Philhealth Insurance Guide
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Welcome to your guide on how to use your PhilHealth benefits at Unihealth Southwoods Hospital and Medical Center, a PhilHealth accredited, leading tertiary hospital in Laguna!
This page will walk you through essential information about your PhilHealth coverage, the availment process for your PhilHealth benefits, or requirements you may need to present such as your PhilHealth ID card or Member Data Record (MDR) to make your visit at Unihealth Southwoods Hospital smooth and hassle-free.
What is Philhealth?
PhilHealth or Philippine Health Insurance Corporation, a government-owned corporation, is the national health insurer for Filipinos.
It implements the National Health Insurance Program, providing health insurance coverage and financial protection against medical costs through a contribution and subsidy system, making healthcare services more affordable and accessible to Filipinos.
Who is eligible for PhilHealth Benefits?
By law, under the Universal Healthcare (UHC) Act, all Filipinos can become PhilHealth members. However, to be eligible to claim PhilHealth benefits, you must:
- Be a registered PhilHealth Member: You can register through your employer or as an Individually Paying Member if you are self-employed or an OFW.
- Pay your premium contributions: Pay three (3) months worth of contributions within the last six (6) months before your requested date to avail of PhilHealth services. (ex. You're using your PhilHealth benefits on October. Your April, May, and June contributions must have already been paid for you to be eligible.)
- Identify if you are automatically eligible: If you are an Indigent, Senior Citizen, PWD, or a Sponsored Member, you are immediately eligible upon registration.
- Properly declare your dependents: Make sure that qualified dependents are declared on your PhilHealth Member Data Record (MDR).
How can you declare dependents properly for PhilHealth?
To add your PhilHealth dependents, you must:
- Identify which of your immediate family you will declare as your dependents.
- Prepare supporting documents that prove your relationship. (Photocopy & Original)
- Spouse: Marriage Certificate
- Children: Birth Certificate; Medical Certificate, for those who have disabilities, aged twenty-one (21) years old and above
- Parents: Birth Certificate (or equivalent proof of birth/age); Medical Certificate if disabled
- Get a PhilHealth Member Registration Form (PMRF) from the PhilHealth website or any PhilHealth branches near you.
- Fill out the form for "Updating" and clearly list your dependents in the designated section.
- Submit your PMRF and supporting documents to a PhilHealth Local Health Insurance Office (LHIO), PhilHealth Express, or your employer's HR department.
- Receive your updated Member Data Record (MDR), issued by PhilHealth usually within 1-2 weeks of processing.
What are the PhilHealth Benefits you may receive?
PhilHealth can provide a wide variety of benefits to members and their dependents through a “case rate” basis. This is a system where fixed amounts are covered for specific medical conditions and procedures. Here are the benefits that PhilHealth may provide.
Inpatient Benefits
PhilHealth may cover services for hospital admissions that require the patient to be admitted for 24 hours and above. They may cover:
- Room and Board
- Medicines Used
- Laboratory Exams
- Use of Operating Room
- Doctor's or Specialist's Professional Fees
Outpatient Benefits
PhilHealth may also cover medical procedures or services that do not require admissions. These may include:
- PhilHealth Konsultasyong Sulit Tama (Konsulta): PhilHealth's comprehensive outpatient benefits that follows the Universal Health Care Law. This covers consultations, health risk screenings & assessments, selected laboratory and diagnostic tests, and selected medicines.
- Outpatient Emergency Care Benefit (OECB): PhilHealth's new package. It includes coverage for emergency procedures or services even when a patient is not admitted. This can be diagnostic tests such as ECG, X-ray, or CT scan, laboratory tests, and medicines.
- Surgical Procedures: PhilHealth can cover surgeries where the patient was admitted and discharged on the same day.
- Radiotherapy: PhilHealth can cover cancer treatment sessions.
- Hemodialysis: PhilHealth also has coverage for patients who have kidney failure (up to 156 sessions per year).
- Specific Targeted Disease Packages: This covers services for treatments for specific diseases such as Directly Observed Treatment Short-course (DOTS) Package for Tuberculosis, Outpatient HIV-AIDS Package, and Animal Bite Treatment Package.
- Blood Transfusion: PhilHealth covers one day of transfusion of any amount blood or blood product (ex. platelets, plasma) that counts as one session.
Special Benefits
Also known as Z Benefits, these PhilHealth benefit packages are designed to provide a wide variety of coverage for critical illnesses and conditions that require prolonged or lifelong treatments such as:
- Cancers: Acute Lymphocytic/Lymphoblastic Leukemia (standard risk, for children), Early Breast Cancer (Stage 0 to IIIA), Prostate Cancer (low to intermediate risk), Cervical Cancer, Colon Cancer (Stages I-III), and Rectal Cancer (Stages I-III)
- End Stage Renal Disease: Specifically, Kidney Transplants
- Heart Surgeries:Coronary Artery Bypass Graft (CABG) Surgery (standard risk), Total Correction of Tetralogy of Fallot (for children), Closure of Ventricular Septal Defect (for children)
- Z Benefits for Mobility, Orthosis, Rehabilitation, and Prosthesis Help (ZMORPH): This could cover orthopedic implants and some rehabilitation services.
- Z Benefits for Peritoneal Dialysis (PD) First
- Z Benefits for Premature and Small Newborns
- Z Benefits for Children with Disabilities
How to Avail PhilHealth Benefits at Unihealth Southwoods Hospital and Medical Center
Admission:
- Head to the Admitting Office and fill out the Philhealth Benefit Eligibility (PBEF).
- After filling out the form, the patient's benefit eligibility will be checked.
- Patients or the patients' relative will be informed if additional documents if needed.
Discharge:
- First, the patient's chart will be evaluated to check their diagnosis, case rate, and criteria.
- Once evaluated, the amount that Philhealth can cover will be deducted from the total hospital bill.
- The PhilHealth deduction will then be forwarded to the billing station and, after processing, the final bill will be given to the patient or their relative.
- Required PhilHealth forms must be accomplished and submitted before settling the payment.
Reminder:
Always keep your PhilHealth ID (or PIN) and updated MDR ready for smooth transactions
Helpful Answers
Frequently Asked Questions
Can I use PhilHealth with my HMO?
Yes, you can. Coverage from your PhilHealth will be deducted first. The reamaining amount may be covered by your HMO depending on your plan.
How can I get a copy of my MDR?
You may simply visit any PhilHealth branches nationwide, obtain it through the online portal by registering using your PhilHealth Identification Number (PIN) , or send an email to PhilHealth’s Action Center (actioncenter@philhealth.gov.ph or ofp@philhealth.gov.ph).
How much will PhilHealth cover?
PhilHealth covers medical expenses through a “case rate” system. This means that they cover a certain amount for certain medical treatments and procedures. This also depends on whether the facility you visit is PhilHealth accredited. You may check PhilHealth circulars online or visit your nearest PhilHealth branch to inquire for the exact figures.