Healthcare is not a privilege, it’s a human right for everybody. In the Philippines, the Philippine Health Insurance Corporation (PHIC) or simply PhilHealth plays a major role in Republic Act No. 11223 or simply the Universal Health Care (UHC) Act which mandates that all Filipinos should have access to affordable healthcare. To achieve this, PhilHealth provides access to health insurance for the country. And whether you notice it or not, you're probably already paying for it; PhilHealth contributions are deducted from salaries or paid voluntarily by self-employed individuals. So why not make the most out of it?
While PhilHealth offers significant support in reducing medical expenses, it’s still best to have additional protection. This is where your Health Maintenance Organization (HMO) comes in. Together, PhilHealth and an HMO can help you reduce out-of-pocket costs and lessen the stress of hospital or clinic visits.
As a government-owned corporation, PhilHealth provides social health insurance to all Filipinos. But prior to being covered, registration and updated contributions are still required for eligibility. With that, your employment status dictates your contributions, and thus, your covered PhilHealth benefits.
If you’re employed in the private or government sector, your monthly PhilHealth contribution is shared between you and your employer. You’re automatically covered and eligible to claim benefits.
Freelancers, entrepreneurs, or those working in the gig economy can voluntarily pay PhilHealth contributions to stay covered.
Even if you’re currently unemployed or part of the informal sector, you can still avail of PhilHealth benefits by registering as a voluntary member. This can be done by applying for a PhilHealth ID at the closest PhilHealth Local Insurance or PhilHealth Express Office.
(Written as of May 30, 2025)
PhilHealth offers various benefit categories depending on the type of medical service you need. Here’s a simplified guide to help you understand what’s covered.
These cover hospital confinement or admissions that require you to stay at least 24 hours in a healthcare facility.
Example: If you’re admitted for pneumonia, which has a case rate of let’s say ₱15,000, PhilHealth will pay up to that amount directly to the hospital, regardless of how much your total hospital bill is. If the facility is accredited and you’ve submitted all requirements.
These are services that don’t require confinement and can be availed on a walk-in or scheduled basis.These include but are not limited to:
Example: If you need regular dialysis sessions, PhilHealth offers a per-session case rate (₱2,600 for hemodialysis), which is deducted from your bill. If you have an HMO, it can cover the remaining balance, if any.
These are special packages for patients with catastrophic or life-threatening illnesses that require expensive and long-term treatment. The name “Z Benefits” stands for the zenith of medical conditions in terms of their severity and expense. These cases are often financially crippling without support, and PhilHealth created these packages to provide additional coverage.
Covered conditions include but not limited to:
Example: For early-stage breast cancer, PhilHealth may cover surgery and chemotherapy as part of its Z package, which can amount to ₱100,000 or more depending on the case. Pre-authorization is usually required.
It’s important to note that claiming Z benefits require pre-authorization and are available only in selected contracted hospitals.
These align with the United Nations' Sustainable Development Goals and support the health of vulnerable sectors like women and children.
Includes but not limited to:
Example: A mother giving birth in an accredited hospital may receive PhilHealth maternity benefits of ₱6,500–₱19,000 depending on the method of delivery (normal, CS, etc.).
In light of the recent PHIC circular 2005-003, the following Benefits Packages may be covered by PhilHealth:
When taken into account some of the benefits covered by PhilHealth, there are common benefits that are also covered by your HMO. It helps to think of PhilHealth and HMO coverages in a Venn diagram. Some treatments fall under both— which are the cases you can definitely avail of to get bigger deductions in your total bill. But there are other cases that are exclusive to one. Having both ensures you’re covered from all sides.
HMO coverage is primarily used in private hospitals and clinics. Typically, HMOs are not accepted in public hospitals. Patients may use both PhilHealth and HMO to significantly reduce the final bill if the private hospital is both accredited by Philhealth and accredited by your HMO provider.
PhilHealth contributions are based on your monthly income. For example, if you earn PHP 30,000 a month and the contribution rate is 5%, the total contribution is PHP 1,350—split between you and your employer.
Here’s a simple example of how billing works if you seek care at a private hospital that’s accredited by both PhilHealth and your HMO provider:
PhilHealth coverage extends to legal dependents, such as your spouse, children, and parents who are senior citizens. For example, your senior parent admitted to a hospital can benefit from both PhilHealth and a 20% senior discount, which can significantly reduce the bill before your HMO coverage kicks in.
Before availing of PhilHealth benefits, dependents must be declared in the PhilHealth Member Data Record (MDR). In the event that a family member is not yet declared as a dependent, some hospitals may assist in updating your MDR or declaring the dependent on-site for urgent cases. However, if the hospital is not able to assist the member, they or a representative must go to the nearest PhilHealth office to update their MDR. Exceptions are made for newborns, who are registered automatically for 90 days after birth.
In accredited hospitals, simply present your PhilHealth ID and MDR upon admission. For dependents, ensure that they are declared in your Medical Data Record (MDR). The hospital will process the PhilHealth deduction and reflect it in your Statement of Account.
For reimbursements, if direct filing in the hospital is not possible, submit all necessary documents to the nearest PhilHealth office or via your employer or HR within 60 days after discharge.
As mentioned above, the general rule when claiming discounts or assistance for medical procedures et al. is that the PhilHealth coverage is the first discount applied from the patient’s bill. After this process is done, the process for HMO assistance depends on whether the hospital or clinic is included in your HMO’s accredited provider network, and if not, whether out-of-network reimbursements are part of your coverage.
The following requirements must be prepared prior to claims:
After the PhilHealth deduction, the remaining balance will be forwarded to the HMO provider for coverage, up to the limits of your HMO plan. Usually, it is the hospital’s HMO coordinator that will process this for your final bill.
If out-of-network availment is not part of your HMO coverage, the remaining balance after the PhilHealth deductions can be settled out of pocket. However, if out-of-network availment is part of your HMO coverage, this is typically filed with the HMO as a reimbursement claim. The following requirements that need to be submitted with claim include (but are not limited to, based on the HMO) the following:
All HMO providers require that PhilHealth’s share is deducted first before they cover the rest. This means your PhilHealth membership directly reduces how much your HMO plan needs to shoulder, leaving more room in your annual limit for future needs.
Members benefit because:
Access to quality healthcare is a fundamental right. Nobody should face a financial crisis just because they or their loved ones got sick. By making the most of your PhilHealth benefits and pairing it with HMO coverage, you’re building a safety net that ensures you get the maximum amount of deductions possible and also prolong your benefit limit with your HMO.
At Hive Health, we believe in making healthcare radically accessible for all Filipinos. Learn more about how we support members with seamless HMO and PhilHealth coordination here: ourhivehealth.com
https://www.philhealth.gov.ph/
