PhilHealth Coverage

[customheat 1]

My father who is 62 lives in Nabua, Camerines Sur. He suffers from high blood pressure and has risk of stroke. He should be entitled to automatic full PhilHealth coverage but when he needs to go to the hospital they charge him in excess of PhilHealth coverage and if he does not have money they will keep him there until he pays. Is this true. I hear that many hospitals charge you what they want and withhold medicine that they are supposed to give you through PhilHealth and make you go and pay at a pharmacy outside the hospital. I would appreciate any expert advice regarding Philhealth and how to avoid the doctors and hospitals from ripping off the patient. The local Barangay is supposed to help with a discount for medicine but they told him "since your daughter is married to an American you should give your benefit to someone else who really needs it". Is there a method to the madness?

[sweet01 39]

My father who is 62 lives in Nabua, Camerines Sur. He suffers from high blood pressure and has risk of stroke. He should be entitled to automatic full PhilHealth coverage but when he needs to go to the hospital they charge him in excess of PhilHealth coverage and if he does not have money they will keep him there until he pays. Is this true. I hear that many hospitals charge you what they want and withhold medicine that they are supposed to give you through PhilHealth and make you go and pay at a pharmacy outside the hospital. I would appreciate any expert advice regarding Philhealth and how to avoid the doctors and hospitals from ripping off the patient. The local Barangay is supposed to help with a discount for medicine but they told him "since your daughter is married to an American you should give your benefit to someone else who really needs it". Is there a method to the madness?

Hi customheat,

Wow , I understand your frustration here.. I feel bad on the situation as a medical graduate... but to me it sounds off when your father was told "since your daughter is married to an American you should give your benefit to someone else who really needs it". I would be very angry as well.

Knowing this, I think it's much better to call PhilHealth office in the Philippines and report your dad's case. I remember when my mom was hospitalized for Cancer 2 yrs ago, we used her PhilHealth coverage especially she's 68 years old. There are rules in using PhilHealth coverage and it depends on what type of hospital and room you're in. Make sure you know the details. For my mom's case too, some medicines were not included on the coverage so we bought it at any pharmacy (FYI: actually some pharmacies have much cheaper price compared to hospitals). Regarding the discount for medicine, all senior citizens by law has 20% discount and I'm sure on that. Here are some of the info I got below;

Inpatient Benefits (http://www.philhealth.gov.ph/benefits/)

- These benefits are paid to the accredited Health Care Institution (HCI) through All Case Rates

- The case rate amount shall be deducted by the HCI from the member’s total bill, which shall include professional fees of attending physicians, prior to discharge

- The case rate amount is inclusive of hospital charges and professional fees of attending physician

- Availment condition: Member must have at least three (3) months’ premium contributions within the immediate six (6) months prior to the month of availment

- Documents needed: copy of Member Data Record or PhilHealth Benefit Eligibility Form (PBEF) and duly accomplished PhilHealth Claim Form 1

Where available: all accredited HCIs*

*Different case rate amounts for selected medical conditions are being implemented when done in Primary Care facilities (PhilHealth Circular 14, s-2013)

Only admissible cases shall be reimbursed

Hope this information and link helps.

[GandD 5,966]

~~Moved to Philippines forum for region specific advice.~~

[customheat 1]

Thank you so much. You have a great help.

[VOL 425]

if he does not have money they will keep him there until he pays.

I have heard this statement a few times.

How can a hospital hold someone against their free will?

[Greenbaum 12,258]

My father who is 62 lives in Nabua, Camerines Sur. He suffers from high blood pressure and has risk of stroke. He should be entitled to automatic full PhilHealth coverage but when he needs to go to the hospital they charge him in excess of PhilHealth coverage and if he does not have money they will keep him there until he pays. Is this true. I hear that many hospitals charge you what they want and withhold medicine that they are supposed to give you through PhilHealth and make you go and pay at a pharmacy outside the hospital. I would appreciate any expert advice regarding Philhealth and how to avoid the doctors and hospitals from ripping off the patient. The local Barangay is supposed to help with a discount for medicine but they told him "since your daughter is married to an American you should give your benefit to someone else who really needs it". Is there a method to the madness?

Up till 2007 the hospitals would hold patients until there bill was PAID IN FULL. No installments, post dated checks, or loan of chickens would be excepted till the bill was paid. That changed in April 2007. See below. The full legislative bill is here: http://www.lawphil.net/statutes/repacts/ra2007/ra_9439_2007.html.

Please read all of the Act 9439 as there are conditions. If your father goes in be sure to have a copy of this with you and STAND YOUR GROUND as even now they still will use that line "we will hold you till you pay" ( and you reply Horse Manure and show them your rights with a copy of the Act).

