PhilHealth-accredited hospitals apply a predetermined fixed rate or case rate on each treated case or disease, and then deduct the said rate from the total actual charges.

Therefore, the percentage of hospital expenses that PhilHealth will cover depends on your case/disease. PhilHealth has a search portal that the public can use to determine the case rate for every condition/procedure. This can help you make an accurate estimate as to how much you will be paying the hospital.

Case rates are classified as either first case rate or second case rate¹.

If an individual is to claim a medical/procedure case as a 1st case rate (e.g., Tuberculosis), 100% of the case rate is to be deducted from the total charges. Whereas, if the condition is considered as a 2nd case rate (e.g., Hemodialysis), only 50% of the case rate is to be deducted.

For a claim with a combination of case rates, 100% amount for the first case rate plus 50% of the second case rate will be deducted from the total bill.

The following procedures are exempted from the 50% Rule on the second case rate:

To have a better grasp on the case rates, refer to the figure below:

The computed total benefit (sum of the first case rate and the second case rate) shall be deducted from the total actual charges (HCI fee + PF).

The remaining amount after the deduction shall be shouldered by the beneficiary. However, this does not apply to members under the No Balance Billing policy (NBB)².

Related: How to Register in PhilHealth Online

References

1. PhilHealth Circular No. 0035, s. 2013 (ACR Policy No. 2 — Implementing Guidelines on Medical and Procedure Case Rates). (2013). [PDF]. Retrieved from https://www.philhealth.gov.ph/circulars/2013/circ35_2013.pdf
2. Indigent Members. Retrieved 27 January 2021, from https://www.philhealth.gov.ph/members/indigent/#gsc.tab=0