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February 20, 2025 | 6:02pm
MANILA, Philippines — Filipinos seeking outpatient emergency care can now receive reimbursements from the Philippine Health Insurance Corp. (PhilHealth), but only if the treatment is provided at state-accredited hospitals.
According to a PhilHealth advisory, the facility-based emergency (FBE) benefit has been available since February 14 for outpatient emergency cases. This applies to services rendered in the emergency departments of accredited hospitals and their extensions.
The facility-based emergency benefit covers services such as imaging, laboratory tests, routine blood work and therapeutics, according to the state insurer.
The benefit package, outlined in PhilHealth Circular 2024-0033, sets reimbursement limits for outpatient emergency services not covered under existing case rates or benefit packages.
It includes costs for medical services, essential medicines, and supplies needed to manage urgent or emergent conditions, including diagnostic and laboratory procedures.
To qualify, patients must not require hospital admission or must be discharged within 24 hours of entering the emergency department.
Aside from hospital services, the package covers prehospital emergency benefits, including patient transportation for those experiencing symptoms. This extends to land ambulance services.
How will reimbursements work?
PhilHealth will use a blended payment mechanism, combining:
- Fixed fee schedules - standardized rates for diagnostics, medications, equipment, supplies and other services.
- Case-based payments - reimbursements based on the overall treatment a patient receives, rather than itemized services.
Rates and fees are prospectively set, meaning they are determined before treatment, but retrospectively paid, meaning hospitals are reimbursed after services are delivered.
Similar to PhilHealth’s case rate system, healthcare providers must submit claims for review before reimbursements are processed.
Accreditation. The Department of Health said on Thursday, February 20, that accredited hospitals do not need separate accreditation for facility-based emergency services, as it is already covered under their existing accreditation.
“However, those with extension facilities must submit to their respective PhilHealth Regional Offices a certification stating the name of [the] affiliated extension facility and its complete address,” it added.
What services are covered?
A total of 342 outpatient emergency services, medicines and supplies are covered under a fixed fee schedule.
For diagnostic services, PhilHealth will reimburse P1,326 per use for arterial blood gas tests and P423 for electrocardiograms. The use of an emergency bed is set at P650 per instance.
Consultations are also covered, with emergent consultations reimbursed at P707 per use and urgent consultations at P260.
Medical equipment such as defibrillators, Doppler monitors, infusion pumps, intubation kits, intravenous cannulation or insertion, mechanical ventilators, nebulizers and oxygen are included in the package.
Imaging services covered range from CT scans, which cost between P3,211 and P18,554 per use depending on the area examined, to MRI, ultrasound and X-ray procedures.
The coverage for ambulance services under the prehospital emergency benefit is still undergoing a cost study and will be announced at a later date.
The circular mandates PhilHealth to review the existing list of services and commodities covered under the outpatient emergency care benefit package for potential expansion and adjustments.
PhilHealth already covers other non-emergency outpatient benefits, including day surgeries that do not require hospital admission, radiotherapy, hemodialysis and blood transfusion.
