PhilHealth Benefits Scheme Outline

PhilHealth Benefits Scheme Outline

Overview

• PhilHealth provides a benefits scheme that pays for a set of services at predetermined rates.

Claims Payment

• Claims payments can be uncertain.

  • Whole claims and individual items may be disregarded or reduced.

Impact on Private Hospitals

• Private hospitals rely significantly on PhilHealth payments due to:

  • Largest number of PhilHealth members employed in the private sector.

  • Private sector employees commonly seek care at private hospitals.

Supplementary Health Insurance

• Health Maintenance Organizations (HMOs) and private prepayment schemes supplement PhilHealth coverage, facilitating access to private hospital services.

Regulation of Private Health Sector

• Department of Health (DOH) regulates private health institutions through:

  • Standards via licensure procedures.

  • Accreditation procedures of PhilHealth.

• Professional organizations and medical specialty groups participate in certification systems and programs.