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PhilHealth Benefits Guide for Regular and Voluntary Members

Unexpected expenses, like a sudden hospitalization, can put a huge dent on your savings. Fortunately, there are PhilHealth benefits we can take advantage of. The Philippine Health Insurance Corporation or PhilHealth is a government agency mandated to financially help Filipinos with their medical needs. As of 2015, about 88% of the country’s population are contributing members of the agency^[1]. Members and their qualified dependents can avail of PhilHealth benefits as long as they meet the eligibility criteria.

Keep on reading to know more about PhilHealth and the benefits you can get as a member.

What is PhilHealth and How Does It Work?

Established in 1995, PhilHealth aims to financially help Filipinos with their medical expenses. Contributions made by members and funding from both local and national governments enable PhilHealth to operate and aid its contributing members.

The government requires all employees to become PhilHealth members. Self-employed individuals (also called voluntary members) can also apply.

PhilHealth works like an insurance company, except that it is mandated by the government. The agency can help cover your medical bills or parts of it. However, there are eligibility requirements you must meet before you can enjoy PhilHealth benefits.

Read more: A Complete Guide to PhilHealth Voluntary Membership Registration

What PhilHealth Benefits are Available?

PhilHealth subsidizes your hospital bills based on the amount you have incurred. The agency typically pay parts of doctor’s professional fees, laboratory tests, and other medical costs.

1. Inpatient benefits

If you are admitted to a hospital to receive care, you can get PhilHealth benefits. Part of your total bill will be shouldered by the agency, as long as the hospital where you were admitted is a PhilHealth partner.

2. Outpatient benefits

If you need medical care but do not need to be admitted, you can still benefit from PhilHealth. The agency can cover part or the entire cost of your day surgery, hemodialysis, radiotherapy, and other primary care. Doctor consultation is also covered as PhilHealth benefits for outpatients.

3. Z benefits

Treatment for leukemia, prostate cancer, breast cancer, and cervical cancer is also covered by PhilHealth. However, the agency doesn’t cover the entire amount of the treatment and you have to go to a PhilHealth partner hospital to get Z benefits.

4. SDG-related benefits

Animal bite, HIV-AIDs, outpatient anti-tuberculosis treatment are covered by PhilHealth’s SDG-related benefits. Just like its other cluster of benefits, PhilHealth should part of your treatment costs.

For a more complete list of PhilHealth benefits, click here.

PhilHealth Benefits for Foreign Citizens and Dual Citizens

Expats and foreign retirees in the Philippines, as well as Filipinos with dual citizenship, may now avail of PhilHealth benefits.

Foreigners and their qualified dependents can enjoy inpatient and outpatient benefits in any PhilHealth-accredited hospital or clinic in the Philippines. However, they cannot avail of the Z benefit packages and PhilHealth benefits for women who are about to give birth. They also cannot make reimbursement claims for hospital confinements abroad.

On the other hand, Filipinos with dual citizenship and their qualified dependents can have all PhilHealth benefits in accredited healthcare facilities nationwide and abroad. To qualify for benefits, they must pay at least three monthly PhilHealth contributions within six months before ailment.

How to Apply for PhilHealth Membership?

Photo from philhealth.gov.ph

To apply as a PhilHealth member, you have to prepare these requirements first.

PhilHealth basic requirements

• Two valid IDs or PSA Birth Certificate
• Two copies of the PhilHealth Member Registration Form (PMRF)
• Two 1×1 passport-sized photos

For foreign retirees

• Applicant must be registered with the Philippine Retirement Authority (PRA)
• Accomplished PhilHealth Member Registration Form (PMRF) for Foreign Nationals that must be submitted to any PRA office
• Special Resident Retiree’s Visa (SRRV)
• Permanent residency status

For foreigners living or working in the Philippines

• Valid Alien Certificate of Registration Identity Card (ACR I-Card) issued by the Bureau of Immigration
• Valid working permit
• Accomplished PMRF for Foreign Nationals that must be submitted to any Local Health Insurance Office

For Filipinos with dual citizenship

• Accomplished PMRF
• Certificate of Re-acquisition/Retention of Philippine Citizenship (CRPC)
• Identification Certificate (IC) issued by the Philippine Embassy or Philippine Consulate abroad or by the Bureau of Immigration

After securing all PhilHealth requirements, follow these steps:

1. Visit your nearest Local Health Insurance Office or PhilHealth branch.
2. Make sure you have all the requirements. You can get the PMRF at the branch you’re visiting.
3. Fill out two copies of PMRF and submit the accomplished forms.
4. Wait for the staff to release your PhilHealth Member Data Record (MDR) and ID

Read more: Simple Steps to Getting a PhilHealth ID

PhilHealth Contribution Table

Your PhilHealth contribution depends on your monthly salary and your type of employment. Half of your monthly premium is paid by your employer, while the rest is deducted from your salary.

Here is the PhilHealth contribution table for members of the formal economy (kasambahay, sea-based OFWs, family drivers, etc.) and employees of public and private sectors:

PhilHealth Contribution Table for 2020

PhilHealth Contribution Table for 2021

PhilHealth Contribution Table for 2022

PhilHealth Contribution Table for 2023

PhilHealth Contribution Table for 2024 onwards

PhilHealth Contribution for Voluntary Members

If you are a voluntary PhilHealth member, your monthly premium depends on your monthly salary. However, the payment is done annually and in the full amount.

PhilHealth Annual Contributions for Foreign and Dual Citizens

• Foreign retirees: PHP 15,000
• Expatriates: PHP 17,000
• Dual citizens: PHP 3,600

PhilHealth Benefits Eligibility and Application

PhilHealth members who have at least three months of contribution within the immediate six months before their confinement are eligible for the benefits. Your qualified dependents can also take advantage of the abovementioned PhilHealth benefits.

