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.

940 Comments

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  1. Hi Cjay, yes, legit yon, kasi website nila. But you still need to go to Philhealth with your ID and get your MDR and card, if available. The hospital requires MDR and premium receipt.

  2. Hi Grace, puedeng magamit uli ang Philhealth kahit confined for the same illness kasi more than 90 days na ang lumipas since last May. Ang 90-day single period of confinement rule ay ganito: isang Philhealth coverage lang ang magamit kapag na-ospital uli within 90 days.

  3. Ang aking ina po ay GSIS pensioner,subalit tila walang gsis accredited na ospital d2 sa Laguna.
    Siya po ay philhealth member din.
    Maari ko po bang malaman kng ano ang benepisyo na maaari niyang mkuha mula sa philhealth.
    Siya po ay nangangailangan ng agarang lunas sa knyang gall bladder problem.Ilang porsyento po ang dicount for laboratory test like ultrasound and citiscan?
    Paano po ang dapat gawin kng maconfine sia at nais naming gamitin ang kanyang philhealth?
    May opisina po ba ang philhealth sa Laguna?
    Maraming salamat po agarang tugon.

  4. Hi Juliana, sorry for the delayed reply. And sorry hindi sagot ng Philhealth ang ultrasound at CT scan. Dapat punta sa hospital na Philhealth-accredited. Fixed amount ang sagot ng Philhealth sa bawat kind of illness, ke naospital ka sa public o sa private, sa mas mura o sa mahal. Present your Philhealth MDR and premium receipt upon admission. Fill up the claim form.

  5. Hi, ask ko lang po kapag operation ng ankle fracture ang bali ng buto. How much po kaya yung rates?. Ooperahan m po kasi ako ng 2nd week ng nov. Thank u po

  6. My Dr prescribed an MRI at a cost of 15,200php. How much of that can be covered by PhilHealth? The general hospital does not have a machine so I will be going to the Private hospital which does not like to wait for PhilHealth…. Can I pay out of pocket and get reimbursed?
    Thank you

  7. Hello, Ako ofw ng Hk.gusto kong paalis tong warts ko sa my side ng armpits ko and its cost 1000+hk $ marereinburse ko po ba? thanks:-)

  8. Hi Douglas, sorry, I can’t see MRI on the coverage list, and based on comments on this blog from patients, Philhealth does not cover a lot of outpatient diagnostic tests, like MRI, CT scan, ultrasound, etc.
    For hospitalization, the SOP is for you to submit your Philhealth MDR and premium payment receipt and claim form 1 to the hospital so the coverage can be deducted from the bill before discharge. Ask the hospital too

  9. Hi clarita, yes, puede. Ang coverage for myomectomy is 23,300 pesos (12,600 for Hospital and 10,700 for PF). Ask your surgeon how much you will pay if you use Philhealth.

  10. Puede ko po bang mgamit uli ang philhealt ko sa panganay ko since nagamit ko po last april 2016 sa bunso ko?

  11. Hi eleanor, yes, puede. Kung gamitin mo this month of Nov, ang receipt na gamitin mo is any payment for any 3 months within June to Nov.

  12. Hi po. Ako po si espie. Na confine ako last oct 28 to 29,2016. Employed po ako pero abg lumabas sa info ng hospital ay NO contributions and self employed. 17 months na akong employed and nag deduct na sa akin every month. Gastroenteritis ang diagnosis sa akin. Nagbayad ako ng 6k sa hopsital. wala daw po makukuha sa philhealth.sabi sa company ay 20% lang ang pde mabalik sa akin. Tama po ba un?
    salamat.

