Updated December 2014:
Philhealth started implementing its Case Rates Payment system for maternity cases and other medical/surgical cases in September 1, 2011.
For Normal Spontaneous Delivery (NSD) in Level 1 hospitals and in lying-in facilities, maternity clinics, RHUs and birthing facilities, the total Philhealth benefit consists of 8,000 pesos (6,500 for the facility and health professional and 1,500 for prenatal care).
For NSD in Levels 2 to 4 hospitals, the total Philhealth payment consists of 6,500 pesos (5,000 for the facility and health professional and 1,500 for prenatal care). Prenatal care ORs must be submitted to the hospital.
For Delivery by Caesarian Section (CS) in accredited Levels 2 to 4 hospitals and performed by accredited health professionals, Philhealth’s coverage is 19,000 pesos. 11,400 pesos is for hospital costs and 7,600 pesos is for the doctors. CS is not covered in level 1 hospitals or maternity clinics. There’s no prenatal care benefit for CS cases.
The Newborn Care Package (NCP) is worth 1,750 pesos. NCP includes physical examination, eye prophylaxis, Vitamin K administration, BCG vaccination, first dose of Hepatitis B immunization, newborn screening tests, and breastfeeding advice.
Based on recent Philhealth circulars and advisories, here are some bits of info about Philhealth maternity benefits:
Q: How much is the total maternity benefit for normal deliveries?
The total benefit is 6,500 pesos at Level 1 hospitals and in lying-in and maternity clinics.
It is 5,000 pesos at Levels 2 to 4 hospitals.
There’s an additional benefit of 1,500 pesos if you submit ORs of prenatal care services. Philhealth will refund this prenatal benefit. It will not be reflected or deducted from the hospital bill.
Many lying-in and maternity clinics require that prenatal care services are performed by them.
Q: Can I receive this maternity benefit for all my normal deliveries?
There was a plan to cover all normal deliveries. But as of now, only the first 4 births are covered under the normal delivery package. Ask the hospital or clinic where you are giving birth.
Q: Can I automatically receive the total benefit of 6,500 pesos or 8,000 pesos for my normal delivery?
You do not always get the total benefit. The benefit of 8,000 pesos pays for the following:
– hospital costs
– for the attending doctor
– 1,500 pesos for prenatal care
For lying-in clinics or midwife-managed facilities:
6,500 pesos for midwife and facility services
1,500 pesos for prenatal care
For level 2 to 4 hospitals:
3,000 pesos for hospital costs
2,000 pesos for the doctor
1,500 pesos for prenatal care
So if you didn’t submit prenatal care receipts, you get only 5,000 pesos or 6,500 pesos. Your prenatal care refund amount also depends on the amount of ORs you submit.
Q: If I’m 1 month to 8 months pregnant now, can I apply for Philhealth membership so I can avail of the maternity benefits when I give birth?
Yes and No.
Yes, if you’re still within the deadline to be able to pay for 3 months within 6 months prior to delivery.
No, if it’s already too late to pay for 3 months prior to delivery.
But if you can accept possible denial, you can go to the nearest Philhealth and ask if you can avail if you pay for 1 year in advance. The rule about this has not yet been made very clear.
Yes, if you’re an OFW or an OFW dependent. You can avail of the benefit as long as your delivery date is within the validity dates written on your premium receipt.
The same condition for Sponsored Members. They also have validity dates, as reflected in their Sponsored ID cards.
For Employed Members, payment for 3 months of the 6 months prior to delivery are required.
Q. If the hospital or clinic is Philhealth-accredited, can I be sure that I get the maternity benefit?
No. You have to make sure that your doctor is also Philhealth-accredited.
Q: How do I get my pre-natal care benefit?
Keep your official receipts for paid prenatal consultation and care, and then submit them to your accredited hospital/clinic/lying-in/maternity facility, so the receipts will be included in the Philhealth claim. You will get your refund from Philhealth. The refund check will be in your name and will be sent to your address. Many lying-in or maternity clinics require that your prenatal care services are done by them.
Q: When should I file my claims?
BEFORE discharge from the hospital or clinic. Upon admission or during admission, ask the hospital about their Philhealth policies, so you have time to remedy if there are problems.
Direct filing by patients with Philhealth is no longer allowed, so submit your documents to your accredited health facility before discharge so that your maternity and newborn test cost benefits will be deducted from your hospital/clinic bill.
