Philippine Health Insurance Corporation (PhilHealth)

In today’s ever-evolving healthcare landscape, understanding and accessing health insurance is more crucial than ever. This is particularly true in the Philippines, where the Philippine Health Insurance Corporation, commonly known as PhilHealth, is very much a need. PhilHealth stands at the forefront of providing health insurance coverage to millions, ensuring that quality healthcare is not just a privilege, but a right accessible to all Filipinos all over the globe.

Established to deliver affordable and comprehensive healthcare services, PhilHealth is an integral part of the Philippine healthcare system. It strives to make medical services more accessible and affordable, especially for those in dire need.

philhealth logo
Credits: Philhealth / Facebook

History and Background of PhilHealth

The Philippine Health Insurance Corporation (PhilHealth) has been a cornerstone in the provision of accessible and affordable healthcare to Filipinos. Its evolution mirrors the broader development of health insurance in the Philippines, underpinned by a commitment to social responsibility and the welfare of its citizens.

Early Beginnings: Laying the Foundation

PhilHealth’s roots can be traced back to the 1960s with the Philippine Medical Association’s MARIA Project, which aimed to offer medical assistance in underserved areas. This initiative highlighted the critical need for a national health insurance system. The significant leap towards this goal occurred in 1969 with the enactment of the Philippine Medical Care Act (Republic Act 6111), establishing the Medicare program primarily for government employees. This legislation marked the first substantial stride towards comprehensive health coverage in the nation.

Expansion and Growth: Towards a Unified System

Over the following decades, the Medicare program saw gradual expansion, eventually including private sector employees and their dependents. However, the system was still fragmented, lacking comprehensive coverage for the entire population. The transformative moment came in 1995 with the passing of the National Health Insurance Act (Republic Act 7875), leading to the creation of PhilHealth. This act helps to establish a unified and sustainable health insurance system for all Filipinos.

PhilHealth commenced its operations in 1996, absorbing the administration of the Medicare program from various government agencies. Since its inception, PhilHealth has broadened its coverage ambitiously, encompassing:

  • Self-employed individuals.
  • Voluntary members.
  • Overseas Filipino Workers (OFWs).
  • Members of the informal sector.
  • Indigents.

The Quest for Universal Health Coverage

Despite its significant strides, PhilHealth has navigated through numerous challenges, such as resource limitations, financial sustainability issues, and bureaucratic complexities. Nonetheless, it has steadfastly pursued its mission of making healthcare affordable and accessible for all Filipinos. The Universal Health Care Act (Republic Act 10606), enacted in 2010, further bolstered PhilHealth’s mandate, providing a clear direction toward achieving universal health coverage.


Today, PhilHealth stands as an entity in the Philippine healthcare landscape, extending coverage to approximately 85 million Filipinos. It offers an extensive array of benefits, including inpatient and outpatient services, preventive care, diagnostics, and maternity care.

However, the journey is ongoing. PhilHealth continues to confront challenges such as enhancing its benefit packages, extending specialized care and assistance in rural areas, and securing additional funding.

As PhilHealth progresses, it’s vital to acknowledge its historical journey it has played—and continues to play—in safeguarding the health and well-being of Filipinos. This journey underscores a commitment not just to health insurance, but to the very essence of social welfare and community care in the Philippines.

PhilHealth Services and Coverage

PhilHealth, as the cornerstone of health insurance in the Philippines, offers a wide spectrum of services and coverage, designed to make healthcare both affordable and accessible to all Filipinos. The array of benefits provided caters to various health needs, from routine check-ups to critical care. Understanding these benefits is essential for effectively utilizing your health insurance plan and ensuring you get the most out of it.

1. Inpatient Care

  • What it Covers: This includes expenses incurred during hospitalization for illnesses, injuries, or surgeries. Coverage extends to room and board, professional fees of attending physicians and surgeons, operating room fees, and specific diagnostic and therapeutic procedures.
  • Where to Avail: Services must be availed at PhilHealth-accredited hospitals to be covered.

