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 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 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
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.


Add a Comment
  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. My mother is a gsis pensioner and she has philhealth din po.
    Sa gsis po kase wala kming mkita na gsis accridited hospital,kya po philhealth po ang solusyon nmin na mkakatulong sa immediate need ng mother ko.
    Kelangan pong i confine ng aking nanay dahil sa kanyang gall bladder problem.
    Ano po ba ang sakop ng benepisying maari niyang makuha..halimbawang sia ay kailangang mag undergo ng laboratory test like ultrasounds kr citiscan.
    At ilang porsyento po ang kanyang mkukuha sa pagkaka cofine(roomrates and doctor fees)?
    At papaano po procedures ng pag claim at saan po ang opisina ng philhealth sa probinsya ng laguna?
    Maraming salamat po sa agarang tugon.

  4. 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.

Leave a Reply

Your email address will not be published.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

Working Pinoy © 2008-2016 Frontier Theme