Inpatient Benefits

 These benefits are paid to the accredited Health Care Institution (HCI)
through All Case Rates
 The case rate amount shall be deducted by the HCI from the member’s total
bill, which shall include professional fees of attending physicians, prior to
discharge
 The case rate amount is inclusive of hospital charges and professional fees of
attending physician
 Availment condition: Member must have at least (3) months premium
contributions within the immediate six (6) months prior to the first day of
confinement
 Documents needed: copy of Member Data Record or PhilHealth Benefit
Eligibility Form (PBEF) and duly accomplished PhilHealth Claim Form 1
 Only admissible cases shall be reimbursed

Outpatient Benefits

1. Day Surgeries (Ambulatory Or Outpatient Surgeries) are services that include

Elective (Non-Emergency) Surgical Procedures ranging from minor to major
operations, where patients are safely sent home within the same day for Post-
Operative Care

 Payments for these procedures are made to the accredited

facility through All Case Rates
 The case rate amount shall be deducted by the HCI from the
member’s total bill, which shall include professional fees of
attending physicians, prior to discharge
 The case rate amount is inclusive of hospital charges and
professional fees of attending physician
 Availment condition: Member must have at least (3) months
premium contributions within the immediate six (6) months
prior to the first day of confinement
 Documents needed: copy of Member Data Record and duly
accomplished PhilHealth Claim Form 1
 Where available: Accredited Ambulatory Surgical Clinics (ASCs)

2. Radiotherapy

 The case rate for radiotherapy using cobalt is P2,000 per session
and P3,000 per session for linear accelerator
 Includes radiation treatment delivery using cobalt and linear
accelator
 Claims for multiple sessions may be filed using one (1) claim
form for both inpatient and outpatient radiation therapy
 May be availed of even as second case rate (full case rate
amount)
  45 days benefit limit: One session is equivalent to one day
deduction from the 45 allowable days per year
 If procedure is done during confinement, only the total number
of confinement days shall be deducted
Exempted from Single Period of Confinement (SPC)
rule (admissions and re-admissions due to same illness or
procedure within 90-calendar day period)
 Availment condition: Member must have at least (3) months
premium contributions within the immediate six (6) months
prior to the first day of confinement
 Where available: Accredited HCIs including Primary Care
Facilities that are accredited for the said service

3. Hemodialysis

 The Case Rate for hemodialysis is P2,600 per session

 Covers both inpatient and outpatient procedures including
emergency dialysis procedures for acute renal failure
 Claims for multiple sessions may be filed using one (1) claim
form for both inpatient and outpatient hemodialysis
 May be availed of even as second case rate (full case rate
amount)
 90 days benefit limit: One session is equivalent to one day
deduction from the 90 allowable days per year
 If procedure is done during confinement, only the total number
of confinement days shall be deducted
 The procedure is exempted from Single Period of Confinement
rule (admissions and re-admissions due to same illness or
procedure within 90-calendar day period)
 Availment condition: Member must have at least (3) months
premium contributions within the immediate six (6) months
prior to the first day of confinement
 Where available: All Accredited HCIs – this benefit is no longer
restricted to hospitals and free standing dialysis centers
provided that the service is within their capability as provided
for in the DOH license

4. Outpatient Blood Transfusion

 The case rate for outpatient blood transfusion is P3,640 (one or

more units)
 Includes Drugs & Medicine, X-ray, Lab & Others, Operating
Room
 Covers outpatient blood transfusion only
 One day of transfusion of any blood or blood product, regardless
of the number of bags, is equivalent to one session
 May be availed of as second case rate (full case rate amount)
  45 days benefit limit: One session for each procedure is
equivalent to one day deduction from the 45 allowable days per
year Exempted from the SPC rule
 Where to avail: All Accredited HCIs

5. Primary Care Benefits 1

i. Preventive Services

1. Consultation
2. Visual inspection with acetic acid
3. Regular BP measurements
4. Breastfeeding program education
5. Periodic clinical breast examinations
6. Counseling for lifestyle modification
7. Counseling for smoking cessation
8. Body measurements
9. Digital rectal examination

ii. Diagnostic Examinations (as recommended by the doctor)

1. Complete blood count

2. Urinalysis
3. Fecalysis
4. Sputum microscopy
5. Fasting blood sugar
6. Lipid Profile
7. Chest x-ray

iii. Drugs and Medicines

1. Asthma including nebulisation services

2. Acute Gastroenteritis (AGE) with no or mild dehydration
3. Upper Respiratory Tract Infection (URTI)/Pneumonia
(minimal and low risk)
4. Urinary Tract Infection (UTI)

