How is PhilHealth coverage calculated for hospital bills?

PhilHealth reimburses hospitalizations using the All-Case Rates (ACR) system. Instead of covering a percentage of the total bill, PhilHealth assigns a fixed benefit amount per illness or surgical procedure. This amount is split into the Health Care Facility (HCF) fee and the Professional Fee (PF). If your hospital bill is lower than the case rate, PhilHealth covers only up to the actual incurred amount.

What is the deduction order for hospital bills in the Philippines?

By Philippine law, the proper deduction sequence is: 1) Gross Hospital Bill, 2) 20% Senior Citizen or PWD Discount (applied to VAT-exempt qualified charges), 3) PhilHealth Case Rate benefit (split into Facility Fee and Professional Fee), 4) HMO or Private Health Insurance coverage, and 5) Final Patient Out-of-Pocket Co-Payment.

What is the PhilHealth No Balance Billing (NBB) / Zero Balance Billing Policy?

Under the Universal Health Care (UHC) Act and PhilHealth NBB guidelines, qualified members (such as Indigent, Sponsored, Senior Citizens, and members admitted to basic/ward accommodations in accredited government hospitals) are entitled to zero out-of-pocket payments for covered medical and surgical conditions.

Did PhilHealth increase its case rates for 2024–2026?

Yes. PhilHealth implemented a 30% across-the-board increase under Circular No. 2024-0001, followed by an additional 50% benefit expansion under Circular No. 2024-0037 for approximately 9,000 medical conditions and surgical procedures including Pneumonia, Dengue, Appendectomy, Cesarean Delivery, and Hemodialysis.

PhilHealth Coverage Calculator 2026 | Hospital Bill & Benefit Estimator

PhilHealth Case Rates 2026 Updated

PhilHealth Coverage Calculator

Estimate hospital bill deductions, professional fees, Senior/PWD discounts & out-of-pocket balance

Common Medical & Surgical Presets Tap to auto-fill

Hospital / Facility Type

Room Accommodation

Diagnosis / Procedure Case

PhilHealth Case Rate Total ICD: J18.9

₱

Facility Fee (HCF) ₱20,475

Doctor Fee (PF) ₱8,775

Published Package ₱29,250

Actual Hospital Charges Room, Labs, Meds

₱

Doctor’s Professional Fees Attending/Surgeon PF

₱

Senior Citizen / PWD (20%) Applies statutory 20% discount

HMO / Private Insurance Covers after PhilHealth

Zero Balance Billing (NBB) Qualified: Admitted to a government ward bed. Under the Universal Health Care Act, eligible patients have ₱0.00 out-of-pocket expenses for covered conditions.

PhilHealth Covered ₱29,250.00

Est. Out-of-Pocket ₱23,750.00

PhilHealth pays 55% of Gross Bill Total Bill: ₱53,000.00

Total Gross Bill (Hospital + Doctor PF)	₱53,000.00
Less: Senior Citizen / PWD 20% Discount	– ₱0.00
Less: PhilHealth Facility Coverage (HCF)	– ₱20,475.00
Less: PhilHealth Doctor Fee Coverage (PF)	– ₱8,775.00
Less: HMO / Private Insurance Coverage	– ₱0.00
Estimated Balance to Pay at Discharge	₱23,750.00

How PhilHealth Case Rates Work in Philippine Hospitals

The Philippine Health Insurance Corporation (PhilHealth) utilizes the All-Case Rates (ACR) payment mechanism. Rather than reimbursing a variable percentage of your total hospital bill, PhilHealth covers a fixed statutory amount based on the patient’s primary diagnosis (ICD-10 code) or surgical procedure (RVS code).

1. Separation of Facility Fee (HCF) and Professional Fee (PF)

Every PhilHealth case rate is divided into two distinct components:

Health Care Facility (HCF) Fee: Deducted exclusively from room and board, diagnostic laboratory tests, imaging, IV fluids, operating room fees, and hospital pharmacy medicines.
Professional Fee (PF): Deducted exclusively from the billing charges submitted by attending physicians, surgeons, and anesthesiologists.

Important Rule: If your actual physician fees are less than the PhilHealth PF allowance, the excess PF balance cannot be applied to reduce hospital facility charges.

2. Proper Legal Sequence of Hospital Bill Deductions

Under Department of Health (DOH) Administrative Orders and Republic Act No. 11223, hospitals must deduct benefits in this exact chronological order:

Gross Total Bill: Aggregation of all hospital charges and medical professional fees.
Senior Citizen (RA 9994) / PWD (RA 10754) 20% Discount: Deducted from eligible VAT-exempt charges before state insurance.
PhilHealth Benefit Package: Fixed case rate amount deducted directly from the Statement of Account (SOA).
HMO / Private Health Insurance / Corporate Guarantees: Applied to the remaining balance according to your LOA limits.
Net Out-of-Pocket Balance: The remaining co-payment settled by the patient upon discharge.

Frequently Asked Questions (FAQ)

Under the Universal Health Care Act and PhilHealth NBB guidelines, qualified members (including Indigent, Sponsored, Senior Citizens, and Kasambahays) who are admitted to basic/ward accommodations in DOH-licensed government hospitals pay ₱0.00 out-of-pocket expenses. Complete medical treatment, room accommodation, necessary medicines, and physician care are fully covered.

Yes. PhilHealth case rates apply equally in accredited private and public hospitals. However, in private hospitals, room rates, specialized diagnostic procedures, and specialist professional fees frequently exceed the fixed case rate, resulting in a co-payment balance.

Hospital billing sections require: 1) PhilHealth Claim Form 1 (CF1) or Member Data Record (MDR), 2) Claim Form 2 (CF2) filled out by your attending physician, and 3) Valid government-issued ID. For qualified dependents, proof of relationship (e.g., PSA Marriage Certificate or PSA Birth Certificate) is required.

PhilHealth covers up to 156 hemodialysis sessions per calendar year for chronic kidney disease stage 5 (CKD5) patients, reimbursing up to ₱4,000–₱6,350 per session depending on the facility accreditation and clinical supplies package used.

PhilHealth Services