PhilHealth benefits now cover outpatient emergency services
The Philippine Health Insurance Corp. (PhilHealth) will now pay for emergency procedures and other services for patients who do not need to be confined in hospitals.
Under its “Outpatient Emergency Care Benefit (OECB)” package, which took effect on Jan. 1 through PhilHealth Circular No. 2024-0033, all outpatient services and commodities given at the emergency department (ED) and accredited health care facilities will be covered, including services provided before a patient’s arrival such as transport to the ED.
The package also applies to patients who do not require hospital admission and are discharged within 24 hours after arriving at the ED, or die while seeking emergency treatment.
Among the cases covered under the OECB package are dizziness, diarrhea, persistent vomiting, elevated blood pressure, nontraumatic bleeding, seizures, severe headache and sexual assault. Also included are essential emergency care services such as diagnostic (electrocardiogram), ED services (nebulization, intubation), imaging (X-ray, CT scan), laboratory (blood tests) and medicines.
The package is likewise available to Filipinos abroad and foreign nationals requiring outpatient emergency services provided they are registered with PhilHealth and have been remitting monthly contributions.
Transport covered
The OECB package shall cover land ambulance services as prehospital transport. Sea and air ambulances “can be included for coverage, following the establishment of relevant policies and regulations.”
“The current All Case Rates (ACR) of PhilHealth reimburses procedures done at the ED as part of the service coverage for the hospital course of an admitted patient. Although ACR covers some conditions that require management at ED but do not warrant confinement, this coverage is primarily for surgical procedures,” the PhilHealth circular stated.
“There is a substantial need to support the delivery of acute care for cases not requiring admission or outpatient services provided in emergency settings,” it added.
PhilHealth said that patients availing of the new benefit package should seek services in OECB-accredited health facilities although it has yet to provide a list of these facilities.
Followup care
“Beneficiaries who accessed outpatient emergency care in nonaccredited facilities have to pay for these services out-of-pocket or through other health financing mechanisms (such as insurance provided by health maintenance organizations or HMOs),” it said.
Upon their discharge from the ED, patients shall be referred by their doctors to a Konsulta primary care provider for followup checkups.
Konsulta is the comprehensive outpatient primary care benefit package that includes free consultation, targeted health risk screening and assessment, selected laboratory and diagnostic tests, drugs and medicines as recommended by the health-care provider.
But to be able to avail of Konsulta packages, patients need to register with an accredited PhilHealth Konsulta provider of their choice. Based on PhilHealth’s list as of December, there were 3,117 accredited Konsulta providers nationwide.
