PHILHEALTH revised inpatient care benefits

The following are the maximum allowances or ceilings to be applied per single period of confinement**
effective April 5, 2009 admissions onwards.
Level 1 Hospitals (Primary)
Case Type
Benefit Item
A B
Room and Board
300 300
(maximum of 45 days per year)
Drugs and Medicine
(per single period of 2,700 9,000
confinement)
X-ray, Laboratory and Others 1,600 5,000
(per single period of confinement)
Operating Room 500 500
Professional Fees
a. Daily Visits
General Practitioner (Groups 1, 5, & 6)
Per Day 300 400
Maximum per
1,200 2,400
confinement
Specialist (Groups 2, 3, & 4)
Per Day 500 600
Maximum per
2,000 3,600
confinement
b. Surgery (for Case Type A and B)
Surgeon Anesthesiologist
General Practitioner
RVU x PCF 40=PF1 40% of surgeon's fee (PF1)
1st Tier (Group 1)
With Training
RVU x PCF 48=PF2 48% of surgeon's fee (PF1)
2nd Tier (Group 5 and 6)
Diplomate/Fellow
RVU x PCF 56=PF3 56% of surgeon's fee (PF1)
3rd Tier (Group 2, 3 and 4)
Maximum of 2,000 per Maximum fee computed as percentage of
confinement 2,000
* Not to exceed 45 days for each calendar year.
** Refers to a confinement or series of confinements of the same illness not separated from each other by 90 days
within a calendar year. In this case, a member or beneficiary is not entitled to another set of benefits until after 90
days. They can only avail of the unused portion of the benefits and the room and board fees until the 45 days
allowance is exhausted.
However, a member can avail of new set of benefits if succeeding confinements are of different illness or condition.

Individually paying members - benefit availment conditions

Eligibility Requirements
 Payment of at least three monthly premiums within the immediate six months prior to
the month of confinement. For pregnancy-related cases and availment of the newborn
care package, dialysis (except those undergoing emergency dialysis service during
confinement), chemotherapy, radiotherapy and selected surgical procedures, payment
of nine (9) monthly premium contributions within the last 12 months shall be required
except for those enrolled under the KASAPI program.
 Confinement in an accredited hospital for at least 24 hours (except when availing of
outpatient care and special packages) due to an illness or injury requiring hospitalization.
 Attending physicians must also be PhilHealth-accredited.
 Availment is within the 45-day allowance for room and board.
Post availment reminders
After the automatic deduction or reimbursement of your benefits, PhilHealth will send the
Benefit Payment Notice or BPN to the address indicated in the member’s claim form. The BPN is
a report of actual payments made by PhilHealth relative to member’s the
confinement/availment. Should there be discrepancies between the amounts reflected in the
BPN and in the member’s final billing statement issued by the hospital, or if the member has
other concerns pertaining to benefit availment, he may contact PhilHealth or the health care
provider. The member must bring the BPN as reference document.

Case Rates
Since September 1, 2011, the following medical cases and surgical procedures are being paid through
case rate:
Surgical Cases
1. Radiotherapy 3,000
2. Hemodialysis 4,000
3. Maternity Care Package (MCP) 8,000
4. NSD Package in Level I Hospitals 8,000
5. NSD Package in Levels 2 to 4 Hospitals 6,500
6. Caesarean Section 19,000
7. Appendectomy 24,000
8. Cholecystectomy 31,000
9. Dilatation and Curettage 11,000
10. Thyroidectomy 31,000
11. Herniorrhaphy 21, 000
12. Mastectomy 22,000
13. Hysterectomy 30,000
14. Cataract Surgery 16,000

Medical Cases
1. Dengue I (Dengue fever, DHF grades I&II) 8,000
2. Dengue II (DHF grades III & IV) 16,000
3. Pneumonia I ( moderate risk) 15,000
4. Pneumonia II (high risk) 32,000
5. Essential Hypertension 9,000
6. Cerebral Infarction (CVA-I) 28,000
7. Cerebral Hemorrhage (CVA-II) 38,000
8. Acute Gastroenteritis (AGE) 6,000
9. Asthma 9,000
10. Typhoid Fever 14,000
11. Newborn Care Package in Hospitals and Lying in Clinics 1,750

