A Complete Guide To Health Insurance In The Philippines

Written by Marc Adrian

Health insurance is a form of financial service that provides financial security in the midst of an illness or when health calls for it. It is a form of insurance that covers medical and surgical costs, either by preventive or corrective means. In most cases, individuals who have health insurance literally pay nothing after a procedure is done. In order to enjoy such benefits, the insured pays a premium.  While health insurance is mandatory in the country through Philhealth, its coverage leaves a lot to be desired.

Illnesses especially debilitating ones can come with a hefty price – literally. If you want to spare your wallet when you’re having a rough health condition, it’s the first thing that you should consider. If you’re informed enough to get the right healthcare at the right time, you can even score more funds for your health than you need.

Before you go ahead and spend money on consulting an insurance expert’s help, here are the essentials that will give you a headstart on this subject.

What’s the difference between Philihealth, HMO, and Health Insurance?

Philhealth aside which we all know is state-provided health insurance, there are two types of private health insurance in the Philippines: Health Maintenance Organizations (HMO) and health insurance policies.  While they both have the same end goal, they deliver their services contrastingly. Each has its own share of benefits, but they work differently depending on your situation.

Here three types of medical insurance you can get in the Philippines:

1. Philhealth

PhilHealth is the health insurance provider run by the government. It is an affordable and progressive insurance program that extends financial assistance to all citizens seeking medical help, whether employed or unemployed. Membership is compulsory for all employees and half of the monthly contribution is covered by the employer while the other half is deducted from the employees’ salary. The amount of financial assistance it extends to its members will vary according to the disease.

If you want to learn more, check out our extensive coverage about PhilHealth and find out its benefits and advantages for members.

2. HMO

Health Maintenance Organizations (HMO) are private providers of healthcare insurance, except they give you access to doctors within their network. Plans are usually comprehensive and customizable but are only limited to a certain amount annually. The bigger the premium the employer or individual is paying, the higher the annual allowance.

HMOs administer programs such as:

• inpatient/outpatient services
• surgeries
• other ancillary services such as laboratory tests and medication

Some of the well-known HMO providers in the Philippines are Medicard, Maxicare, Intellicare, and Fortune Care. This is commonly provided to employees in private companies, on top of their PhilHealth membership contribution.

3, Health insurance

Private health insurance gives access to more comprehensive private healthcare networks, offering a lot more than HMOs do. In the Philippines, a private health insurance is usually bought by the individual voluntarily. There are some companies that provide this type of insurance to their employees.

Premiums can be steep and are fully paid by the insured. Immediate family members can be also insured on the policy at an additional cost. Private insurers offer many benefits and features. Their facilities are usually at par with international standards and some even extend their policy outside the country.

The benefit of this insurance can include the following:

• inpatient/outpatient services
• hospitalization and surgical assistance
• cash assistance for loss of income due to accident/illness
• other ancillary services such as laboratory tests and medication
• Bigger cash compensation depending on the illness

Some of the well-known companies in the Philippines are Sun Life, AXA, Prudential Life, and Manulife. You can also compare health insurance providers on our site for a quick reference.

In-depth breakdown and comparison

While the goal of all these health insurance providers in the Philippines is to cover their policyholders’ or members’ medical expenses, the method or medium they use to transmit their services are different.

	Health insurance	HMO	PhilHealth
Provider	Insurance companies	HMO companies	Government
Governing agency	Insurance Commission	Insurance Commission	Government/ DOH
Coverage age	16-75	Up to 65 only	No age limit. Senior citizens are automatically covered for free.
Policy term	Fixed term	Yearly renewal and subject to health status assessment.	Senior citizens - indefinite Non-senior members - for as long as they're actively paying.
Premium	Premium increases according to age.	Premium increases according to age.	Constant, unless government impose changes.
Benefits	1. Some providers include Life insurance saving (dividends/fund values) 2. Hospitalization 3.Critical illness benefit 4. Some outpatient benefits	1. Hospitalization 2. Emergency hospitalization 3. Outpatient consultation 4. Dental services (depending on the plan)	Cash assistance (fixed amount) depending on the illness.
Critical illness benefits	Lump sum cash if policyholder is diagnosed with a critical or terminal disease.	Covered by the policy but is limited to the consumable amount set by the HMO.	Z benefits package - subsidize specific amount for treatment and hospitalization depending on the illness.
Daily hospitalization	Daily hospital income benefit is provided. The amount varies according to the plan chosen by the policyholder.	Divided into 3 categories: 1. Ward type 2. Semi private 3. Private The type of room provided will depend on the coverage or the HMO plan.	Case dependent. Will vary depending on the availability of rooms and case of patient.
Transmittal of financial subsidy or assistance	Reimbursement	The accredited hospital or clinic will charge your bill against the consumable limit or amount provided by the HMO. Just provide HMO card.	Automatically deducted from the hospital bill.
When policy is not used after a year or in the contract period	Earn dividends which can be withdrawn.	Policy defaults back after 1 calendar year and your contribution whether or not you’ve consumed your annual limit.	Contribution will be added to PhilHealth’s fund to extend financial assistance to their members who are in need.

