Benefits and Privileges Government-Mandated Benefits National Health Insurance Program

The following enjoy PhilHealth coverage without additional premiums for each qualified dependent:

  1. Legal spouse (non-member or membership is inactive)
    Children – legitimate, legitimated, acknowledged and illegitimate (as appearing in birth certificate), adopted or step child below 21 years of age, unmarried and unemployed.  Also covered are children 21 years old or above but suffering from congenital disability, either physical or mental, or any disability acquired that renders them totally dependent on the member for support
  2. Parents (non-members or membership is inactive) who are 60 years old, including step parents (biological parents already deceased) and adoptive parents (with adoption papers).


All your qualified dependents are entitled to a separate coverage of up to 45 days per calendar year.  However, their 45 days allowance will be shared among them.

 

Important:

Your dependents need to be declared in the PhilHealth Member Data Record (MDR).  Your MDR should be updated every time you have a new dependent. Your updated MDR will make your benefit availment easier and convenient.

Availment Conditions

The following must be met before you can avail of your PhilHealth benefits:

  • Payment of at least three monthly premiums within the immediate six months prior to confinement
  • Confinement in an accredited hospital for at least 24 hours (except when availing of outpatient care and special packages) due to an illness or disease requiring hospitalization.  Attending physicians must also be PhilHealth accredited.
  • Availment is within the 45-day allowance for room and board

 

Benefit Availment Procedures

1.   For outright/automatic deduction of benefits:

Submit to the billing section the following prior to discharge from the hospital:

·        Duly accomplished PhilHealth Claim form 1 (original)

·        Clear copy of Member Data Record (MDR)

-         If dependent – patient is not listed yet in the MDR, submit applicable proof of dependency

·        Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit

·        Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill

2.   For direct filing / reimbursement

Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge:

·        Philhealth Claim Form 2 (to be filled up by the hospital and attending physicians)

·        Official receipts or hospital and doctor’s waiver

·        Operative record for surgical procedures performed

 

Benefits

Inpatient coverage:

PhilHealth provides subsidy for room and board, drugs and medicines, laboratories, operating room and professional fees for confinements of not less than 24 hours. (See Appendix J – PhilHealth Benefits).

Outpatient Coverage:

Day surgeries, dialysis and cancer treatment procedures such as chemotherapy and radiotherapy in accredited hospitals and free-standing clinics.

Special benefit packages:

·        Coverage for up to the third normal delivery

·        Newborn Care Package

·        TB Treatment through DOTS

·        SARS and Avian Influenza Package

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