Members to expect higher benefits from PhilHealth

The Philippine Health Insurance Corporation (PhilHealth) is set to adjust the rates of most of its benefit packages starting in 2024, which will result in increased financial coverage for Filipinos’ hospitalization expenses.

The adjustment is prompted by the increasing costs of healthcare in the country brought about by inflation. It was in 2013 when the state insurer first implemented the case rate payment system wherein PhilHealth reimbursed a fixed amount for a specific medical condition or surgical case.

“It is about time that PhilHealth adjusts its rates in order for our members to cope with the increasing cost of medical care. We want our members to feel the value of their benefits which translates to meaningful financial risk protection. Dapat ramdam ng mga kababayan natin ang benepisyo nila sa PhilHealth,” said Emmanuel R. Ledesma Jr., PhilHealth President and Chief Executive Officer.

The case rates are likely to increase to a maximum of 30 percent across all cases. This is expected to lower out-of-pocket expenses of patients during hospitalization and in the availment of PhilHealth benefits for outpatient care.

However, to minimize untoward inflationary effects after rate adjustments, PhilHealth said it will prescribe a cost-sharing mechanism wherein health facilities and the members will have fixed co-payment rates on top of what is being paid for by PhilHealth as the insurer. This way, health facilities will be more efficient in the use of resources to achieve desired health outcomes, while members can predict how much they should pay for amenities and other extra services availed of beyond those provided in basic or ward accommodations. Other strategies to control the untoward effects of this adjustment include measures to prevent insurance fraud and doctor moral hazard.

“This will be our way of controlling healthcare costs, in making member’s expenses predictable, and in discouraging irrational use of healthcare services among facilities,” the PhilHealth chief clarified.

PhilHealth shall adopt a variable inflation adjustment across types of health facilities, which means that higher-level facilities shall get higher adjustments in rates up to a maximum of 30 percent.

The upward adjustment in case rates is on top of the ongoing benefit expansion and rationalization that was already approved by the PhilHealth Board. ”Ang malawakang increase sa case rates benefits natin ay iba pa sa mga nauna at ilalabas pa nating benefits enhancements ngayong taon. Tugon natin ito sa panawagan ni Pangulong Ferdinand Marcos Jr. gayundin ng ating stakeholders kasama ang Kongreso at patient groups na gawin pang lalong makabuluhan ang benepisyo para sa mga miyembro saan man sila sa bansa,” Ledesma added.

For 2023, PhilHealth has implemented the expansion of dialysis coverage to 156 sessions from the previous 90 sessions. It also rationalized the rates for conditions mostly availed of among Filipinos. Recently, it released its Circular 2023-0021 where it increased coverage for ischemic stroke from P28,000 to P76,000, and hemorrhagic stroke from P38,000 to P80,000. It is set to release a circular before year-end to widen its coverage for pneumonia high-risk from P32,000 to 90,100.

The state health insurer also launched its Outpatient Mental Health Package in mid-October, and will soon launch a package for Severe Acute Malnutrition. It also started to enhance its various Z Benefits Packages. In 2024, Z Benefits for breast cancer shall likewise be expanded which will include coverage of targeted therapy of up to P1M per patient per year.

“PhilHealth will continue to respond to Filipinos’ needs in line with President Ferdinand Marcos Jr.’s 10-point agenda, especially in the area of affordable and universal health care for all Filipinos,” Ledesma stressed.