To apply for such benefits, you need the following documents:

• Member Data Record (MDR)
• Employer-signed original copy of PhilHealth Claim Form from your HR or PhilHealth branch
• PhilHealth ID
• Another valid ID

Submit the documents to your PhilHealth partner hospital before being discharged so that they can already deduct PhilHealth’s subsidy to your total medical bill.

How to Claim Philhealth Benefits

Hospitalization can cost upwards of PHP 25,000, and paying out of pocket is your only option if you don’t have insurance. PhilHealth, or the Phillippine Health Insurance Corporation, provides PhilHealth benefits to all employed members.

As a member, you’re entitled to health and hospitalization subsidies for you or any dependents you have enrolled. As of 2014, hospitalized members need not directly file their claims.

Here’s how you can claim your PhilHealth benefits:

Step 1: Conditions

To be eligible to avail of your PhilHealth benefits when hospitalized, the following conditions must be met:

• Payment of at least 3 months’ worth of premiums within the immediate 6 months of confinement.
• Confinement in an accredited hospital for 24 hours due to illness or disease requiring hospitalization. Attending physician(s) must also be PhilHealth accredited.
• The claim is within the 45 days allowance for room and board.^[2]

Step 2: Required Documents

You’ll also need to submit the following documents before being discharged from the hospital for automatic deduction:

• A Clear, Updated copy of your Member Data Record (MDR). If you are dependent, make sure that you are listed in the MDR.
• An original copy of PhilHealth Claim Form 1, which you can get at Philhealth, the hospital or your employer. Submit the original copy signed by your employer.
• Receipt of Premium payments. Employees only need to submit the Certificate of Premium Payments with OR numbers.
• Your PhilHealth ID and a valid ID.

Ask the hospital regarding their PhilHealth submission rules. If you can’t submit the claim form personally, have an authorization letter and a valid ID ready for your representative.

What is the PhilHealth Claim Form?

The PhilHealth Claim Form 1 (CF1) is divided into two parts. Here’s an overview to guide you when answering the form:

•  Personal Information and Eligibility: The first part of the PhilHealth Claim Form requires the personal information of the PhilHealth member and/or the patient who will claim the benefit. This is important to identify the eligibility of the patient filing a claim.
• Employer Details and Contributions: The second part of the CF1 is for employed PhilHealth members. Here you will see all employer details that certify all monthly PhilHealth contributions remitted to PhilHealth in the past 6 months perio^[3].

Step 3: Claiming and Post-Claims

As direct filing is no longer needed, submission of the documents to the hospital before the end of your stay means automatic deduction of your benefits from your total hospital bill.

Once your benefits have been automatically deducted, PhilHealth will send a benefit payment notice to the address declared in your MDR. This details the actual payments made by PhilHealth relative to your claim or confinement.

Keeping your PhilHealth up to date is important, as it’ll be a great help if you or anyone declared as your dependent requires hospitalization.

Frequently Asked Questions About PhilHealth Benefits

1. How many times can I use my PhilHealth benefits in a year?

You can avail of PhilHealth benefits anytime of the year as long as you fulfill the contribution requirements and benefit eligibility criteria discussed above.

2. How much is covered by PhilHealth?

The agency covers part or all of your medical costs, but it depends on the medical case. For a list of medical rates covered by PhilHealth, click here.

3. Who can be my PhilHealth dependents?

The following are qualified dependents:

• Legal spouse who is not a member
• Children below 21 years old
• Children over 21 years old who have physical or mental disability
• Parents aged 60 years old and over
• Parents with permanent disability

4. How Can I use my PhilHealth for dependents?

To avail of PhilHealth benefits, you must have at least three months of contribution within the immediate six months before your dependent is confined. Claiming of benefits and its requirements are the same.

5. Is MRI covered by PhilHealth?

Unfortunately, MRI is not covered by PhilHealth since it’s a diagnostic procedure.

6. Is CT Scan covered by PhilHealth?

Yes, CT scan can be covered by the agency.

7. Are there maternity benefits for pregnant women and newborns?

PhilHealth members who are 24 to 36 weeks pregnant and at risk of premature birth are covered by PhilHealth. Additionally, premature newborns who are very small (500g to 2,499g fetal weight) at 24 weeks to less than 37 weeks (fetal age) are also covered by the agency.

Read more: 

• Expecting a Baby Soon? Don’t Ignore These PhilHealth Maternity Benefits and Rules
• PhilHealth and SSS Maternity Benefits Every Parent Needs to Know
• Complete PhilHealth Online Registration Guide for New Members

8. Can senior citizens apply as PhilHealth members?

Yes, they can. Senior citizens can enroll by visiting the Office for the Senior Citizens Affairs or through a Local Health Insurance Office.

Senior citizen premiums are sourced from the proceed of the Sin Tax Law. This means they do not have to pay for monthly contributions.

9. What cases are not covered by PhilHealth benefits?

The agency doesn’t shoulder part of the cost of the following:

• Fifth and subsequent normal obstetrical deliveries
• Non-prescription drugs and devices
• Cosmetic surgery
• Optometric services
• Other cost-ineffective procedures defined by PhilHealth

Final Thoughts

Knowing the benefits you can get by being a PhilHealth member can help minimize your medical expenses. Your qualified dependents can also enjoy the same PhilHealth benefits you have. If you are a foreign or dual citizen, you can still get these benefits. Make sure to be on top of your contribution to avoid any inconvenience when claiming your benefits.

Source: 

• ^[1] PhilHealth Enrolment (Official Gazette of the Philippines)
• ^[2] Hospital Room and Board Benefits for PhilHealth Members
• ^[3] Guidelines on the Proper Accomplishment of Revised Philhealth Claim Forms 1, 2, & 3

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