PhilHealth Out-of-Pocket Calculator
Estimate your actual cash balance before hospital discharge. Includes PhilHealth case rates, Senior Citizen / PWD 20% statutory discounts, and HMO limits.
Includes room, lab, diagnostics, pharmacy, and doctor professional fees.
20% is legally deducted from the gross bill prior to PhilHealth application.
Maxicare, Intellicare, Medicard, PhilCare, Pacific Cross, or Corporate Plan.
Official PhilHealth All Case Rate (ACR) Quick Reference
| Condition / Procedure | ICD-10 / RVS Code | PhilHealth Case Benefit | Est. Private Bill | Quick Apply |
|---|---|---|---|---|
| Pneumonia (Moderate Risk) | J18.9 | ₱19,500 | ₱50,000 – ₱75,000 | |
| Cesarean Section (C-Section) | 59514 | ₱24,700 | ₱80,000 – ₱120,000 | |
| Appendectomy (Open/Lap) | 44950 | ₱31,200 | ₱70,000 – ₱110,000 | |
| Dengue (without warning signs) | A90 | ₱13,000 | ₱25,000 – ₱45,000 | |
| Cholecystectomy (Gallbladder) | 47600 | ₱40,300 | ₱110,000 – ₱160,000 |
*Note: PhilHealth case rates are fixed amounts regardless of whether the actual bill is lower or higher. Figures reflect the recent 30% benefit rate enhancement across standard case rates.
How Philippine Hospital Billing Deductions Work
By law (RA 9994/RA 10754), 20% discount plus 12% VAT exemption must be applied to eligible hospital items and doctor fees before any health insurance deduction.
PhilHealth acts as the primary payer. The fixed Case Rate is deducted from the remaining discounted bill. In government ward rooms, No Balance Billing applies to qualified members.
HMO / private health cards pay the excess up to your Maximum Benefit Limit (MBL). Any unapproved room upgrades or excess PF are paid as patient out-of-pocket cash.
Frequently Asked Questions (FAQ)
What happens if my total hospital bill is less than the PhilHealth case rate?
Under the PhilHealth All Case Rate policy, PhilHealth pays the exact designated case rate to accredited health care institutions. If your eligible hospital charges are equal to or lower than the package rate, you will have zero out-of-pocket expenses (subject to hospital accreditation and accommodation level).
Who is entitled to the PhilHealth No Balance Billing (NBB) policy?
The No Balance Billing (NBB) policy applies to Indigent members, Sponsored members, Pantawid Pamilyang Pilipino Program (4Ps) beneficiaries, Senior Citizen members, and Kasambahay members who are admitted to accredited government/public hospitals and stay in ward-type accommodations.
Can I use both my HMO and Senior Citizen / PWD discount together?
Yes. The hospital billing department must first deduct your 20% statutory discount on medical services and doctor professional fees. Next, PhilHealth deductions are applied. Finally, your HMO covers the net balance according to your policy’s Maximum Benefit Limit (MBL) and room entitlement.
Where can I get additional financial assistance if my out-of-pocket share is high?
You can approach the Malasakit Center located in any DOH-operated government hospital. Malasakit Centers serve as a one-stop shop consolidating financial assistance from the Philippine Charity Sweepstakes Office (PCSO), Department of Social Welfare and Development (DSWD), PhilHealth, and DOH Medical Assistance for Indigent Patients (MAIP).
Disclaimer: This calculator is an independent financial planning and estimation tool designed to help Filipino families budget for hospitalization. Actual billing statements are computed and finalized solely by accredited hospital billing officers based on specific medical interventions, actual pharmacy usage, and doctor contracts.
Referenced Laws: Republic Act No. 7875 (National Health Insurance Act), RA 9994 (Expanded Senior Citizens Act), RA 10754 (PWD Act), and PhilHealth Circulars 2024–2026.