PhilHealth to give higher benefit packages effective Feb. 14

PhilHealth (INQUIRER FILE PHOTO)

MANILA, Philippines — Here’s some good news from the Philippine Health Insurance Corp. (PhilHealth) amid the increase in premiums paid by its members.

According to the state health insurer, the 30-percent increase in the coverage rate of most of its benefit packages would take effect on Feb. 14, Valentine’s Day, and also the 29th anniversary of PhilHealth.

Under PhilHealth Circular No. 2024-001, signed on Jan. 29 by its president and CEO Emmanuel Ledesma Jr., PhilHealth adopted an inflation adjustment factor of 30 percent for existing case rates to account for price changes over the past decade.

“The aim of the adjustment in our benefit packages is to lessen the balance or completely eliminate the out-of-pocket expenses for Filipinos availing [themselves] of health services in hospitals and other medical facilities after being covered by PhilHealth,” PhilHealth spokesperson Rey Baleña said in an interview on dzBB on Saturday.

Since 2013 when the state insurer first implemented the case-based payment system—wherein PhilHealth reimbursed accredited health-care providers a fixed amount for a specific medical condition or surgical case—most case rates have not been adjusted.

“We are catching up with the inflation of health-care costs that’s why we are implementing these adjustments. We have not increased the case rate packages in the past years,” Baleña explained.

Cases not covered

The PhilHealth official, however, said not all case rate packages would be adjusted to inflation since these were recently increased, some by more than 30 percent.

According to the circular, excluded in the inflation-based adjustment are benefit packages that have been adjusted in the past five years.

For example, PhilHealth expanded in June last year the hemodialysis sessions covered in its package for Stage 5 chronic kidney disease patients to 156 sessions from 90 sessions a year—or from P234,000 to P405,600 at P2,600 per session, which was equivalent to a 74-percent increase.

In October last year, PhilHealth also raised the coverage for ischemic stroke to P76,000 from P28,000 (up by 171 percent), and hemorrhagic stroke to P80,000 from P38,000 (an increase of 111 percent).

The coverage for high-risk pneumonia was also raised to P90,100 from P32,000 (up by 182 percent).

Also excluded in the inflation-adjusted rates were the benefit packages being recomputed and scheduled for adjustment within the year such as the following:

• Z Benefits package which covers 20 listed catastrophic illnesses and health conditions requiring expensive treatments and hospitalizations)
• benefit packages that have been developed in the past five years (such as the Outpatient Mental Health Package)
• cases that are identified to have a high risk for moral hazard or adverse incentives (such as cataract procedure)
• benefit packages paid through other provider payment mechanisms (such as the Konsultasyong Sulit Tama or Konsulta)

More increases coming

PhilHealth has yet to upload the complete list of adjusted case rates on its website.

According to the circular, PhilHealth would use a two-tier approach in adjusting its benefit packages, micro-costing for some prioritized cases, and an inflation adjustment factor for the remaining case rates.

The inflation-adjusted case rates would depend on the volume of claims and the “contribution to catastrophic expenditure” on the finances of the patient.

Baleña said that PhilHealth management was also looking to increase the coverage “beyond 30 percent” for six more conditions this year.

In December last year, PhilHealth committed to adjusting the rates of most of its benefit packages in 2024 to help lower Filipinos’ hospitalization expenses.

“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,” Ledesma had said.

While PhilHealth maintained that its fiscal position remained “strong and robust,” it implemented an increase in the contribution of its members from 4 percent to 5 percent this year.

READ: PhilHealth members’ contribution hikes to 5% this 2024

Health Secretary Ted Herbosa, who serves as the ex officio chair of PhilHealth, appealed to President Marcos to suspend again the implementation this year of the increase in premiums.

Mr. Marcos, however, has yet to decide on the appeal.

Under Republic Act No. 11223, or the Universal Healthcare Act, PhilHealth is mandated to raise members’ premiums by 0.5 percent every year starting in 2019. The scheduled increases will end in 2025 when it reaches the second year of the 5-percent limit.