PhilHealth explains new benefit availment rules

CEBU, Philippines – Effective January 1, 2011, PhilHealth will implement additional conditions on members’ eligibility to avail of benefits. These conditions are aimed at making benefits more responsive and safeguarding the funds from possible abuse to ensure the sustainability of the program.

Under Circular No. 31, series of 2010, if a hospital acquires PhilHealth accreditation (initial or reaccreditation) or its accreditation expires within a patient’s confinement period, the member is still entitled to PhilHealth benefits for drugs and medicines, x-ray, laboratory procedures and others, as well as coverage for operating room and professional fees. However, benefit for room and board charges extend only to the period or days falling within the validity of the hospital’s accreditation.

The same circular also provides that if a patient reaches the age of 60 years old in the middle of his or her confinement in the hospital, such patient may be declared as dependent-parent of a member.

In which case, the member is entitled to benefits for drugs and medicines, x-ray, laboratories and others, and operating room and professional fee charges for the full confinement period. However, charges for room and board are covered only from the time the patient became eligible as dependent-parent of the member.

Similarly, hospital room and board charges for sponsored and overseas Filipino worker members are covered only when it falls within the validity period of their coverage. All other benefit items (that is, drugs and medicines, professional fees, and others) shall be paid accordingly.

PhilHealth reiterates that patients confined for less than 24 hours are not covered, except when the patient is transferred to another facility, when it is an emergency case, or when the patient dies.

However, if patients are ordered admitted but are made to stay in the emergency room or within hospital premises pending the availability of rooms, and the patient has been there for more than 24 hours, the hospital may be paid reimbursement for such admission provided it is able to give justification for admitting more patients than allowed under its accredited bed capacity. If a member dies, membership privileges also end. This means that his or her dependents cannot assume the eligibility or entitlement to benefits formerly enjoyed by the member. (FREEMAN)