2. Outpatient Care

  • What it Covers: This category includes consultations, laboratory tests, X-rays, and other diagnostic and therapeutic procedures that do not require hospitalization.
  • Where to Avail: Coverage is applicable at PhilHealth-accredited clinics, diagnostic centers, and other outpatient facilities.

3. Preventive Care

  • What it Covers: PhilHealth emphasizes preventive health services like vaccinations, well-child checkups, and cancer screenings, focusing on preventing illnesses and promoting early detection.
  • Aim: These services aim to uphold the overall health and well-being of the community.

4. Maternity Care

  • What it Covers: This encompasses comprehensive care for pregnant mothers, including prenatal, delivery, and postnatal services. It covers normal deliveries, cesarean sections, and newborn care.
  • Aim: To ensure mothers and babies receive the necessary care during this critical period.

5. Family Planning Services

  • What it Covers: This includes various family planning methods and counseling, offering couples resources to plan their families responsibly.
  • Services Provided: Access to different contraceptives and sterilization procedures are part of this coverage.

6. Special Packages and Programs

  • Z Benefit Package: For catastrophic illnesses, providing substantial aid in severe health situations.
  • Senior Citizen Health Insurance Program (SCHIP): Tailored for the elderly, ensuring they receive appropriate care.
  • Malasakit Program: Aids financially disadvantaged patients in accessing healthcare.
  • Tuberculosis DOTS Program: Focused on combating tuberculosis.
  • HIV/AIDS Treatment Program: Provides comprehensive care for individuals with HIV/AIDS.

Eligibility and Coverage Levels

  • Eligibility: Your eligibility for PhilHealth benefits depends on your membership category (employed, self-employed, voluntary, etc.) and your contributions.
  • Coverage Levels: The extent of coverage varies based on your membership category and the specific service or package availed.

Eligibility and Membership

PhilHealth, the Philippine Health Insurance Corporation, is a beacon of hope, offering Filipinos access to affordable and quality healthcare. Understanding who is eligible, the types of membership available, and how to maintain active status is essential in leveraging the full extent of these benefits. This section provides a comprehensive look at these aspects, along with an insight into dependent coverage.


Eligibility Criteria

  • Citizenship: Be a Filipino citizen.
  • Age: Fall within the prescribed age range for the chosen membership category.
  • Exclusivity: Not be covered by another social security program.
  • Financial Capability: Be capable of paying the required contributions.

Types of Membership

  1. Employed Members: Those in the private sector with a monthly salary of at least Php 200, employed by an SSS-registered employer.
  2. Self-Employed Members: Filipinos aged 18-60 with an annual income of at least Php 25,000.
  3. Voluntary Members: Filipinos aged 15-60 not covered by any other social security program.
  4. Overseas Filipino Workers (OFWs): Filipinos employed overseas with a monthly salary of at least Php 200.
  5. Kasambahay (Domestic Workers): Filipinos employed as domestic workers earn at least Php 5,000 per month.
  6. Senior Citizens: Filipinos aged 60 and above are automatically covered by PhilHealth through the Senior Citizen Health Insurance Program (SCHIP).

Steps to Become a Member

  • Register online at the PhilHealth website.
  • Visit a PhilHealth branch and submit the necessary documents for verification and processing.
  • Start paying monthly contributions through accredited payment channels.

Maintaining Active Status

  • Ensure the regular payment of monthly contributions.
  • Report any changes in employment status, income, or other relevant information to PhilHealth.
  • Note that failure to comply with these requirements may result in the suspension of PhilHealth benefits.

Dependents and Their Coverage:

  • Qualified dependents of PhilHealth members are also entitled to benefits.
  • Dependents include:
    • Spouse
    • Legitimate, adopted, and stepchildren below 21 years old or regardless of age if suffering from a disability preventing self-support
    • Parents who are 60 years old and above
  • Coverage for dependents is subject to certain conditions and may require additional contributions.

Contribution Structure

The contribution structure of PhilHealth, which forms the backbone of its financial sustainability, underwent significant changes in accordance with the Universal Health Care Law of 2019 and its implementing rules. This section aims to clarify these changes, ensuring members understand their responsibilities and the benefits they stand to gain.

