Estimated Hospital Bill Breakdown & PhilHealth Deduction
Generated via Civic Health PH Calculator • Citations: RA 9994, RA 10754, PhilHealth ACR System
PhilHealth Hospital Bill Calculator
Estimate how much of your hospital bill will be covered by PhilHealth Case Rates, Senior Citizen / PWD 20% discounts, and private HMO insurance—and know your exact out-of-pocket balance.
Billing Parameters
Step 1 of 2Calculation Summary
Estimated Balance- Gross Hospital Bill ₱65,000.00
- Subtotal After Discounts ₱65,000.00
- Primary PhilHealth Case Rate − ₱15,000.00
- Estimated Net Out-of-Pocket ₱50,000.00
How Hospital Billing & PhilHealth Deductions Work
Philippine healthcare billing follows a legally mandated deduction order established under Republic Act 9994, Republic Act 10754, and PhilHealth Circular No. 2017-0017.
Gross Billing Audit
The hospital compiles total actual charges itemized into facility usage, room, laboratory/diagnostics, medications, and attending physician professional fees (PF).
20% Senior / PWD Discount
If the patient is a verified Senior Citizen or PWD, 12% VAT exemption and a 20% discount are deducted from actual unbundled gross charges before insurance.
PhilHealth Case Rate
The predetermined All-Case Rate (ACR) package is subtracted. If two qualifying diagnoses exist, the secondary case rate is credited at 50% value.
HMO & Final Cashier
Private HMO insurance pays remaining covered hospital expenses. Any excess beyond policy limits represents the final out-of-pocket balance.
2026 Common PhilHealth Inpatient Case Rates
PhilHealth All-Case Rates (ACR) are fixed amounts encompassing both the Health Care Institution (HCI) facility fees and Professional Fees (PF).
| Condition / Procedure | ICD-10 / RVS Code | Total Case Rate | Hospital Facility Share | Doctor Fee (PF) Share |
|---|---|---|---|---|
| Pneumonia (Moderate Risk) | J18.9 | ₱15,000 | ₱10,500 | ₱4,500 |
| Pneumonia (High Risk) | J18.0 | ₱32,000 | ₱22,400 | ₱9,600 |
| Dengue Fever (without warning) | A90 | ₱13,000 | ₱9,100 | ₱3,900 |
| Dengue Fever (with warning signs) | A91 | ₱16,000 | ₱11,200 | ₱4,800 |
| Acute Gastroenteritis (AGE) | A09 | ₱9,000 | ₱6,300 | ₱2,700 |
| Cesarean Section (C-Section) | 59514 | ₱19,000 | ₱11,400 | ₱7,600 |
| Appendectomy (Simple) | 44950 | ₱24,000 | ₱14,400 | ₱9,600 |
| Ischemic Stroke / Infarction | I63.9 | ₱38,000 | ₱26,600 | ₱11,400 |
| Hemodialysis (per session) | 90999 | ₱4,000 | ₱4,000 | ₱0 (Comprehensive) |
Understanding No Balance Billing (NBB) Policy
The “Walang Dagdag Bayad” or No Balance Billing Policy ensures that vulnerable Filipino patients admitted to accredited government health facilities leave the hospital without paying any out-of-pocket co-payment.
Who is Qualified for NBB?
- Indigent Members: Individuals identified under the DSWD Listahanan database.
- Sponsored Members: Beneficiaries whose premiums are paid by LGUs or national government agencies.
- Pantawid Pamilyang Pilipino Program (4Ps): Active conditional cash transfer beneficiaries.
- Senior Citizen Members: Covered under RA 10645 in ward facilities.
- Kasambahay Members: Formally registered domestic workers.
Key Conditions for Zero Out-of-Pocket Balance
NBB applies strictly to admissions in government hospital ward beds. If the patient requests voluntary transfer to a private or semi-private room, or purchases medicines/supplies outside the hospital’s pharmacy consignment, NBB protection is waived, and standard billing rates apply.
Frequently Asked Questions (FAQ)
Authoritative answers to common questions regarding PhilHealth deductions, claim forms, and hospital bill negotiations.
1. PhilHealth Claim Form 1 (CF1): Signed by your employer (if employed) or self-certified (if voluntary/individual).
2. Member Data Record (MDR): Updated copy showing qualifying contribution history.
3. PhilHealth Claim Form 2 (CF2): Completed by the hospital billing department and attending doctors.
4. Valid Government ID / Senior Citizen ID / PWD ID.
Methodology & Verification Notice
Calculations are based on public circulars from the Philippine Health Insurance Corporation (PhilHealth), Republic Act No. 11223 (Universal Health Care Act), RA 9994 (Expanded Senior Citizens Act), and RA 10754 (An Act Expanding the Benefits and Privileges of Persons with Disability).
Disclaimer: This tool provides an estimate for planning purposes. Official bill totals, exact case rate eligibility, and final out-of-pocket copayments are determined exclusively by the hospital billing department and attending physicians upon medical discharge audit.