Recto: PhilHealth benefits must be commensurate with premiums

Paying members of the Philippine Health Insurance Corp. (PhilHealth) should receive benefits commensurate with their monthly contributions, according to Executive Secretary Ralph Recto.

He raised the proposal following the death of a 47-year-old father from Manila, who had been diligently paying his monthly premiums for more than two decades, but was denied of availing any PhilHealth benefit package.

READ: Recto pushes for more PhilHealth benefits for paying members

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Recto said he would meet with PhilHealth officials this week to discuss the expansion of benefits for the more than 33 million paying members of the state-run health insurance provider.

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“Under the law, they have a different benefit package. Let’s increase it,” he said in an interview on dzRH over the weekend.

Recto said he understands the frustrations of those who regularly pay their PhilHealth premiums but feel that the benefits they receive do not match their contributions.

According to Recto, indigents pay nothing to avail of services of PhilHealth, as their contributions are subsidized by the government.

Meanwhile, direct members regularly pay their PhilHealth premiums amounting from P6,000 to P60,000 annually, yet they do not receive proportionate benefits.

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“If you’re indigent, you paid zero to avail of PhilHealth benefit packages, so you’re already ahead. That’s why I believe those who are paying should receive higher PhilHealth benefits,” he said.

Direct, indirect contributions

Under Republic Act No. 11223, or the Universal Health Care (UHC) Act enacted in 2019, there are two types of PhilHealth members: direct and indirect contributors.

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Direct contributors are those who have the capacity to pay their premiums, including those who are employed and self-earning, including their qualified dependents, as well as lifetime members, who have paid 120 months of their PhilHealth premiums.

Under the current 5 percent premium rate of PhilHealth, direct contributors need to pay a monthly contribution ranging from P500 to P5,000, depending on their basic salary.

Meanwhile, indirect contributors and their dependents, are those whose premiums are subsidized by the national government, including senior citizens, persons with disability, indigents, 4Ps beneficiaries, and those without the capacity to pay.

The government allocated P53 billion for the implementation of the National Health Insurance Program to subsidize the premiums of indirect contributors under PhilHealth’s budget for this year.

Under Section 9 of the UHC law, PhilHealth shall provide additional program benefits for direct contributors.

Based on PhilHealth’s data as of end of 2025, of the 108.1 million registered members of PhilHealth, 48 percent are direct contributors at 33.3 million (with 18.7 million dependents), while the remaining 36.6 million at 52 percent are indirect members (with 19.6 million dependents).

Direct contributors paid P209 billion in premiums last year, but were only able to avail P121 billion in claims—equivalent to 42 percent of the P289.2 billion claims that PhilHealth processed last year.Majority of the claims (58 percent) were reimbursements for indirect members at P167.9 billion.

Sulit’s case

Recto’s call follows the death of Marvin Sulit from brain hematoma on June 4 without being able to avail of any PhilHealth benefits despite being a paying member for more than 25 years.

His wife Maria Lourdes said Sulit was rushed to a private hospital in Manila which informed them that a lifesaving surgery would cost about P4 million. Because of the exorbitant amount, they transferred to another hospital, also in Manila, where the operation cost would be reduced to P2 million, but they would need to pay a P1 million deposit upfront for the surgery to proceed.

“With time running out and no way to raise that amount immediately, we had no choice but to wait for Marvin to die. It was heartbreaking and devastating,” Sulit’s wife recounted in a viral Facebook post.

When they were settling the hospital charges, Sulit’s family learned that the bill had reached P200,000 in seven hours since being admitted until his death.

Worse, the hospital informed them that Sulit was not eligible for any PhilHealth benefits because he had been hospitalized for less than 24 hours.

Under PhilHealth’s current 24-hour confinement rule, a patient needs to be confined in an accredited healthcare facility for at least 24 hours to be able to avail of inpatient benefit packages.

Their claim of the P7,800 resuscitation package was also denied since they did not authorize for Sulit to be revived.

“What is the purpose of PhilHealth if the people who have contributed for decades cannot access the benefits when they need them most?” she lamented.

Expanded benefits

Recto has been recommending expanded benefit packages for contributing PhilHealth members belonging to the middle class.

In January, he met with Department of Health (DOH) and PhilHealth officials to ensure that middle-income Filipinos would equally benefit from the Marcos administration’s zero balance billing (ZBB) program in selected government hospitals, which were provided mostly to indigent patients.

Under the ZBB program, all patients, regardless of their economic status, will no longer have to pay out of pocket when they are admitted at the basic ward of any of the 87 DOH-operated hospitals.

This year, the ZBB was expanded to selected local government-run hospitals and the University of the Philippines-Philippine General Hospital in Manila.

The ZBB, however, only applies to basic or ward accommodation. A patient who opts to be transferred to a private room shall not be entitled to the program.

Hospital and professional fees incurred by a patient under the ZBB are shouldered by the applicable PhilHealth benefit package, while the remaining are charged to the DOH hospital’s budget for maintenance and other operating expenses.

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The DOH’s ZBB is different from the “no balance billing” (NBB) of PhilHealth, which has been implemented since 2011. PhilHealth’s NBB, however, only covers members and dependents who are considered indigent, sponsored, domestic workers, senior citizens and lifetime PhilHealth members. INQ