Benefits of health insurance

One main reason to get insurance is to avoid going broke while taking care of your health. Whether we like it or not our health deteriorates the older we get, and even if you’re affluent enough to amass wealth that can afford you a hospital stay for a year, that still isn’t a sound financial and retirement plan.

Getting health insurance may not grant you a lump sum of money to spend for your health all the time, but it will at least pay for all the medical and services that you will be required when the needs call for it such as the following:

1. Inpatient Care

As the prefix “in” implies, inpatient care means taking care of a patient that needs inside the hospital. There is a need for immediate care, specialized procedures, and facilities that the patient or family cannot perform outside of the hospital. A patient is only considered an inpatient once he is admitted in the hospital or if it is written on the admission book of the hospital. Normally the benefits that encompass inpatient benefits are the following.

1. Hospitalization
2. Mental Health
3. Rehabilitation
4. Ambulance
5. Medicine
6. Laboratory tests
7. Pediatrics

2. Outpatient Care

Outpatient differs by inpatient care by this difference alone, a patient goes to the hospital and seeks medical attention, but the patient is not admitted inside the hospital since the condition can be treated at his own home or doctor’s clinic. Most of the time, the attending physician gives or prescribes medication for the patient to prevent the condition from happening again. Outpatient care includes the following benefits.

1. Wellness
2. Preventive Care
3. Laboratory tests
4. Annual Physical Examinations (APE)

3. Emergency Care

Not to be mistaken as urgent care, this benefit is more focused in giving immediate care for the insured; this is the type of benefit wherein a patient walks in through delivery of an ambulance or going through the emergency room to seek immediate healing of whatever he is suffering from. These are the more serious conditions that the insured faces, these instances are acquired from accidents and similar cases of which they need to be medically attended immediately. Emergency care commonly covers the following benefits:

1. Critical Care
2. Travel Coverage

4. Optional Benefits

These are benefits that are not usually embedded with the health insurance packages. For you to avail of some of these benefits, you have to pay an additional premium. Optional benefits usually are the more popularly sought benefits but are separate from healing from a critical illness. From a business perspective, it is impractical for providers to include these unless more people seek them. An example of this scenario is maternity benefits, where a provider would need to recruit more than 25 females in the group to get it.

Here are the optional benefits you can find in health insurance.

1. Dental
2. Optical
3. Maternity

Health insurance from one provider to the other varies greatly, some may not even include outpatient care but if health insurance has all the benefits listed above with the right price that fits your budget, then good for you!

While health insurance doesn’t come cheap, its benefits can literally prevent you from spending a fortune when your health needs to recuperate. Health insurance companies have a network of affiliated hospitals, doctors, and specialists who serve your medical needs without you having to shell out money. The whole idea is basically paying for the monthly premium so you won’t have to cover the entire cost of hospitalization, consultations, or tests, and etc., all at once.

Ideally, the question isn’t whether you should get health insurance, but rather, which one and how many should you get?  In the Philippines, health insurance can be broken down into three categories: Private health insurance, Philhealth, and HMO.

Cost of health insurance in the Philippines

We would be lying if we tell you that health insurance is cheap. While it does cost some amount of money especially if you get a policy at a later age, it isn’t exactly expensive either – after all, many insurance policies nowadays can let you customize your plan to adjust your premium. With that being said, the cost of a health insurance actually varies, for the case of Philhealth it’s depending on your salary, for the private ones age will be a significant factor.

The estimates below are derived from the range provided by Philhealth and the average cost quoted from all the biggest insurance providers in the Philippines. 

Name / Type	Cost per year
PhilHealth	₱1,400 to ₱6,600 (depending on your salary range)
HMO	₱10,000 to ₱60,000 (depending on the coverage)
Health insurance	₱40,000 (the lowest available plan) and up.

Health insurance providers in the Philippines

There’s a wide range of insurance providers in the country which provide coverage for different kinds of needs and budget. Here we list down the most popular and common providers in the market today.

PhilHealth

If you’ve been formally employed in the Philippines, chances are, you’re already covered by this since all employers in the country are obliged to pay for their employees’ Philhealth premiums. You can read our PhilHealth Guide For a more in-depth discussion on PhilHealth.

How to choose the health insurance for you?