New Contribution Schedule for Direct Contributors

  • Definition: Direct contributors are those employed with an employer-employee relationship, including Kasambahays, self-earning individuals, practicing professionals, and Overseas Filipino Workers (OFWs).
  • Premium Rate Changes: As per PhilHealth Circular No. 2019-0009, the premium rate for Direct Contributors was 2.75% of the monthly basic salary, with an adjusted ceiling of P50,000. This rate increased to 3% in 2020 and will rise by 0.5% each year, reaching a 5% limit by 2025.
  • Income Floor and Ceiling Adjustments: The income floor is fixed at P10,000, while the salary ceiling will increase by P10,000 annually, reaching P100,000 by 2025.
Image: Philhealth website

Contribution Computation

  • Individuals earning below P10,000 contribute based on the minimum threshold.
  • Those earning at the set ceilings/limits pay premiums based on these ceilings.
  • This policy also applies to seafarers.

Premiums for Self-Paying Members, Professionals, and Land-Based OFWs

  • Calculated straight from their monthly earnings.
  • Members must provide financial records like income tax returns or overseas employment contracts for accurate computation.
  • Absent these documents, contributions will be based on the highest computed rate.

How to Avail of PhilHealth Benefits

Navigating the PhilHealth system and utilizing its benefits can be daunting. Here’s a streamlined guide to help you efficiently avail of PhilHealth services, ensuring you and your loved ones receive the healthcare you need with minimal hassle.

Before Availing Services

  1. Ensure Active Membership:
    • Confirm that your PhilHealth membership is active and contributions are current.
    • Check your status online via the PhilHealth Member Portal.
  2. Identify Accredited Healthcare Institution (HCI):
    • Choose a PhilHealth-accredited hospital or clinic for your healthcare needs.
    • Find accredited HCIs on the PhilHealth website.
  3. Prepare Necessary Documents:
    • PhilHealth Member Data Record (MDR).
    • Valid ID.
    • Referral letter from a primary care physician (if required).
    • Medical certificates and prescriptions.
    • Other documents specific to your case.

Availing Inpatient Care

  1. At the Hospital Admission Office:
    • Present your MDR and other documents.
    • Inform staff of your intent to use PhilHealth benefits.
    • The hospital will verify eligibility and process your claim.
    • Be prepared for possible co-payment, depending on membership category and service type.
  2. Compliance with Hospital Procedures:
    • Complete necessary forms and undergo medical examinations.
    • Cooperate with medical staff and adhere to instructions.
  3. Settle Hospital Bill:
    • PhilHealth benefits are deducted from the total bill.
    • You will cover any remaining balance.

Availing Outpatient Care

  1. At the Clinic or Diagnostic Center:
    • Present your MDR and a valid ID.
    • Inform them of your PhilHealth coverage.
    • Eligibility and claim processing will be conducted by the provider.
  2. Consultation and Procedure:
    • Undergo the necessary treatment.
    • Keep receipts and medical certificates for future claims.

Claiming Benefits for Outpatient Procedures

  1. Complete PhilHealth Claim Form 1:
    • Available online or at PhilHealth offices.
    • Fill out accurately and completely.
  2. Submit Claim Form and Supporting Documents:
    • Include receipts, medical certificates, and prescriptions.
    • Submit online via the PhilHealth Member Portal or at a PhilHealth office.
  3. Wait for Claim Processing:
    • PhilHealth reviews your claim and informs you of the result.
    • Benefits are received via bank deposit or check.

Tips for a Smooth Process

  • Know Your Benefits: Understand your eligibility and benefit entitlements.
  • Document Preparation: Gather all necessary documents in advance.
  • Clear Communication: Ask questions and seek clarifications from healthcare providers or PhilHealth staff.
  • Record Keeping: Retain copies of medical records and receipts.
  • Patience is Key: Processing times can vary.

Video: Benepisyo Mo, Alamin Mo!

Wondering how your PhilHealth inpatient benefits are deducted from your hospital bill? Understanding this process is crucial for every PhilHealth member. It’s a seamless process, designed to ensure that your hospital experience is not only about receiving quality care but also about experiencing the financial relief provided by your PhilHealth coverage. Watch this video until the end to learn more.

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