PhilHealth to adjust benefit package rates in 2024

The Philippine Health Insurance Corporation (PhilHealth) is set to adjust the rates of most of its benefit packages starting 2024, to enable its members to cope with the increasing cost of medical care, PhilHealth president and chief executive officer Emmanuel Ledesma Jr. said in a recent statement.

“We want our members to feel the value of their benefits which translates to meaningful financial risk protection. Our fellowmen must be able to feel their benefits from PhilHealth,” he added.

The state health insurance first implemented the case rate payment system in 2013, when it reimbursed a fixed amount for a specific medical condition or surgical case. With the set adjustment, the case rates are likely to increase to a maximum of 30 percent across all cases, resulting to lower out-of-pocket expenses during hospitalization and even for outpatient care.

To minimize untoward inflationary effects after rate adjustments, PhilHealth will prescribe a cost-sharing mechanism wherein health facilities and the members will have fixed co-payment rates on top of what is being paid for by PhilHealth.

This way, health facilities will be more efficient in the use of resources to achieve the desired health outcomes while members can predict how much they should pay for amenities and other extra services availed of beyond those provided in basic or ward accommodations.

Other strategies to control the untoward effects of this adjustment include measures to prevent insurance fraud and doctor moral hazard. “This will be our way of controlling healthcare costs, in making member’s expenses predictable, and in discouraging irrational use of healthcare services among facilities,” Ledesma stressed.

Ledesma said PhilHealth will adopt a variable inflation adjustment across types of health facilities, which means that higher-level facilities shall get higher adjustments in rates up to a maximum of 30 percent. The upward adjustment in case rates is on top of the ongoing benefit expansion and rationalization that was already approved by the PhilHealth Board.

For 2023, PhilHealth has implemented the expansion of dialysis coverage to 156 sessions from the previous 90 sessions, and rationalized the rates for conditions mostly availed of among Filipinos.

Through Circular 2023-0021, it increased the coverage for ischemic stroke from P28,000 to P76,000, and hemorrhagic stroke from P38,000 to P80,000. It is set to release a circular before yearend to widen its coverage for pneumonia high-risk from P32,000 to P90,100.

In 2024, Z Benefits for breast cancer will likewise be expanded, which will include coverage of targeted therapy of up to P1 million per patient per year.

Z Benefits cover 20 catastrophic illnesses and health conditions requiring expensive treatments and hospitalizations: acute lymphocytic leukemia, early breast cancer, prostate cancer, kidney transplant, standard risk coronary bypass graft, tetralogy of Fallot, ventricular septal defect, cervical cancer, Z MORPH (Mobility, Orthosis, Rehabilitation and Prosthesis Help), selected orthopedic implants, peritoneal dialysis, colon cancer, rectal cancer, expanded mobility orthosis rehabilitation help, premature and small newborns, children with developmental disabilities, children with mobility impairment, children with visual impairment, children with hearing impairment, and rheumatic heart disease. (PNA)