PhilHealth, HMOs, insurers agree to coordinate benefits under Yakap

MANILA, Philippines — The Philippine Health Insurance Corp. (PhilHealth) has partnered with private health insurers (PHIs) and health maintenance organizations (HMOs) to coordinate their benefits under the Yaman ng Kalusugan Program (Yakap) HMO/PHI Benefit Complementation.

The partnership aims to align coverage between PhilHealth and private health plans, with the state insurer serving as the primary provider while HMOs and PHIs provide secondary coverage.

PhilHealth was joined by 13 existing private health plans in signing a memorandum of understanding (MOU), marking the start of the partnership for the initiative.

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PhilHealth acting president and CEO Dr. Beverly Lorraine Ho said the agreement seeks to ensure that members get the full value of the premiums they pay to both PhilHealth and private health plans.

Under the arrangement, PhilHealth and private health plans would work together instead of providing overlapping coverage, she said.

“A growing number of Filipinos, especially in the employed sector, are covered twice,” Ho said. “They pay for PhilHealth and private health insurance plans and members pay for both, but they still don’t get probably twice the value.”

The agreement also seeks to simplify the process for members by allowing them to access PhilHealth and HMO benefits through the same health care provider, with the two payers coordinating the charges.

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One of the long-term goals of the partnership is to reduce duplication in health care coverage by identifying which services will be covered by PhilHealth and which will be shouldered by private health plans.

“Because if we complement, then we pay for certain set of things and our private insurers or HMOs pay for another set of things. And in the end, the patient or members wins,” Ho said.

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Ho added that complaints from employees prompted the initiative, noting that many workers contribute to PhilHealth while also receiving HMO coverage from their employers.

“They contribute to PhilHealth every month and they have an HMO card from their employer. But when they get sick, they only use their HMO or health insurance for most of their healthcare needs,” she said.

Through YAKAP, PhilHealth will cover consultations, 13 laboratory tests, selected outpatient medicines under the GAMOT package, and outpatient services for six cancer screening tests.

The primary care program will also cover specialized outpatient benefits, including animal bite treatment, maternal care, tuberculosis directly observed treatment, Tuberculosis DOTS, HIV/AIDS management, and mental health services.

HMOs and PHIs, meanwhile, will cover costs that exceed PhilHealth’s benefits or fall outside its primary care coverage. These include specialized procedures, branded medications and hospital room upgrades.

PhilHealth said it plans to map and align its systems and processes with participating HMOs and PHIs over the next three months before conducting a pilot program and eventually scaling it up.

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The state insurer said the pilot program will be implemented by 2027 as part of efforts to coordinate public and private health coverage under the Universal Health Care Act. /mr