Philhealth Benefits — Case Rates Payments for Certain Medical and Surgical Cases

Updated June 2, 2014:

Since January 2014, all hospitalizations and outpatient treatments eligible for Philhealth coverage are already being covered under the Philhealth Case Rate system.  Each medical or surgical case is covered by a fixed amount.

For medical cases, 30% of the fixed amount is for Doctors’ Professional Fees  (PF) and 70% is for hospital costs.

For surgical cases, it’s 40% for PF and 60% for hospital costs.

You can no longer file your Philhealth claims directly with Philhealth.

Submit your Philhealth documents to the hospital BEFORE DISCHARGE, so the hospital will deduct the Philhealth coverage from your bill.  It will be to the hospital that Philhealth will send the check.

If the hospital asks you to sign a waiver, READ the waiver.

You can see the coverage amounts here: Procedure Case Rates and Medical Case Rates.

The coverage amounts listed in the charts below, posted in August 2011, are still correct, but the list below includes only the first procedures and conditions covered under the Case Rate program.

 

Article below was posted on August 2011:

Last September 1, 2011, Philhealth started implementing its policy of paying fixed rates or fixed amounts to accredited hospitals and clinics for 11 medical cases and 11 surgical cases under its reimbursement scheme called Case Rates Payment.

If we count 9 case rates payment packages implemented since 2003, there are now 31 medical and surgical cases paid by Philhealth under its Case Rates Payment scheme. Other cases are paid under the regular Fee-for-Service scheme.

The fixed Philhealth payments are made directly to the hospitals or clinics. The fixed Philhealth payment is deducted from the total hospital bill and the balance will be paid by the patient.

Philhealth said that the Case Rates basis of payments for SURGICAL CASES  is applied to cases managed at Levels 2 to 4 hospitals (bigger hospitals), with certain exceptions.

For sponsored members and their dependents, the No Balance Billing Policy will apply when they are confined in government hospitals or clinics. It means the Philhealth payments will be adequate to cover their expenses for these 22 medical and surgical cases and they don’t need to pay anything. In cases where patients are asked to buy certain drugs or supplies, they will be reimbursed.

These are the selected medical and surgical cases and the fixed amounts that Philhealth is going to pay to hospitals or clinics, implemented for patients admitted starting September 1, 2011:

MEDICAL CASES

Medical cases Case Rates in Pesos
1.  Dengue 1
Dengue Fever and DHF Grades 1 and 2 8,000
2.  Dengue 2
DHF Grades 3 and 4 16,000
3.  Pneumonia 1 – Moderate Risk 15,000
4.  Pneumonia 2 – High Risk 32,000
5.  Essential hypertension 9,000
6.  Cerebral infarction (CVA I) 28,000
7.  Cerebro-vascular accident
hemorrhage (CVA II) 38,000
8.  Acute gastroenteritis (AGE) 6,000
9.  Asthma 9,000
10.  Typhoid fever 14,000
11.  Newborn care package (NCP) 1,750
SURGICAL CASES

Surgical Cases Case Rates in Pesos
1.  Radiotherapy 3,000
2.  Hemodialysis 4,000
3.  Maternity care package (MCP) 8,000
Normal spontaneous delivery (NSD)
in Level 1 Hospitals 8,000
NSD in Levels 2 to 4 Hospitals 6,500
4.  Delivery by caesarian section (CS) 19,000
5.  Appendectomy 24,000
6.  Cholecystectomy 31,000
7.  Dilatation and curettage 11,000
8.  Thyroidectomy 31,000
9.  Herniorrhapy 21,000
10.  Mastectomy 22,000
11.  Hysterectomy 30,000
PHILHEALTH PACKAGES launched from 1993 to 2010

Medical or Surgical Case Fixed Payments Year Implemented
TB-DOTS 6,500 2003
SARS 50 to 100k 2003
Avian Influenza 50 to 100k 2006
Bilateral Tubal Ligation (BTL) 4,000 2008
Vasectomy 4,000 2008
Cataract 16,000 2008
Malaria 600 2008
Normal Spontaneous Delivery
(NSD) with BTL 10,500 2009
Outpatient HIV/AIDS Treatment 30,000 per year 2010
Note:
Treatment for influenza A (H1N1) is now paid as Case Type A under the Fee-for-Service scheme. It was previously paid at a package rate of from 75k to 100k since 2009.