When choosing a health insurance provider, most of us would probably look for providers that offer the cheapest premiums.  However, like any other package, cheaper premiums could mean limited services or limited accredited physicians or hospitals.  But a health insurance policy is an important investment and worth scrutinizing. The things you should consider when choosing a good health insurance provider are:

1. Policy Updates

A timely critique of health insurance policies.  This is probably the most important key indicator since it details the coverage a person can avail.  This also dictates the amount of premium that you are asked to pay. For less expensive policies, it might only cover certain cases or hospitalization.  More expensive ones can include annual and comprehensive check-up and dental care. It may also include consultation that can be availed of by your dependent.  An oft-reviewed policy keeps up with the possible needs of consumers.

Some insurance companies may also stipulate in their contract or policy that even if your premium remains fixed, the coverage may increase. This is advantageous, especially because health services have a tendency to increase charges within a couple of years.  Another advantage of a health insurance policy that is regularly reviewed is that coverage of services may be expanded. It may already include particular medical procedures like dialysis if it wasn’t included before. The insurer might also add other diagnostic procedures or services, like physical therapy.

2. List of affiliates and accreditation

The insurer often has a panel of accredited physicians, hospitals or clinics.  Having more accredited physicians and clinics simply means that you have more choices.  And even if you contract a disease or condition — like diarrhea or food poisoning — while you’re on vacation, you can still avail of services that will be paid for by the insurer.

In addition, more accredited physicians can provide more doctors you can consult with even for rare or uncommon diseases.  Take for example, a brain tumor. Not many insurance companies have an accredited neurologist or neurosurgeon. But if they have an accredited neurologist, then you don’t have to pay for consultations or follow-ups.

3. Inclusions

These are insurance companies that offer inpatient as well as outpatient care to members.  Some insurance companies only offer inpatient services which means that if you have a respiratory problem that does not need hospitalization, the costs you incur from recovering from your condition is not covered.  This may include medicines or medical supplies. So you’ll have to opt for hospitalization for your expenses to be paid for by the insurance company. It is even possible nowadays to have a minor operation, such as removing a cyst or even a cataract operation, without being admitted to a hospital.

Health insurance providers that cover outpatient services also mean that the company covers more services, like diagnosis.  Diagnosis can take the form of an MRI, CT scan or some other expensive procedure. It may also mean that rehabilitation or physical therapy is covered.  Likewise, it’s advantageous to the insurer because it costs less than hospitalization.

Health insurance vs HMO

While we don’t really suggest that these two insurance actually works against each other, in fact, having both will provide better coverage for the policyholder because if anything, health insurance, and HMO works hand-in-hand. HMO can cover you on the spot medical expenses such as clinic visits or checkups and even hospital admission. Meanwhile, the reimbursement scheme of health insurance can cover your long term medical expenses like your medicine, more expensive diagnostic tests, and your overall hospital bills.

However, if you’re just starting out or simply in a budget, which among the two should be your top priority? 

Should you get an HMO?

There are various considerations that can come into play if you’re deciding whether to get an HMO or not. Here’s a quick breakdown for you. 

Does your current job provide HMO?

If you’re employed and your company provides HMO, the short answer is “don’t get one anymore,”…. At least not yet!  Are you planning to stay for a long time with your current employer who provides this benefit? If yes, that span of time might be the perfect period for you to pay for a health insurance premium instead of your own HMO. 

Of course, since the HMO is tied to your company, leaving your job means you won’t have access to it anymore, it’s also wise to get your own personal HMO down the line after you’ve completed the premium for your health insurance (or even if you haven’t yet but your budget can allow you to already). 

No insurance coverage at all

However, if your job doesn’t provide this type of insurance coverage you’ll be in a position to choose between short-term and long-term coverage. 

HMO is a short-term coverage, but it’s a practical choice for people who just want health insurance on the go. Do you just want fuss-free health insurance that gives you access to healthcare facilities whenever you need it without having to shell out even a little cash? Then go for an HMO.

You have a health insurance policy already

If you currently have existing health insurance, it’s a no brainer to get an HMO to boost your coverage and cash benefits when you need it. 

Should you get a health insurance policy now?

While it’s imperative that we all get one, the route to take in arriving at such a decision can vary our existing circumstances.  Truth be told, health insurance is an investment that could easily eat up a huge portion of an average Filipino’s monthly income. Depending on the age when you signed up for a health insurance policy, the premium can be quite steep the older you become. However, you don’t have to be affluent to have one.

If you’re still young, chances are you can get one for at least PHP3,000 or less. If you’re older though, it might not be as cheap. And, if you’ve reached past the age of retirement, you may have a slim chance of getting approved for one. Also, health insurance coverage for people within the age of retirement can be expensive.

Despite all that, you could never go wrong with health insurance. Just keep in mind to get a policy that you actually need, not what’s affordable. If you want to make the most out of your policy, make sure that at least it fits with your healthcare needs and can cover your possible illnesses (based on your family history).

 

 

This article was originally published on May 16 2019 and is updated to keep information relevant and up to date.