  13. Hi Esperanza, mas mabuti pa ang company na hindi nagbabawas ng Philhealth kesa company na nagde-deduct pero hindi naman nagre-remit. Sana sinabihin na lang kayo na mag-register as Individual Payors. Ang coverage ng gastroenteritis ay 6k. Dapat bayaran ng company mo ang 6k kasi yan ang babayaran ng Philhealth kung naka-file ka sana. Walang regulation na 20%. Saan nila pinulot yong rule na yon? Okay, kung tatawad yong company, pinaka-minimum na dapat yong hospital cost na 4,200, kasi sure na sure yon na binabawas sa hospital kung merong Philhealth. Meron kasing ibang hospitals, yong PF (1,800), hindi binabawas sa bill, dinadagdag sa bayad sa doctor or sa hospital mismo, dahil matagal daw magbayad ang Philhealth.
    I hope makahanap ka ng ibang company. Kumusta naman ang SSS nio? Puede ring mag-file ng SSS sickness benefit kung wala ka nang sick leave, at kung nag-leave ka ng at least 4 days. Required na rin that all companies file their Sickness and Maternity Benefit Payment thru Banks form para maka-file ng sickness or maternity benefits ang mga employees.

  14. Hi Dexie, coverage for ovarian cystectomy (removal of ovarian cyst) is 23,300. Coverage for total hysterectomy (removal of ovaries, uterus, cervic and fallopian tubes) is 30k pesos.

  15. Gysto ko nrin po itanong. Voluntary payor po ako, n stop lng byad ko nung 2012. Ngayon po ofw na po ako, gusto kong ipagpatuloy yung bayad, pero na check ko yung status ko naging indigent, pati yung benneficiary ko naging invalid. Ano po b ggawin ko pra maging ofw yung status ko dun, e kasalukutan po akong nsa Dubai. pg ngbyad ba ako dito s Dubai, automatic n maging ofw nayung status ko?. Salamat

  16. Good day maam/sir,presently im working here in saudi,now my case was like this.I have been a surgical treatment of my varicous vein and it is already done last Nov.3,2016 here in saudi Al Mana hospital in Alkhobar.And i want to file a claim for insurance,then how much could i receive amount for this,and what is the step by step procedure,what document requires to file this claim,Hope you response me soon.Thank you.

  17. Hi po. Magkano po ang macover ng philhealth for uti? Dependent ko po at voluntary member po ako. Thank you.

  18. Hi Karen, coverage is 7,500 (2,250 for PF; 5,250 for hospital cost). UTI should be admissible, meaning merong mga symptoms na dapat talagang for confinement ang severity ng UTI)

  19. Hi tanong ko lng po.. kung ngayon buwan plang ako kukuha ng philhealt magagamit ko nba sya sa march nextyear kung kalahating taon nman babayaran ko?

  20. Is Amoebeasis covered?

    ! was confined of Amoebiasis; Acute Gastroenteritis. with moderate dehydration. I found out in my billing statement, no benefit given to me. I read below the billing statement. Phic not compensable due to final diagnosis. Why?

  21. Hi po last Aug lng po kmi ng umpisa mg byad ng philhealth tapos mg byad uli ako ngayon pra s last quarter pwede n po b magamit nmin yong philhealyh ngayon? Thanks po

  22. hi po s inyo ako po si David Ken Toca my ka-live in at my 2 anak n po kmi ang panganay po nmin ay 2 taon n at ang bunso ko ay 3 wiks plang.ask ko lang po sakop po b ng philhealth ang anak nmin kung sakali ma-admit siya sa hospital sa sakit na Pheumonia?salamat po

  23. Hi David Ken Toca, yes, dependent nio ang mga anak nio kasi minors pa lang sila. Sino sa inyo ang merong Philhealth, puedeng dependent niya ang mga anak nio. Ipa-update lang sa Philhealth ang MDR nio para maisulat ang names nila as dependents sa MDR. Bring their birth certificates (original and xerox). If both of you have Phihealth, mamili na lang kayo kung sino ang ipapa-update. Yon na lang madaling ipa-update. Kahit naka-confine na, puede pang ipa-update, or ask the hospital kung puedeng birth certificate muna ang i-present nio.

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