750 Comments

Add a Comment
  1. Hi danzen, pay Philhealth for Jan to March (600 pesos) at Philhealth, so you can use it for surgery in March. Bring your ID, fill up registration form, check For Updating, then receive your MDR.
    About SSS, you can file for sickness benefit if you paid at least 3 contributions within Oct 2014 to Sep 2015

  2. Hi danzen, it’s the doctor who can say if you should have D and C. Yes, Philhealth’s coverage is only 11k. Ask your doctor how much you will pay if you use your Philhealth. If you haven’t paid Philhealth for 3 monthly premiums within Sep to Feb, you cannot use Philhealth this February. If you pay Jan to March now, you can use it in March, but it might not be safe to postpone your D and C. Ask your doctor. Ask others too.

  3. Hi Nora, my mother is currently confined at PGH due to Pneumonia, Kidney complications and GI bleeding. She is currently has tube ventilator and had dialysis 2 times now. PGH billing department says bill is more than 150K now and that we need to make some payment. She is a senior citizen philhealth member. Does philhealth cover her hospitalization and is PGH allowed to balance bill? Thank you very much for your helpful blog.

  4. Hi Robin, each illness has a fixed coverage amount, but only one illness will be covered (the one with the biggest cost; but you still pay the balance if the coverage is not enough. Coverage for high-risk pneumonia is 32,000). Dialysis is one of the few procedures that can be covered too as an additional coverage (2,600 per dialysis). Balanced bill is usually done for a patient with only one illness, which means the coverage for that one illness is enough to cover all the costs. Ask the billing department about Philhealth. Ask for discounts at the social services dept. If you have a relative who can go to offices at the Senate or House, or Vice-Pres and ask for help (bring PGH documents, ORs and IDs), it will help.

  5. after my grandfather stroke, he cannot eat. Doctors recommended PEG insertion which will cost us the endoscopy procedure. he will need to stay in teh hospital for 2 days. what will the philhealth covers

  6. Hi cherry, I can’t find percutaneous endoscopic gastrostomy (PEG) in the list. There’s this procedure: Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube. Coverage is 18,000 (8,400 for PF and 9,600 for hospital cost). There’s also percutaneous placement of gastrostomy tube. Coverage is 8,020 (2,520 PF; 5,500 hospital cost)

  7. Hi po, my child was twice operated on at pgh. The doctor is at fmab, so it’s private but we are 4ps member. Is that really how small the discount is? And doctors fee is cash? My child has brain tumor; we lined up at charity, it’s been 1 month and wasn’t yet operated on and their prognosis was 2mos so we were forced to turn to a private doctor. Where can we go for financial help so we can reduce our debt, thanks po

  8. Hi Joy, sorry about what you went through, but I hope your child is on fast recovery now. Are your bills already fully paid? Approach the PCSO desk of PGH and ask if they can help you with the documents needed to get assistance from PCSO. You can also go to the offices of VP Binay (Coconut Palace, CCP Pasay) and the offices of Senators (GSIS Bldg, Financial Center, Roxas Blvd) and Congressmen (Batasan, QC). Bring xeroxes of your medical documents and hospital bills, your 4P IDs, barangay certificates. It’s really possible to ask and receive help from these offices, specially now that it’s campaign time.

  9. Hi mareneil, the coverage hepatic amoebiasis is 10, 000 (3,000 for PF and 7,000 for hospital cost); for nonhepatic amoebiasis, coverage is is 6,000 (1,800 for PF and 4,200 for hospital cost)

  10. Last March 2014 i stopped working as clinical instructor due to positional vertigo and hypertension. Since then i failed to pay my monthly Philhealth contribution. If iget hospitalized can i still avail of Philhealrh benefits?

