New PhilHealth benefits you should demand from hospital

THE hospitalization and death (on March 31, after just three hours in the emergency room) of my beloved nephew Cokee made me realize that hospitals aren’t implementing two very new huge benefits from the Philippine Health Insurance Corp. (PhilHealth).

I don’t know if this is out of ignorance on the part of hospital administrators, or is a deliberate non-compliance because of many hospitals’ experience that their costs on a patient are reimbursed only after a long time, even after a year. Or perhaps PhilHealth has been slow in informing hospitals of these two benefits.

PhilHealth officials should brief Finance Secretary Ralph Recto and Budget Secretary Amenah Pangandaman on the additional costs of these new benefits for PhilHealth as the two (or President Marcos Jr. himself) have acted so cavalierly in transferring P90 billion in PhilHealth funds to “unprogrammed funds.” I hope the Supreme Court rules this despicable move illegal.

These unprogrammed funds are the kind of funds that are easily diverted to small infrastructure projects (i.e., barangay roads, “multi-purpose buildings” in municipalities) from which the politicians easily divert graft money. (A friend who was bidding to build such a P20 million building in a southern province was asked an “SOP” [the grafters’ lingo for bribe money] of P5 million by a congressman who has managed to portray himself in recent months as a graft-buster.)

The problem, of course, with rich people like Recto is that they have never ever experienced the shock of astronomical hospitalization fees for themselves or their families, which not only the poor but even middle-class people have experienced. A friend in retirement who was hospitalized for a stroke last year for a week was charged P5 million by the hospital, wiping out his savings, which I am convinced drove him to such extreme depression that he willed his death.

In the case of my nephew’s hospitalization and death, the hospital charged his family around P600,000 for his three-hour stay there until his death. It turned out that some P360,000 could have been charged to PhilHealth’s new benefits. (Our family and I are extremely grateful to PhilHealth Assistant Vice President Rey Balena for correcting the huge error with the hospital, right after he read my Facebook post on this anomaly. We would have just blamed our unlucky nation for such really unfair costs, if Rey had not sprung to action.)

Impoverished

I wonder how many families have been impoverished by hospitals who were told by some hospital clerk: “PhilHealth doesn’t cover those expenses. Pay up, we don’t care if your relative died.”

I do hope though that PhilHealth fixes its website to make it easier for people to check what benefits the hospital should charge on a particular ailment they or their relative is being hospitalized for. For such earthshaking new PhilHealth benefits, there was nothing on the website announcing these, that I had to ask my artificial-intelligence app to research the new benefits and the corresponding official PhilHealth documents. These new benefits are the following:

PhilHealth Circular 2024, signed Dec. 23, 2024, expands PhilHealth coverage for Emergency Department (ED) medical services, with the most important change being the inclusion of surgical procedures, laboratory tests and expensive imaging such as CT scans (P18,544 for spinal scans). Even the jaw-dropping P49,621 per vial cost of the drug Altephase, used to dissolve blood clots in heart attacks, is covered by the new ED benefits.

PhilHealth doesn’t provide us with an analysis on what services are now included that weren’t before, so it’s impossible for me to estimate how much the new benefits entail. But from my own experience, I nearly went back to the emergency right after I got the bill for a three-hour stay in a hospital’s ED.

As has been my experience also and that of Cokee’s family, they were told that PhilHealth doesn’t reimburse anything if a patient stays less than 24 hours in the hospital, with emergency cases mostly lasting only a few hours at the hospital. There’s just no PhilHealth circular ordering that.

Open heart

The second huge new PhilHealth benefit is that it covers much of the cost of open-heart surgeries, a very laudable move by the government since heart disease is the leading cause of death in the country, representing 20 percent of all fatalities. I myself had a heart bypass surgery in 2004, and I certainly wouldn’t have been able to afford the P3 million cost, if not for the Philippine Charity Sweepstakes Office, which had a hospitalization benefit for government officials and friends’ generous donations.

These benefits for heart surgeries were actually mandated by the National Health Insurance Act of 2013, but strangely or not, it took 11 years for PhilHealth to approve it last February. It took effect March 1, 2025. My sources claim that rather than the previous president, Emmanuel Ledesma, it should be the president before him, Ted Herbosa, as well as the current president, Edwin Mercado, who should take credit for this, though Mercado was appointed only last Feb. 4. Herbosa had been pushing for these benefits, while Mercado had been working as a PhilHealth consultant on the heart-surgery benefits before his appointment as secretary.

What PhilHealth covers for open-heart surgeries is big, which is why these were called “Z benefits.” They cover primary disease conditions that are perceived as economically and medically “catastrophic.” PhilHealth claims these benefits are designed to provide comprehensive financial protection for patients with severe medical conditions, ensuring they receive quality care without incurring significant financial burdens.

The package of benefits includes mandatory diagnostics, operating room expenses, doctors’ professional fees, room and board, and medicines. The biggest benefit is P960,000 for “coronary artery bypass graft (CABG) surgery, expanded risk”; P660,000 for the same kind of surgery, but for “standard risk”; P498,000 for “closure of ventricular septal defect.” The benefits even include P54,000 for cardiac rehabilitation for post-CABG surgery.

I was told that Z benefits are also being formulated for other “catastrophic” diseases, mainly cancers and kidney transplantation.

Kudos to Marcos for appointing Mercado as PhilHealth president. The worst boos possible for Finance Secretary Recto and Budget Secretary Pangandaman for not resisting Marcos’ and Speaker Martin Romualdez’s orders to divert P80 billion in PhilHealth funds to whatever projects will facilitate congressmen’s corruption. If PhilHealth or the hospital says they can’t cover your or your loved one’s emergency department medical services or open-heart surgeries because of lack of funds, blame these people.

(Copies of the two circulars are posted along with this column in my personal website, rigobertotiglao.com.)

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New PhilHealth benefits you should demand from hospital
Source: Breaking News PH