SARS and Avian Influenza Package

Inclusions
Amount of For members and their qualified dependents - Php 50,000 per case
Coverage For health care workers(forefront and high risk) - Php 100,000 per case
Professional fees (Php 2,500 - pay to doctor)
Services Hospital charges (Php 42,500 - pay to hospital)
Official receipts amounting to Php 12,000 (Php 5,000 - pay to member)
Patients must be admitted only in accredited DOH-designated SARS or AI/IP
hospitals.
Providers
Confinements abroad shall be paid compensated provided a certification from the
attending physician is submitted
Must be certified by the DOH as SARS or avian influenza/influenza pandemic patient
Eligibility
Confinement within the validity period as stated in the Member Data Record
Exclusions
 SARS suspect cases
 Cases of acute respiratory illness where an alternative diagnosis can fully explain such illness.
Other conditions
Rule on single period of confinement and 45-days allowance for room and board per year applies.
For afflicted health care workers:
 Must also be active PhilHealth members.
 Contracted the disease while caring for a SARS or AI/IP patient (person to person transmission).
 Renders service in DOH-designated hospital.
 DOH attests that HCW contracted the disease while on official duty.

Novel Influenza A (H1N1) Package

To mitigate the direct medical cost for the treatment of complicated human cases of novel Influenza A
(H1N1) with complication or co-morbidities requiring hospitalization. The following shall be effective in
all local and overseas confinements with admission dates starting May 1, 2009.
Inclusions
Amount of Maximum of Php 75,000 for non-health worker-members
Coverage Maximum of Php 150,000 for health worker-members
Services For Members/Dependents:
- Room and board allowance of 1,500/day but up to 10,000 only
 - Drugs and medicines; X-ray, lab and others (including supplies and personal
protective equipment and transfer services) and operating room fees – 50,000
- Professional fees of 1,000/day but up to 15,000 only

For Health Care Workers:

- Room and board allowance of 1,500/day but up to 20,000 only
- Drugs and medicines; X-ray, lab and others (including supplies and personal
protective equipment and transfer services); operating room and other medically
necessary care – 100,000
- Professional fees of 1,000/day but up to 30,000 only
Hospitals designated by DOH as referral centers (national, sub-national and satellite)
for Influenza A (H1N1) and other emerging and re-emerging diseases with the
exception of confinements abroad.
Providers
Admissions in private hospitals may be covered if confirmatory tests were
coordinated with or confirmed by the RITM, DOH-CHD or other DOH certified
laboratories.
Limited to members and health qualified workers with novel swine-origin influenza A
(H1N1) virus infection confirmed by the Department of Health (DOH)

Confinement within the validity period as stated in the Member Data Record

For qualified health care workers (HCWs):

Eligibility - Rendered service in a DOH-designated hospital for Influenza A (H1N1) and
contracted the disease while performing their duties and or caring for an influenza A
(H1N1) patient as certified or attested by DOH.
- Qualified dependents of HCWs who also contracted the disease shall be provided a
maximum coverage of Php 75,000.

Eligibility
Limited to members and health qualified workers with novel swine-origin influenza A (H1N1) virus
infection confirmed by the Department of Health (DOH)
For qualified health care workers (HCWs):
 Rendered service in a DOH-designated hospital for Influenza A (H1N1) and contracted the
disease while performing their duties and or caring for an influenza A (H1N1) patient as certified
or attested by DOH
 Qualified dependents of HCWs who also contracted the disease shall be provided a maximum
coverage of Php 75,000.
Confinement within the validity period as stated in the Member Data Record.
Exclusions
 Probable and case under observation*
 Admissions in non-DOH designated hospitals*
 Influenza-like illnesses (ILI*)
 Other seasonal outbreaks of influenza by established flu virus
(e.g., H1N2, H5N1*, SARS**, Avian flu***)
Other conditions
Reimbursement (to members) for drugs, medicines and supplies or laboratory procedures bought or
performed in other facilities shall be based on the following:
 Facility cannot provide necessary items and services covered by the benefit.
 These items and services are used during confinement.
 Official receipts and/or other purchase documents are submitted.
 Reimbursement depends on actual cost of receipts submitted but not more than the difference
between maximum benefit and reimbursement to facility.
 Facility acknowledges that cost of benefits and services provided is less than the maximum
benefit
Confinements abroad shall also be covered provided that a certification from their Ministry of Health (or
its equivalent) confirming that case is due to A (H1N1) is submitted.
Availment of the package shall be charged against the 45-days annual limit and is covered by the rule on
single period of confinement (only one Influenza A (H1N1) Package shall be paid within 90 days).
*Covered by regular hospitalization benefit
**Covered by SARS package
***Covered by Avian Flu package