In the Philippine healthcare system, the Philippine Health Insurance Corporation (PhilHealth) serves as the primary implementer of the Universal Health Care (UHC) Act (Republic Act No. 11223). While the UHC Act aims for comprehensive coverage, the extent of benefits during short-term confinement in private institutions is governed by specific "Case Rate" packages and membership categories.
I. The Nature of Coverage: The Case Rate System
PhilHealth currently utilizes a Case Rate System for inpatient benefits. Unlike a reimbursement system based on actual costs, a case rate is a fixed amount that PhilHealth pays the hospital for a specific diagnosis or surgical procedure.
- Fixed Deductions: The amount deducted from your hospital bill is predetermined based on the ICD-10 code (International Classification of Diseases) assigned to your diagnosis.
- Two-Tiered Payment: Each case rate is divided into two parts:
- Health Care Institution (HCI) Fees: Covers room and board, laboratory tests, imaging, and medicines.
- Professional Fees (PF): Covers the attending physician, surgeon, and anesthesiologist.
II. Eligibility and the "24-Hour Rule"
For a hospital stay to be classified as "confinement" eligible for inpatient benefits, the following conditions generally apply:
- Duration: The patient must be confined for at least 24 hours. Short-term stays of less than 24 hours are typically treated as outpatient cases unless they involve specific procedures (like dialysis, chemotherapy, or minor surgeries) that fall under PhilHealth’s outpatient packages.
- Qualifying Contributions: Under the UHC Act, all Filipinos are technically members. However, to avail of benefits without friction, "Indirect Contributors" (indigents, seniors) or "Direct Contributors" (employees, self-earning) must ensure they meet the minimum contribution requirements—traditionally at least 3 months of premiums within the 6 months preceding the month of confinement.
III. Private vs. Public Hospital Dynamics
A critical legal distinction exists regarding how PhilHealth benefits are applied in private versus public facilities:
1. The "No Balance Billing" (NBB) Policy
In government hospitals, the NBB policy ensures that marginalized members (Indigents, Sponsored Members, Senior Citizens) pay zero for their confinement.
2. The Balance Billing in Private Hospitals
Private hospitals are not bound by the NBB policy. If the total bill in a private facility exceeds the PhilHealth Case Rate, the patient is legally responsible for the "balance."
- Example: If a respiratory infection has a Case Rate of P9,000, and the private hospital bill is P25,000, PhilHealth pays the P9,000, and the member pays the remaining P16,000.
IV. Breakdown of Benefits in Private Confinement
When a member is admitted to a private hospital for a short duration, the following are covered up to the maximum limit of the specific Case Rate:
- Room and Board: Use of the hospital room and meals.
- Drugs and Medicines: Essential medications listed in the Philippine National Formulary (PNF).
- X-ray and Laboratory: Diagnostic tests required for the specific diagnosis.
- Professional Fees: PhilHealth pays the doctor based on a relative unit value. In private hospitals, doctors often charge "Private Rates," which may exceed the PhilHealth PF cover. The member must pay the difference.
V. Common Short-Term Case Rates
While there are thousands of codes, common short-term confinements in the Philippines include:
| Condition | Approximate Total Case Rate (PhP) |
|---|---|
| Acute Gastroenteritis | 6,000 to 9,000 |
| Pneumonia (Moderate Risk) | 15,000 |
| Urinary Tract Infection (UTI) | 7,500 |
| Dengue (Non-severe) | 10,000 |
VI. Limitations and Exclusions
PhilHealth coverage does not extend to all medical expenses. Under Section 35 of RA 7875 (as amended), the following are typically excluded:
- Cosmetic surgery (unless reconstructive due to trauma).
- Optometric services.
- Purely diagnostic stays (where no treatment is administered).
- Stays in non-accredited hospitals.
VII. Procedural Requirements for Claiming
To ensure the deduction is applied before discharge from a private hospital, the following must be submitted to the hospital’s billing department:
- PhilHealth Identification Number (PIN) or a Member Data Record (MDR).
- Claim Signature Form (CSF): Signed by the member or a representative.
- Proof of Contribution: If the record is not updated in the hospital’s "HCI Portal," the member may need to show proof of payment (latest receipts).
- Valid ID: To verify identity and relationship (if the patient is a dependent).
Note on Automatic Deduction: PhilHealth benefits are deducted at the point of service. The member should not pay the full amount and seek reimbursement later unless the hospital is unable to process the claim online due to system downtime or specific administrative issues.