  11. Hi Mary Ann, sorry no. Your 2014 payments are no longer usable. Pay asap for Jan 2016 to March 2016, so you can use it this March or April. Pay at Philhealth so you can get your MDR. Fill up registration form. Check FOR UPDATING. Bring your ID.

  12. Hi,are you from phic po?you seem to be knowledgeable of the svcs..nacurious lang po ako,please enlighten me.i just received my bpn,underwent heart surgery at pgh last year.im under social svcs kaya curious ako sa system kasi hindi po standard yung billing unlike private patients na indicated ung phic deduction..di ko alam na may share o malaki po pala share ng phic sa hospitalization ko,until today lang nung mareceive ko yung bpn.how do i check philhealth deductions sa hospitalization ko?or hindi talaga sya mgaappear if under charity?thanks

  13. Hi Nora, My daughter undergo operation due to raptured appendix. We are required to stay for 5 days for possibility of infection. May I ask if the surgical coverage is different from confinement plus the medicine required by the hospital for confinement period?

  14. Hi Cecil, usually Philhealth covers only one procedure or illness per confinement; usually the more expensive one. This means coverage will only be for the appendectomy which is 24,000 (9,600 for PF and 14,400 for hospital costs). Ask the billing department

  15. hello my daugther was diagnosed with sepsis neonatum due to her jaundice. How much po is the coverage? she’s my dependent po. thank u

  16. Hi lerica, the coverage for newborn sepsis is 11,700 (3,510 for PF and 8,190 for hospital costs)

  17. Hi jhenn, I’m sad that ct scan is not covered by Philhealth. But to be sure, ask the hospital.

  18. Hello my daughter will undergo for a lungs ooeration because of the water inside her lungs is hardened so it needs to be scraped off. how much will be the philhealth coverage? The doctor already told us to prepare 150thou before operation. We don’t have enough for down payment. please give feedbacks thank u

  19. Hi Richie, so sorry about your daughter’s condition. I’ve looked over the Philhealth case rate list, and I can’t determine the exact term for the lung surgery that she will undergo. I even researched the terms, but I can’t find a match in Philhealth’s list. There’s thoracotomy, with removal of intrapleural foreign body or fibrin deposit — coverage is 38,440 (19,740 for PF and 18,700 for hospital cost). I don’t know. Have you tried PGH? At many hospitals, you can also ask the hospital’s social services department to help you with documents to ask help from PCSO while the bill is not yet fully paid. You can also go to the offices of politicians and governments officials.

  20. Hi my father will undergo a stone removal from his bladder. How much will be the philhealth coverage. Thank you.

  21. Hi nora I have been checked by my doctor yesterday .I had a lump in my underarm but he said that this is not cancerous but we need to remove it.so I need to undergo to a minor operation.he asked me if I have philhealth.I have it but it’s not updated my last payment was the year 2011.if I am going to pay 2400 for payment for january to december 2016 can I use it this coming april? Thank u

  22. Hi Beth, you’re not allowed to make payments for past quarters and years. This April, pay Philhealth for Apr to June 2016, then you can use it June or July. Pay at Philhealth so you can update your records and get your new MDR. Bring your ID

  23. Hi Nora, my sister will be be having thyroidectomy next week. Her husband is a philhealth member for 5 years. We are confused on how philhealth works. how much philhealth can be deduct on her hospital bills? is it based on her husband contribution? thank you god bless

  24. Hi april, Philhealth’s coverage is fixed. For thyroidectomy, coverage is 31,000 (12,400 for PF; 18,600 for hospital cost). If with radical neck dissection, coverage is 46,500 (25,200 for PF; 21,300 for hospital cost)

  25. Hi! Just wanna ask if how much yun coverage rate for Macroadenoma operation ( pituitary gland front lobe area) thanks…

  26. Hi Nora,
    I wanted to ask how much coverage from Philhealth I could get for CS+Ligation or possible hysterectomy… We just got married last January29 & my husband already filed it at HR, unfortunately, Renewal of their HMO is every December so I didn’t make the cutoff, so we are solely depending on Philhealth for benefits since I am a housewife & my philh&SSS are not updated. My due should be May22 but it seems like it’s anytime soon… Thanks in advance for your reply

  27. Hi Eliza, Philhealth’s coverage for CS only is 19k (7,600 for PF and 11,400 for hospital cost). Coverage for hysterectomy after CS is 30k (12k for PF and 18k for hospital cost). Coverage for bilateral tubal ligation is 4k. Ask your OB if 4k can be added to the 19k CS coverage.

