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What is PhilHealth?

Philippine Health Insurance Corporation (PhilHealth) was created in 1995 to create a
universal health coverage for the Philippines. It is a tax-exempt, government-owned and
government-controlled corporation (GOCC) of the Philippines, and is attached to the
Department of Health. It states its goal as insuring a sustainable national health
insurance program for all. In 2010, it claimed to have achieved "universal" coverage with 86% of
the population, although the 2008 National Demographic Health Survey showed that only 38
percent of respondents were aware of at least one household member being enrolled in
PhilHealth. Nevertheless, this social insurance program provides a means for the healthy to pay
for the care of the sick and for those who can afford medical care to subsidize those who
cannot. Both local and national government allocate funds to subsidize the indigent.

Who can join Philhealth or to become a member?
1. Retirees/ Pensioners from the Government Sector
Old-age retirees and pensioners of the GSIS, including non-uniformed personnel of the AFP, PNP,
BJMP and BFP who have reached the compulsory age of retirement before June 24, 1997, and
retirees under Presidential Decree 408.
GSIS Disability Pensioners prior to March 4, 1995.
GSIS Retirees who have reached the age of retirement on or after March 4, 1995 and have at least
120 months PhilHealth premium contributions.
Retirees and Pensioners who are members of the Judiciary who have reached the age of
retirement and have at least 120 months PhilHealth contributions.
Retirees who are members of Constitutional Commissions and other Constitutional Offices who
have reached the age of retirement and have at least 120 months PhilHealth contributions.

2. Retirees/ Pensioners from the Private Sector
SSS Pensioners prior to March 4, 1995.
SSS Permanent Total Disability Pensioners prior to March 4, 1995.
SSS Death/ Survivorship Pensioners prior to March 4, 1995.
SSS Old-age Retirees who have reached the age of retirement on or after March 4, 1995 and have
at least 120 months PhilHealth premium contributions.
3. Uniformed Members of the AFP, PNP, BJMP and BFP
a. Uniformed personnel of the AFP, PNP, BJMP and BFP who have reached the compulsory age of
retirement before June 24, 1997, and retirees under Presidential Decree 408.
b. Uniformed members of the AFP, PNP, BFP and BJMP who have reached the compulsory age of
retirement on or after June 24, 1997, being the effectivity date of RA 8291 which excluded them
in the compulsory membership of the GSIS and have at least 120 months PhilHealth premium
contributions.
4. Former employees of the government and/ or private sectors who have accumulated/ paid at
least 120 monthly premium contributions as provided for by law but separated from
employment before reaching the age of 60 years old and thereafter have reached 60 years old.
5. Former employees of the government and/ or private sectors who were separated from
employment without completing 120 monthly premium contributions but continued to pay
their premiums as Individually paying Members and completion of the required 120 monthly
premium contributions and have reached 60 years old as provided by the law.
6. Individually paying Members, including SSS self-employed and voluntary members, who
continued paying premiums to PhilHealth, have reached 60 years old and have met the
required 120 monthly premiums as provided for by law.
7. Retired underground mine workers who have reached the age of retirement as provided for
by law and have met the required premium of at least 120 months contributions.
8. PhilHealth members of Overseas Workers Program and Sponsored Program who have
completed the required premium of at least 120 months contributions and have reached the
age of retirement as provided for by law.

What are the benefits?
PhilHealth beneficiaries have access to a nearly comprehensive package of services,
including inpatient care, catastrophic coverage, ambulatory surgeries, deliveries, and outpatient
treatment for malaria and tuberculosis. Those identified as indigent and OFW are also entitled to
outpatient primary care.
Inpatient care includes room and board, medicines, diagnostic and other services, professional fees
and operating room services. These benefits are subject to some limits, which differ based on the
level of the health facility/hospital (level 1 to 4 hospitals and the Ambulatory surgical centers
equivalent to level 2 hospitals) and the severity of the cause of admission (case-type A, B, C and D).
Catastrophic conditions, ambulatory surgeries including ambulatory dialysis, deliveries and
outpatient malaria and TB-DOTS care.
Except for the outpatient primary care that the poor and OFWs are entitled to via public providers,
patients have free choice of providers, both public and private.
Annual or lifetime coverage limits exist. These limits are expressed in terms of volumes of services
(e.g., days) rather than a peso coverage limit. For example, households are eligible for 45 days of
inpatient admission, sharing 45 days among all household members. Each day of ambulatory
surgery counts as a day of admission.
Providers are allowed to charge the patient the difference between the total cost of care and what
PhilHealth pays (i.e., balance billing)
.
What are the duties and responsibilities of a member?

As a Philhealth member, there are certain things you must do to enjoy your benefits to the fullest:

On Membership
Have in possession at all times your Philhealth Number Card or Identification Card.
Update your Member Data Record (MDR) for any change in personal information such as change in
civil status or addition of a new dependent.
Request for a replacement in case of loss of Philhealth Number Card or Identification Card.
On Contributions
Ensure that you promptly and regularly pay your contributions (for Individually Paying Members and
Overseas Workers Program Members) to avoid suspension of benefits.
For newly hired employees, check if your name is reported by your employer to Philhealth in the Er2
Form (Report of Employee - Members).
Ensure that your monthly Philhealth contributions are deducted from your salary and promptly
remitted and reported by your employer to Philhealth.
Report to Philhealth at once an employer who does not remit premium payments.
Ensure that you have sufficient qualifying contributions to avail of Philhealth benefits anytime.
On Benefit Availment
Secure an updated list of Philhealth-accredited facilities from any Philhealth office wherein you can
avail of benefits.
Submit a properly and completely filled-up Philhealth Claim Form 1 to the hospital and ensure that
all the information you stated in the said form are true and factual.
Ensure that you properly and completely submit all the necessary documents to the hospital
including a copy of your Member Data Record (MDR) to avail of Philhealth benefits.
Clarify with providers (hospital/doctor), the appropriate and final benefits deducted upon
settlement of bills and charges.
Ask for a copy of your Statement of Account/Billing Statement from the hospital upon discharge.
Ask for an Official Receipt (OR) and Waiver from the hospital and doctor for payments made in full.
Ensure that your claim, if you opt for direct filing, is filed at Philhealth within sixty (60) days from the
date of discharge for local confinements, and within one hundred eighty (180) days for
confinements abroad.

What else you must do . . .
Be aware of amendments and updates on Philhealth policies and benefits schedule.
Seek clarification from any Philhealth office on any unclear policy or guideline.
Report at once to Philhealth any hospital that fails, without valid reason, to accommodate a
PhilHealth member who wishes to avail of benefits.
Report at once to PhilHealth any fraudulent transaction that you know about.
Observe and comply with PhilHealth rules and regulations as there are offenses in its Implementing
Rules and Regulations that a member may be held liable for.