 Payments for these services are made to the primary care

provider through Per Family Payment Rate (PFPR)
 Availment condition: Indigent and Sponsored Members, as well
as migrant workers and their legal dependents should avail of
these benefits within the effectivity of their coverage as
indicated in their PhilHealth ID cards or Member Data Records.
iGroup (Gold) members may avail themselves of these benefits
within the validity of their group policy contracts, while DepEd
personnel may avail themselves of the benefits as long as they
are still active members of PhilHealth
  Documents needed: Copy of Member Data Record or PhilHealth
ID
 Where available: accredited rural health units, health centers or
outpatient departments of selected government hospitals where
members are enlisted

Z Benefits

1. Acute Lymphocytic / Lymphoblastic Leukemia

 standard risk
 P500,000

2. Breast Cancer
 stage 0 to IIIA
o P100,000

3. Prostate Cancer
 low to intermediate risk
o P100,000

4. End-state renal disease eligible for requiring kidney transplantation

 low risk
o P600,000

5. Coronary Artery Bypass Graft Surgery

 standard risk
o P550,000

6. Surgery for Tetralogy of Fallot in Children

 P320,000

7. Surgery for Ventricular Septal Defect in Children

 P250,000
8. Cervical Cancer:
 Chemoradiation with Cobalt and Brachytherapy (low dose) or Primary
surgery for Stage IA1, IA2 – IIA1
o P120,000
 Chemoradiation with Linear Accelerator and Brachytherapy (high dose)
o P175,000
9. Z-MORPH (Mobility, Orthosis, Rehabilitation, Prosthesis Help)
 first right and/or left below the knee
o P15,000
 both limbs
 o P30,000
10. Selected Orthopedic Implants

a) Implants for Hip Arthroplasty

 Implants Hip Prosthesis, cemented*
o P103,400
 Total Hip Prosthesis, cementless**
o P169,400
 Partial Hip Prosthesis, bipolar
o P73,180

*cemented: 66 years old and above

** cementless: 65 years and 364 days old and below
b) Implants for Hip Fixation
 Multiple screw fixation (MSF)*** 6.5mm cannulated cancellous
screws with washer
o P61,500

***59 years and 364 days old and below (both displaced
and undisplaced fracture); 60 years old and above
(undisplaced fracture)
c) Implants for Pertrochanteric Fracture
 Compression Hip Screw Set (CHS)
o P69,000
 Proximal Femoral Locked Plate (PFLP)
o P71,000
 Implants for Femoral Shaft Fracture
 Intramedullary Nail with Interlocking Screws
o P48,740
 Locked Compression Plate (LCP) – Broad / Metaphyseal / Distal
Femoral LC
o P50,740

11. “PD First” - for End-Stage Renal Disease Requiring Peritoneal Dialysis
 P270,000 per year

12. Colon and Rectum Cancer

a) Colon Cancer
Stage I-II (low risk) – P150,000
Stage II (high risk) – III – P300,00
b) Rectum Cancer
Stage I (clinical and pathologic) – P150,000
 c) Pre-operative clinical stage I
but with post-operative pathologic
stage II-III
- using linear accelerator as mode of radiotherapy) - P400,000
- using cobalt as mode of radiotherapy - P320,000
d) Clinical Stage II-III
- using linear accelerator as mode of radiotherapy) - P400,000
- using cobalt as mode of radiotherapy -P320,000

13. Prevention of Preterm Delivery

a) Prevention of preterm delivery with severe pre-eclampsia/eclampsia -

3,000.00
b) Prevention of preterm delivery, with preterm pre-labor rupture of
membrane (pPROM) - 1,500.00
c) Prevention of preterm delivery without pre-eclampsia/eclampsia or
rupture of membranes but with labor or vaginal bleeding or multifetal
pregnancy - 600.00
d) With coordinated referral and transfer from a lower level of facility -
4,000.00

14. Preterm and Small Newborns (32 to < 37 weeks)

a) Essential interventions for 32weeks to < 37 weeks - 24,000.00

b) Essential interventions with mechanical ventilation and Kangaroo Care
for 32 weeks to < 37 weeks - 71,000.00

15. Children with Developmental Disabilities

 Assessment and discharge assessment ranges from P3,626.00 –
P5,276.00
 Rehabilitation Therapy Sessions P5,000.00 per set*

*Eligible children with developmental disability can only avail of a

maximum of nine sets of therapies. Each set of therapies has a
maximum of 10 sessions

16. Children with Mobility Impairment

 Requiring assistive devices ranges from P13,110.00 – P163,540.00
 Requiring seating device, basic and intermediate wheelchair ranges
from P12,730.00 – P29,450.00
 Yearly services and replacement of devices ranges from P1,590.00 –
P13,690.00