctor. This way, the member can already determine how much will be covered by PhilHealth before hospitalization.

Check the PhilHealth website to find out what the equivalent value of benefits for covered illnesses and operations under the All Case Rates (ACR) program of PhilHealth.

How can you claim your PhilHealth benefits?

Step 1: Conditions

To be eligible for the PhilHealth benefits when hospitalized, the following conditions must be met:

• Payment of at least 3 months’ worth of premiums within the immediate 6 months of confinement. For pregnancies, the new born care package, dialysis, chemotherapy, radiotherapy and selected surgical procedures, 9 months’ worth of contributions in the last 12 months is needed.
• Confinement in an accredited hospital for 24 hours due to illness or disease requiring hospitalization. Attending physician(s) must also be PhilHealth accredited.
• Claim is within the 45 days allowance for room and board.

Step 2: Required documents

You’ll also need to submit the following documents before being discharged from the hospital for automatic deduction:

• A clear, updated copy of your Member Data Record (MDR). If you are dependent, make sure that you are listed in the MDR.
• An original copy of PhilHealth Claim Form 1, which you can get at PhilHealth, the hospital or your employer. Submit the original copy signed by your employer.
• Receipt of premium payments. Employees only need to submit the Certificate of Premium Payments with OR numbers.
• Your PhilHealth ID and a valid ID.

Ask the hospital regarding their PhilHealth submission rules. If you can’t submit the claim form personally, have an authorization letter and a valid ID ready for your representative.

Step 3: Claiming and post-claims

• As direct filing is no longer needed, submission of the documents to the hospital before the end of your stay means automatic deduction of your benefits from your total bill.
• Once your benefits have been automatically deducted, PhilHealth will send a benefit payment notice to the address declared in your MDR. This details the actual payments made by PhilHealth relative to your claim or confinement.

Keeping your PhilHealth up-to-date is important, remember that updated premiums is key to enjoy your entitlements. It is also essential for you to keep your updated premium payment receipts safe and within easy reach for emergencies. You will definitely need them in asking the hospital billing section to deduct your benefits from your total charges.

In addition, as soon as you have anything to update in the membership profile, i.e. additional dependents or change in civil status, promptly inform the nearest PhilHealth office (by just filling out the PhilHealth Membership Registration Form or PMRF) to effect the needed changes.