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PhilHealth Patient AdvocacyPhilHealth Case Rate Calculator
Estimate your exact PhilHealth hospital bill deduction, health facility coverage, and professional fee copayment. Updated with the latest 30% to 50% benefit increases, dual case rate rules, and Senior/PWD discounts.
Confinement & Diagnosis Details
Step 1 of 2How PhilHealth All Case Rates (ACR) Work
Fixed Case Rate System
PhilHealth does not reimburse a percentage of your total bill. Instead, each disease or surgery has a fixed peso benefit package. Whether your hospitalization costs ₱40,000 or ₱100,000, PhilHealth deducts the predetermined statutory rate.
Hospital Fee vs. Doctor’s PF
Every case rate is divided between the Health Care Institution (HCI) Fee (covering room, diagnostic tests, and medications) and the Professional Fee (PF). If a doctor charges above the PF allocation, the excess becomes the patient’s out-of-pocket copayment.
No Balance Billing (NBB)
Under the Universal Health Care Law, eligible patients (Indigents, 4Ps, Sponsored Members, Senior Citizens) admitted in basic/ward beds in public hospitals pay ₱0 above the PhilHealth benefit under the No Balance Billing policy.
2026 Common PhilHealth Case Rates Quick Reference Table
Circular 2024-0037 Adjusted| Medical Condition / Procedure | ICD-10 / RVS Code | Total Case Rate | Health Facility Fee | Professional Fee |
|---|---|---|---|---|
| Pneumonia (Moderate Risk) | J18.9 | ₱29,250 | ₱20,475 (70%) | ₱8,775 (30%) |
| Pneumonia (High Risk) | J18.9HR | ₱46,800 | ₱32,760 (70%) | ₱14,040 (30%) |
| Cesarean Section (Primary / Repeat) | 59514 | ₱37,050 | ₱22,230 (60%) | ₱14,820 (40%) |
| Dengue Fever (Without Warning Signs) | A97.0 | ₱13,000 | ₱9,100 (70%) | ₱3,900 (30%) |
| Dengue Fever (With Warning Signs) | A97.1 | ₱19,500 | ₱13,650 (70%) | ₱5,850 (30%) |
| Appendectomy (Open / Laparoscopic) | 44950 | ₱31,200 | ₱18,720 (60%) | ₱12,480 (40%) |
| Normal Spontaneous Delivery (Hospital) | 59400 | ₱8,450 | ₱5,070 (60%) | ₱3,380 (40%) |
| Hemodialysis (Per Session) | 90999 | ₱4,000 | ₱3,650 (HCI) | ₱350 (PF) |
| Stroke / CVA Infarction | I63.9 | ₱36,400 | ₱25,480 (70%) | ₱10,920 (30%) |
| Acute Gastroenteritis (AGE) with Dehydration | A09.9 | ₱11,700 | ₱8,190 (70%) | ₱3,510 (30%) |
Mandatory Documents for PhilHealth Discharge Claims
Ensure you submit these completed forms to the hospital billing or PhilHealth section at least 24 to 48 hours before patient discharge to prevent billing delays:
Updated copy showing registered dependents.
Filled out and signed by member or employer.
Completed by attending physician & hospital.
Photocopy of Member & Patient identification.
Frequently Asked Questions
- Deduct 12% Value Added Tax (VAT) from the gross bill to establish the VAT-exempt base.
- Deduct the applicable PhilHealth Case Rate benefit (HCI + PF).
- Apply the 20% Senior Citizen or PWD discount on the remaining eligible hospital balance and professional fee.
- The final remaining figure is the patient’s out-of-pocket copayment.