What is PhilHealth?

PhilHealth, or the Philippine Health Insurance Corporation, is a government-owned and controlled corporation established in 1995 to manage the National Health Insurance Program (NHIP). Its main goal is to provide every Filipino with access to affordable and quality healthcare services. The system follows a social health insurance model, where members contribute a portion of their income in exchange for financial assistance when medical needs arise.

Types of PhilHealth Members

1. Formal Economy Members

These include individuals with a fixed income under an employer-employee relationship. They contribute to PhilHealth through salary deductions.

1. Government Employees – Workers serving in government offices, agencies, military, police, or GOCCs, whether elected or appointed.
2. Private Sector Employees – Individuals working in companies, NGOs, cooperatives, or foreign organizations operating in the Philippines.
3. Project-Based or Contractual Workers – Those hired on specific projects or limited-time employment.
4. Owners of Enterprises – From micro to large businesses.
5. Household Workers (Kasambahay) – As defined under the Kasambahay Law.
6. Family Drivers – Drivers hired by households or individuals.

2. Informal Economy Members

These are individuals earning outside of formal employment structures.

1. Migrant Workers – Filipinos working abroad, whether documented or undocumented.
2. Informal Sector Workers – Includes market vendors, tricycle drivers, small construction workers, and others in similar trades.
3. Self-Earning Individuals – Professionals and entrepreneurs earning through their own practice or business.
4. Filipinos with Dual Citizenship – Recognized as Filipinos but holding citizenship in another country.
5. Naturalized Citizens – Foreigners who have acquired Filipino citizenship.
6. Foreign Nationals Residing in the Philippines – Those with valid work permits or residence status.

3. Lifetime Members

1. Individuals aged 60 and above who have paid at least 120 monthly contributions to PhilHealth or previous Medicare programs under SSS or GSIS.
2. Includes uniformed personnel, underground miner-retirees aged 50 and above, and SSS or GSIS pensioners who retired before March 4, 1995.

4. Sponsored Members

These are individuals whose contributions are paid by another party such as a local government unit (LGU), government agency, or private sponsor.

1. Members from low-income sectors not eligible for full subsidy but whose premiums are covered through cost-sharing.
2. Orphans, abandoned children, out-of-school youth, persons with disabilities, senior citizens, and others under government care.
3. Barangay workers and volunteers like tanods and health workers.
4. Pregnant women who are not yet PhilHealth members, especially indigents.

5. Senior Citizens

Filipinos aged 60 and above, residing in the Philippines, and not yet enrolled under any PhilHealth category are automatically covered. Senior citizens with regular income are still required to contribute based on the applicable membership type.

Qualified Dependents

All qualified members may also declare certain family members as dependents, who are covered without additional premiums. These include:

1. Legal spouse not enrolled as a member
2. Children under 21 years old, unmarried and unemployed (including legitimate, illegitimate, adopted, and stepchildren)
3. Children 21 years or older with congenital or acquired disabilities rendering them fully dependent
4. Foster children as recognized by law
5. Parents aged 60 and above without their own PhilHealth membership and with no regular income
6. Parents with permanent disability regardless of age who are totally dependent on the member

Each dependent is entitled to a maximum of 45 days of hospital benefits per year, which is shared among all dependents.

PhilHealth Benefits

Inpatient Benefits

1. PhilHealth provides financial assistance for hospital confinement through case-based payment.
2. The amount is deducted from the total hospital bill, including doctor’s fees, before the patient is discharged.
3. Benefits can be availed at accredited hospitals, and members must present either their Member Data Record (MDR) or PhilHealth Benefit Eligibility Form (PBEF).

Outpatient Benefits

Includes several services that do not require hospital admission:

1. Day Surgeries – Minor to major elective procedures done in accredited ambulatory surgical clinics.
2. Radiotherapy – Coverage for cancer treatment using cobalt or linear accelerator equipment.
3. Hemodialysis – Up to 90 sessions per year for patients with kidney conditions.
4. Outpatient Blood Transfusion – Includes cost for the transfusion procedure, medication, and laboratory work.

Z Benefits

These are benefits for cases that are medically and financially catastrophic. The program supports patients with severe illnesses such as certain types of cancers, congenital anomalies requiring surgery, and other life-threatening conditions that require long and expensive treatment. PhilHealth has identified these as “Z” cases due to their high burden. Coverage includes surgery, chemotherapy, hospitalization, and other specialized treatments in accredited centers.

SDG-Related Benefits

Aligned with the Sustainable Development Goals (SDG), PhilHealth also provides benefits for conditions such as HIV/AIDS, tuberculosis, and maternal care, among others. These are designed to reduce mortality and improve health outcomes in vulnerable populations. Coverage includes outpatient treatment, screening tests, and prenatal care.

How to Claim PhilHealth Benefits

To claim PhilHealth benefits, members must meet the contribution requirement—usually at least nine months of contributions within the 12 months before the date of confinement or procedure.

Required documents include:

1. Valid PhilHealth ID and another government-issued ID
2. Updated Member Data Record (MDR) or a printout of the PhilHealth Benefit Eligibility Form (PBEF)
3. Accomplished PhilHealth Claim Form 1 (available from the hospital or the PhilHealth website)
4. Proof of premium payments (if not reflected in the MDR)

Hospitals usually assist in filing the claim upon admission. The amount is directly deducted from the bill upon discharge, so there's typically no need for reimbursement unless specific arrangements are made.