PhilHealth lifts 45-day benefit limit rule to improve member care
PHILHEALTH / JANUARY 5, 2025
Personnel attend to queries at the counters of the Philhealth office in Mother Ignacia, Quezon City, on September 26, 2023.
INQUIRER PHOTO / GRIG C. MONTEGRANDE
MANILA, Philippines — To extend “unhampered service” to its members, the Philippine Health Insurance Corporation (PhilHealth) has lifted its 45-day benefit limit rule.
In a statement on Thursday, PhilHealth Acting President and Chief Executive Officer (CEO) Edwin Mercado said the 45-day benefit limit is an “outdated cost-containment strategy.”
The 45-day benefit limit previously allowed PhilHealth members a maximum of 45 days of hospital confinement per calendar year.
Their qualified dependents shared a separate 45-day confinement limit annually, the state insurer added.
“Naiintindihan natin kung bakit ito inilagay noon, ngunit, sa pagbabago ng ating payment mechanism, napapanahon na rin talagang repormahin ito,” Mercado said.
(We understand why this was implemented before, but given the changes in our payment mechanism, it is time to reform this.)
“We cannot always predict or schedule our medical needs. Marami ring mga serbisyo ang kinakailangan ng higit sa 45 days na coverage,” the PhilHealth chief further explained.
(We cannot always predict or schedule our medical needs. Many services also require more than 45 days of coverage.)
PhilHealth has previously expanded its hemodialysis package, increasing coverage from 90 to 156 sessions per year.
READ: PhilHealth announces increased coverage for hemodialysis sessions
With the removal of the 45-day benefit limit, a more inclusive approach will now extend to other medical services, the state insurer emphasized.
“Nais natin na ang mga Pilipinong may malulubhang sakit, chronic conditions, o di kaya’y nangangailangan ng mahaba-habang pagpapaospital ay patuloy na makatanggap ng serbisyong pangkalusugan nang hindi pa nag-aalala kung sila ba ay mababaon sa utang,” Mercado expressed.
(We want Filipinos with severe illnesses, chronic conditions, or those needing extended hospitalization to receive healthcare services without the fear of falling into debt.)
To ensure the responsible implementation of this policy, PhilHealth said it will closely monitor patient admissions, readmissions, and benefit utilization exceeding 45 days.
The agency also underscored that availing of benefits should be based on “proper medical indication, necessity, and alignment with the patient’s treatment plan.”
READ: PhilHealth raises dialysis benefits, but private labs to cost more
“Layon natin na ang bawat serbisyong sinusuportahan ng PhilHealth ay tunay na nagdudulot ng katiwasayan sa myembro. Ginagawa naman na ito ng ating mga ospital,” Mercado said.
(Our goal is for every PhilHealth-supported service to genuinely provide peace of mind to members. Our hospitals are already doing this.)
“Ako rin, bilang hospital administrator noon, ay pinagtuunan namin ng pansin ang pag-momonitor ng outcomes. Ngunit, ang gusto natin ngayon ay unti-unti mag-transition ang PhilHealth to value-based financing,” he concluded.
(I, too, as a former hospital administrator, focused on monitoring outcomes. However, we now aim for PhilHealth to gradually transition to value-based financing.)
