PhilHealth lifts 45-day limit on hospitalization
UPDATED POLICY: Effective April 4, 2025, the Philippine Health Insurance Corp. will shoulder the confinement costs beyond 45 days for members and their dependents, subject to a review or audit. —File photo from Philippine Daily Inquirer
MANILA, Philippines — The Philippine Health Insurance Corp. (PhilHealth) has abolished the “45-day benefit limit” on hospital confinement of its members and their dependents, calling it an obsolete policy that denied some patients access to “critical services.”
“The 45-day benefit limit is an outdated cost-containment strategy. We understand why it was put in place before, but with the changes in our payment mechanism, it is just timely that we reform this policy,” PhilHealth president and CEO Dr. Edwin Mercado said in a statement on Thursday.
“We cannot always predict or schedule our medical needs. Many services need more than 45 days of coverage. So we are thankful to the PhilHealth board for approving this policy update,” he added. The PhilHealth board is chaired by Health Secretary Teodoro Herbosa.
Mercado earlier signed PhilHealth Circular No. 2025-007, which lifts the 45-day benefit limit rule in claims payment. Set to take effect on April 4, it will apply to all medical conditions and surgical procedures under the current All Case Rates payment mechanism of PhilHealth for patients admitted to accredited health facilities and other special packages that are subject to the rule.
Under the 45-day benefit limit rule, a PhilHealth member is entitled to a maximum of 45 calendar days of confinement per year. All the member’s dependents, on the other hand, share among themselves another 45 calendar days every year.
It also stipulated that beyond the 45-day confinement, PhilHealth will not reimburse any benefit claims and these will have to be shouldered by the members themselves or their dependents.
According to the state health insurer, the rule was originally designed to prevent the overutilization of health services. “But with the expanded mandates of PhilHealth under Republic Act Nos. 9241, 10606, and 11223, cost-containment strategies must not hamper access to critical services,” it said.
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Audit or review
Under the new PhilHealth circular, hospitals with admitted patients whose confinements exceed 45 days “are enjoined to conduct a review or audit of the patient case for quality assurance purposes.”
“We want to ensure that Filipinos with severe illnesses and chronic conditions or those who require long periods of hospitalization shall continue to receive health-care services without worrying if they will be falling into debt,” Mercado said.
To ensure the policy’s responsible and effective implementation, PhilHealth said it would closely monitor patient admissions, readmissions, and benefit utilization exceeding 45 days.
The compliance of health facilities with clinical standards and reimbursement rules will be rigorously assessed through the Health Care Providers Performance Assessment System.
Peace of mind
“Our goal is for every service supported by PhilHealth to truly bring peace of mind to its members. Our hospitals are already doing this—in fact, when I was a hospital administrator, we also focused on monitoring outcomes. However, what we want now is for PhilHealth to gradually transition to value-based financing,” said Mercado.
In October last year, PhilHealth also ended another obsolete policy—the controversial “single period of confinement” rule, which states that admissions and readmissions due to the same illness or procedure within 90 calendar days will be compensated only once. Only nine procedures and conditions were exempted from the rule, including blood transfusion, chemotherapy, dialysis, and asthma.