  28. Hi mymy, coverage for cholecystectomy (removal of gallbladder) is 31,000 (12,400 for pf and 18,600 for hospital cost)

  29. hi, nora how about this case ( Diffuse subarachnoid hemorrhage & ruptured atrial communicating aneurysm w/ hydrocephalus ), how much will be the coverage for this..

  30. Hi! How much is philhealths coverage for gastric bypass. I went to st lukes and inquired about it and the doctor told me that the procedure will cost 700k. I was just wondering how much is philhealths coverage for this procedure. Thanks.

  31. Hi Mabs, there are 4 types of gastric bypass listed, and Philhealth’s coverage ranges from 55,000 to 58,800 only. I emailed you the details. I think it’s also good to ask other hospitals.

  32. hello i have a bartholin cyst and im planning to have an operation how much it philhealth coverage thanks

  33. Mrs Nora if ever confinement is needed, how many months should at least paid to cover the confinement??

  34. Hi Sheila, at least 3 months within the past 5 months plus current month. For example, confinement is this April, the member should have paid at least 3 months within Nov 2015 to Apr 2016.

  35. Hello. Il be undergoing tonsillectomy by nextweek. How much po is philhealth’s coverage for tonsillectomy? It will be at davao adventist hospital. I worked last 2013 and after that I stopped paying philhealth. But started it again as individual payer for 2 quarters now.

  36. Hi Noemi, the coverage for extracorporeal shock wave lithotripsy (ESWL) is 18,000 (8,400 for PF and 9,600 for hospital costs)

  37. Hi. My brother has a torn acl. according to the dr at pgh, he needs an operation to restore. He’s unemployed now. He last worked in 2010, so he has only 5 months of contributions to philhealth. Can he use philhealth for the operation? The cost is a bit high. Thanks

  38. Hi Joanna, if he paid Philhealth for Jan to Mar 2016, then he can use Philhealth this April or May. If not paid, and he will pay for Apr to June, he can use Philhealth in June.

  39. Hi Nora! Thanks for this very helpful article and for dutifully answering questions in your comments section. I’m supposed to have ear surgery this May, but I haven’t paid since 2008, I think. If I pay the minimum three months (March to May), can I still use my Philhealth this May or do I have to settle for a June operation?

  40. Hi Jeanne, what you’re allowed to pay this April is April to June and the next quarters. This means you have to wait for June to have the operation, as it seems the operation can be delayed. I hope your surgeon and the hospital are Philhealth-accredited. Thanks a lot for appreciating my efforts.

  41. Hi po!ask ko lng po I give birth for our 2nd child last April 23,2016 and I undergo c.s w/BTL at St.Vincent hospital here in Cebu but the hospital only deducted 19000 for the philhealth..ask ko lng po if cover ba yun BTL sa philhealth,if so?may refund po ba dito sa BTL?ano requirements for refund?

  42. Hi Suzette, your BTL coverage of 4k should also have been deducted. When multiple procedures are performed, usually only one procedures is covered, but in the case of CS and BTL, BTL is covered as second-rate procedure. If you like, call the hospital and tell them that your BTL should also have been covered. If the hospital filed for both 19k and 4k, these will appear in the benefit payment notice that you will receive from Philhealth through the mail. If Philhealth refunded 23k to the hospital, you can use this notice plus your hospital receipts to ask for a refund of 4k from the hospital.

Leave a Reply

Your email address will not be published. Required fields are marked *

Working Pinoy © 2008-2016 Frontier Theme