REPUBLIC ACT NO. 9439 April 27, 2007

AN ACT PROHIBITING THE DETENTION OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS ON GROUNDS OF NONPAYMENT OF HOSPITAL BILLS OR MEDICAL EXPENSES

Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled:

SECTION 1. It shall be unlawful for any hospital or medical clinic in the country to detain or to otherwise cause, directly or indirectly, the detention of patients who have fully or partially recovered or have been adequately attended to or who may have died, for reasons of nonpayment in part or in full of hospital bills or medical expenses.

[manilaraf 28]

Keep in mind that PhilHealth is not an HMO. It, in many cases, will not be enough to pay for medical bills in full.

It's basically a government subsidy in place provided that you or your company have paid into the program. While it's better than nothing, having private medical insurance/HMO coverage is basically a must here in the Philippines unless you want to pay out of pocket.

No European style all inclusive coverage here in the Philippines, believe me. And government subsidies? Come on, this is the Philippines. You think PhilHealth has enough funds to cover everyone, for every case, in full, nationwide? Every barangay or town isn't Makati with its Yellow Cards. (And that's if you're willing to overlook the Binay factor).

Honestly, if you can, enroll him in a private HMO like PhilCare, Maxicare, Caritas etc. PhilHealth won't cover everything, although, unfortunately, people are under the impression that "Full PhilHealth Coverage" means that everything is paid for.

Again, speaking honestly, unless you have private HMO coverage or are wealthy enough/have access to funds or have enough saved, having a serious illness is a major hit to the wallet in this country.

The Inquirer the other day ran a story how a large amount of Hemophiliacs in the country are unable to afford care.

###### like this is why I believe we should be more like China and speedily execute the corrupt. Money that could pay for your dad's care and medicines have gone on to pay for Imelda's shoes and Janet Napoles' handbags and US-based Daughter's luxury cars and condos. If I were in charge, she'd be a greasy streak on a wall instead of spending her days in Mandaluyong.

Edited April 22, 2015 by manilaraf

[manilaraf 28]

I've done a little legwork for you.

Here's some info from PhilHealth themselves via the Makati Med website: http://makatimed.net.ph/main.php?id=56#mmc9

1) List of Medical Case Rates (link is to a PDF Download): http://www.philhealth.gov.ph/circulars/2013/annexes/circ35_2013/Annex1_ListOfMedicalCaseRates.pdf

2) List of Procedure Case Rate (again, PDF Download): http://www.philhealth.gov.ph/circulars/2013/annexes/circ35_2013/Annex2_ListOfProcedureCaseRates.pdf

Basically these are the procedures/medical care that PhilHealth will cover and how much they'll cover. IF YOUR TOTAL BILL IS HIGHER, WHICH IT CAN, YOU WILL HAVE TO PAY FOR THE REMAINDER OF THE COST.

(Example: Say your father gets admitted for Hypertension Stage II (ICD10 Code I10.1) for the first time. The PhilHealth Medical Case Rate (the amount that they will cover) is P9,000.00. Of that, 2,700 goes to the MD for their fee and 6,300 will go to the hospital for the bill. That's the limit. If the MD's Fee or Hospital Bill Total is higher, you or your HMO will have to cover the rest.

For more info: http://www.philhealth.gov.ph/benefits/

And for those seeking a brief overview of PhilHealth: http://en.wikipedia.org/wiki/Philippine_Health_Insurance_Corporation

And I know your father's in CamSur. So please make sure, if he's going to use his PhilHealth that both the hospital and his doctor are PhilHealth accredited. Not every doctor in the Philippines is.

[manilaraf 28]

Also, one more word of advice coming from a doctor.

Make sure your father gets regular checkups with a doctor that he can trust, even if he's doing well. One because it makes sense to have his care be mostly preventative instead of have to be reactive. Also, this way he can buildup a rapport with that doctor (Like the old days where you'd have the same MD for decades), particularly if he's affiliated with good local hospitals.

I personally have given my regular patients steep discounts and freebies, including large amounts of med-rep medication samples and the like, especially to patients I've gotten to know personally over the years. I've actually gone to bat for them against the hospital to get their bills reduced when I could.

Also, make sure he's up front about his financial situation. Again, the perception here, rightly or wrongly, is if you have a relative living in the States or working as an OFW in Saudi or Europe, you'll be able to meet any costs come what may.

Even if it's not the case, tell him to tell people that you're tight with money. That you'll only pay a certain amount. Better that he gets the benefits he's entitled over bragging rights regarding family.

Unfortunately, I've had patients who personally are in tight financial situations tell me Doc, ok lang, yung anak ko is working in Canada as a nurse or is working in Saudi, they'll cover the costs for me.

Edited April 22, 2015 by manilaraf