Special benefit packages

Influenza A (H1N1) Package

PhilHealth Coverage for Confirmed Cases of
Novel Influenza A (H1N1) in Humans

To mitigate the direct medical cost for the treatment of complicated human cases of novel Influenza A (H1N1) with complication or co-morbidities requiring hospitalization. The following shall be effective in all local and overseas confinements with admission dates starting May 1, 2009.

Details of coverage:

Amount of coverage

Maximum of Php 75,000 for non-health worker-members.

Maximum of Php 150,000 for health worker-members.

Services included
Members/ dependents
Room and board allowance of 1,500/day but up to 10,000 only
Drugs and medicines; X-ray, lab and others (including supplies and personal protective equipment and transfer services); and operating room fees – 50,000
Professional fees of 1,000/day but up to 15,000 only
HCWs Room and board allowance of 1,500/day but up to 20,000 only
Drugs and medicines; X-ray, lab and others (including supplies and personal protective equipment and transfer services); operating room and other medically necessary care – 100,000
Professional fees of 1,000/day but up to 30,000 only

Providers

Hospitals designated by DOH as referral centers (national, sub-national and satellite) for Influenza A (H1N1) and other emerging and re-emerging diseases with the exception of confinements abroad.

Admissions in private hospitals may be covered if confirmatory tests were coordinated with or confirmed by the RITM, DOH-CHD or other DOH certified laboratories

Eligibility

Limited to members and health qualified workers with novel swine-origin influenza A (H1N1) virus infection confirmed by the Department of Health (DOH)

For qualified health care workers (HCWs):

  • Rendered service in a DOH-designated hospital for Influenza A (H1N1) and
  • Contracted the disease while performing their duties and or caring for an influenza A (H1N1) patient as certified or attested by DOH
  • Qualified dependents of HCWs who also contracted the disease shall be provided a maximum coverage of Php 75,000.

Premium payment of at least three months within the last six months prior to the month of confinement

Exclusions

Probable and case under observation*

Admissions in non-DOH designated hospitals*

Influenza-like illnesses (ILI)*

Other seasonal outbreaks of influenza by established flu virus (e.g., H1N2, H5N1)*

SARS**

Avian flu**

Other conditions

Reimbursement (to members) for drugs, medicines and supplies or laboratory procedures bought or performed in other facilities shall be based on the following:

  • Facility cannot provide necessary items and services covered by the benefit.
  • These items and services are used during confinement.
  • Official receipts and/or other purchase documents are submitted.
  • Reimbursement depends on actual cost of receipts submitted but not more than the difference between maximum benefit and reimbursement to facility.
  • Facility acknowledges that cost of benefits and services provided is less than the maximum benefit

Confinements abroad shall also be covered provided that a certification from their Ministry of Health (or its equivalent) confirming that case is due to A (H1N1) is submitted.

Availment of the package shall be charged against the 45-days annual limit and is covered by the rule on single period of confinement (only one Influenza A (H1N1) Package shall be paid within 90 days).

*Covered by regular hospitalization benefit
**Covered by SARS package
***Covered by Avian Flu package

Special benefit packages: