The In-Patient Benefits of PhilHealth

PhilHealth’s in-patient benefits for 2025 include expanded coverage for critical medical conditions, enhanced financial support, and streamlined access to care. Below is a detailed breakdown of covered conditions, inclusion requirements, covered services, accredited institutions, and accreditation criteria.

Covered Conditions and Services

1.   Ischemic Heart Disease – Acute Myocardial Infarction

o Inclusion Requirements: Emergency admission for heart attack (STEMI/NSTEMI) requiring urgent intervention.

o Covered Services:

§  Percutaneous Coronary Intervention (PCI) or Coronary Angioplasty: ₱524,000 (up from ₱30,300)[1].

§  Fibrinolysis: ₱133,500 (up from ₱30,290)[1].

§  Emergency medical services with coordinated referral: ₱21,900[1].

§  Post-PCI cardiac rehabilitation: ₱66,140[1].

2.  Z Package for Peritoneal Dialysis (PD)

o Inclusion Requirements: Diagnosis of end-stage renal disease (ESRD).

o Covered Services:

§  Adults: Continuous Ambulatory PD (CAPD) at ₱389,640–₱510,140 annually (up to 89% increase)[1].

§  Pediatric Patients: CAPD (₱510,000–₱765,210) and Automated PD (APD: ₱763,000–₱1.2 million)[1].

§  Exit site infection and peritonitis prevention care[1].

3.  Z Package for Kidney Transplantation

o Inclusion Requirements: ESRD requiring transplantation.

o Covered Services:

§  Living donor transplant: ₱1 million (up from ₱600,000)[1].

§  Deceased donor transplant: ₱2.14 million[1].

4.  Common Medical and Surgical Cases

o Examples: Pneumonia, hypertension, asthma, dengue, typhoid fever, acute gastroenteritis, and cerebral infarction[2][3].

o Coverage Adjustments: 50% increase in case rates for 9,000+ packages (e.g., caesarean sections, cholecystectomy)[1][4].

o Case Rate Examples:

§  Pneumonia (moderate risk): ₱15,000; high risk: ₱32,000[2].

§  Dengue I (DHF Grades I/II): ₱8,000; Dengue II (Grades III/IV): ₱16,000[2].

§  Hemodialysis: ₱6,350/session (up from ₱2,000)[4].

5.   Maternity Care

o Covered Services: Delivery packages (e.g., normal spontaneous delivery, caesarean section) with case rates adjusted by 50%[1][2].

6.  Expanded Z Benefits

o Conditions: Cancers (e.g., colon, ovarian, Wilms’ tumor), trauma surgeries, hip/spine surgeries, prematurity care, and osteogenesis imperfecta[2].

7.   New 2025 Packages

PhilHealth continues to expand its services, with plans to introduce new packages for prescription glasses for children, outpatient rehabilitation services, and assistive mobility devices. These developments underscore the organization's commitment to providing comprehensive healthcare coverage to its members[1][2]. 

o Severe acute malnutrition.

o Outpatient mental health services.

o Preventive oral health services (e.g., screenings, fluoride application)[4].

o Emergency care (non-hospitalization)[1].

Accredited Institutions and Features

1.   Hospital Levels

o Primary (Level 1): Basic emergency care, minor surgeries.

§  Coverage: Room (₱300/day), medicines (₱2,700–₱9,000)[2].

o Secondary (Level 2): Moderate-risk procedures (e.g., appendectomy).

§  Coverage: Room (₱400–₱600/day), medicines (₱3,360–₱22,400)[2].

o Tertiary (Level 3/4): Advanced care (e.g., PCI, transplants).

§  Coverage: Room (₱500–₱1,100/day), medicines (up to ₱40,000)[2].

2.  Specialized Providers

o 51 Accredited PD Centers: Offer peritoneal dialysis and infection prevention care[1].

o Transplant Centers: Accredited for living/deceased donor kidney transplants[1].

o Emergency Care Facilities: Accredited hospitals with 24/7 emergency departments[1][3].

3.  Features of Accredited Institutions

o Direct Billing: Automatic deduction of PhilHealth case rates from hospital bills[3].

o No Balance Billing (NBB): Applies to ward accommodations for sponsored members in government hospitals[2].

Accreditation Requirements for Providers

1.   Facility Standards

o Compliance with PhilHealth’s Service Capability Guidelines (e.g., equipment, staffing).

o Tertiary hospitals must have ICU, advanced imaging, and specialist physicians[2].

2.  Documentation and Processes

o Submit proof of license (e.g., DOH accreditation).

o Implement PhilHealth’s Electronic Claims Processing System for faster reimbursements[4].

3.  Specialized Services

o Dialysis centers: Demonstrate capacity for PD solutions and infection control[1].

o Transplant centers: Compliance with organ transplant protocols and ethics guidelines[1].

Key Requirements for Members

·         Active PhilHealth Membership: Updated contributions for members/dependents[3].

·         Documents: Member Data Record, PhilHealth Claim Form 1, and valid ID[3].

PhilHealth’s 2025 updates prioritize financial protection and equitable access, ensuring Filipinos receive critical care without prohibitive costs. For a full list of covered conditions, visit PhilHealth’s official portal.

References:

1.       https://www.pna.gov.ph/articles/1241535            

2.      https://pagba.com/wp-content/uploads/2013/07/PHIC-benefits_pagba-final.pdf     

3.      https://assistance.ph/philhealth-inpatient-benefits/

4.      https://pia.gov.ph/philhealth-expands-medical-benefit-packages-in-2025/