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Philhealth: Coverage rate for ‘most’ cases up by 30%

THE PHILIPPINE Insurance Corporation (PhilHealth) XI announced the coverage rate for “most” of its benefit packages increased by 30% beginning Feb. 14.

Philhealth Circular No. 2024-001, signed by CEO Emmanuel Ledesma Jr. on Jan. 29, adopted an inflation adjustment factor of 30%  for existing case rates to account for price changes for the past decade.

“The 30% adjustment would apply to all admissions on Feb. 14 onwards, conditions and procedures are on the official website,” Gabrielle Anne La Rosa, benefits administration section medical specialist, said during the 1st Pakighinabi Media Forum at Mandaya Hotel on Feb. 29.

The adjustment will restore substantial coverage to catch up to health inflation and financial risk protection. It is applied to case rate claims of accredited public and private health facilities (HFs).

She said the adjustment will also apply to benefits packages under the Sustainable Development Goals paid as case rates including but not limited to TB-DOTS, outpatient HIV/AIDS treatment package, animal bite treatment, newborn care package, and maternity care package.

All beneficiaries shall be entitled to no co-payment in basic or ward accommodation in public and private HFs.

It will lower the “out-of-pocket expenses” of Philhealth members, through the “no balance billing” policy.

La Rosa said excluded in the 30% adjustment are those already adjusted such as hemodialysis, stroke, and pneumonia.

To recall, hemodialysis coverage increased from 90 sessions to 156 sessions,  coverage for ischemic stroke increased from P28,000 to P76,000; hemorrhagic stroke from P38,000 to P80,000; and pneumonia (high-risk) coverage was at P90,100.

La Rosa advised members to visit the official website of Philhealth under online services to ensure that the deducted payment from the total bill is accurate. Under online services, they may click the case rates search and type in the condition or the medical diagnosis and the final diagnosis upon discharge in the search box to check the old and updated rate deducted from their bill.

La Rosa said members can inquire through email and telephone to verify the accuracy of the deduction. 

“Should they find the hospital bill or the deductions made are inaccurate, we will do further investigation,” she added.

She said they can also approach Philhealth employees in hospitals to ask for assistance from admissions up to discharge.

The adjustment is one of the expansion programs of Philhealth in its benefits payment, amid the 5% increase in contribution rate this year.

To recall, Philhealth started enforcing the increase in members’ premium contribution from the previous 4% to 5% as part of the Republic Act 11223 or the “Universal Health Care Act” of 2019.

Chapter III of the Act states that premium rates will follow the schedule, monthly income floor, and ceiling. In 2024-2025, the premium rate will be 5% for members with an income floor of P10,000 and a ceiling of P100,000.

Employees earning a basic monthly salary of P10,000 are required to contribute P500, while those who earn beyond the basic but not greater than P100,000 will pay a monthly premium ranging from P501 to P5,000. Meanwhile, those who earn P100,000 will contribute P5,000 monthly.


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