Now, only certain direct filing cases are allowed, such as filing for refund by overseas Filipinos giving birth abroad, by employees who are admitted and discharged during weekdays or holidays, and by patients who are asked by their government hospitals to buy medicines and supplies from pharmacies outside the hospitals.
Q. What are the documents needed to enjoy maternity benefits?
1. Updated Philhealth Member Data Record (MDR). Get this from any Philhealth branch. If you’re a dependent, your name should be written in the MDR form as a dependent.
2. Philhealth premium payment receipts.
If you’re Individual Payor, OFW or dependent, bring original and xerox copies.
If you’re employed, ask for a Certificate of Philhealth premium payments from your employer.
3. Philhealth Claim Form 1. You can ask for this form from your employer, the hospital or from any Philhealth branch. Ask for two copies, the other is for your baby’s newborn care package.
4. If you’re a dependent of your husband, bring your marriage certificate, in case the hospital asks.
6. If you have pre-natal care receipts, bring them to the hospital/clinic and attach them to the claim forms. Pre-natal care benefit is 1,500 pesos, if your ORs sum up to 1,500 pesos or more.
3. Philhealth ID or any valid photo ID, in case the hospital asks for identification.
Q. Are there other reasons why I can’t avail of Philhealth’s maternity benefits?
You CAN NOT avail of complicated maternity care in non-hospital facilities such as lying-in and maternity clinics. Avail of complicated maternity services in hospitals.
Here are exclusions (both hospital and non-hospital facilities):
– fifth normal delivery and subsequent deliveries
– normal delivery after 1 breech delivery and 3 normal deliveries
– normal delivery after 1 cesarean delivery and 3 normal deliveries
– normal delivery after 1 preterm delivery and 3 normal deliveries
– normal delivery after 1 stillbirth and 3 normal deliveries
– normal delivery after 1 normal delivery, 1 abortion and 3 normal deliveries
– normal delivery after 3 abortions and 4 normal deliveries
Exclusions in non-hospital facilities: (You should go to a hospital)
– you’re younger than 19
– you’re already 35 years old or older and this is your first time to give birth
– multiple pregnancy
– uterine or ovarian abnormalities, such as ovarian cysts and myoma uteri
– placental abnormality, such as placenta previa
– abnormal fetal presentation, such as breech
– history of 3 or more miscarriages or abortion
– history of 1 stillbirth
– history of cesarean section (CS), or uterine myomectomy, or other major gynecologic or obstetric operation
– history of hypertension, eclampsia, pre-eclampsia, diabetes, heart disease, asthma, epilepsy, bleeding disorders, renal diseases, thyroid disorder and morbid obesity
– risky conditions that may arise during pregnancy such as vaginal bleeding and premature contractions
CS will NOT be covered by Philhealth if it’s performed at a Level 1 hospital or maternity clinic.
Above exclusions are sourced from: Philhealth Circular signed by Philhealth President Rey Aquino on November 10, 2008.
Q: If my child is delivered via Cesarean Section (CS), will Philhealth cover my expenses?
Yes, as long as it is Indicated CS. Under the Philhealth Case Rate program, the coverage for CS is 19,000 pesos. This 19k is allocated as 11,400 pesos for hospital costs and 7,600 pesos for professional fees.
CS is covered only at Level 2 to 4 hospitals.
Q: What is the Newborn Care Benefit?
This is a Philhealth benefit worth 1,750 pesos for your newborn baby:
– 500 pesos for umbilical cord care, eye prophylaxis, thermal care, Vitamin K, BCG vaccine administration, and newborn resuscitation, 1st dose of hepatitis immunization
– 550 pesos for the newborn screening test
– 200 pesos for the newborn hearing screening test
– 500 pesos for the pediatrician
– Available for all normal deliveries, even for fifth and succeeding deliveries, and for CS deliveries.
Ask your doctor about it beforehand because the newborn tests must be performed within a certain number of hours after the baby’s birth in order for the tests to be paid by Philhealth. The pediatrician must be Philhealth-accredited.
Q: What’s the best way to get the maximum Philhealth maternity benefits?
Find an obstetrics-gynecologist who is Philhealth-accredited, who works in a Philhealth-accredited hospital, and who is willing to help you get the maximum benefit starting from prenatal care up to newborn care.
Or find a midwife’s clinic or a lying-in clinic which is Philhealth accredited and willing to help you get the maximum benefit starting from prenatal care, antenal care, maternity care and newborn care. Make sure that your midwife is also Philhealth-accredited.