What is the PhilHealth Case Rate System?
Unlike traditional indemnity insurance that reimburses a percentage of the total bill, PhilHealth pays hospitals using a 'Case Rate' system. Each medical condition or surgical procedure is assigned a fixed code and value. For example, if a patient is admitted for Appendectomy, the Case Rate is ₱24,000. This amount is split into hospital fees (70% or ₱16,800) and doctor's professional fees (30% or ₱7,200). Any cost exceeding ₱24,000 must be settled by the member as out-of-pocket expenses.
The No Balance Billing (NBB) Policy Explained
Under PhilHealth Circular No. 2017-0017, the No Balance Billing (NBB) policy ensures that subsidized members do not pay a single peso out-of-pocket when admitted to a government hospital. Eligible categories include Indigents, Senior Citizens, Lifetime Members, and Point-of-Service (POS) patients, provided they are admitted to basic/ward accommodations. Government hospitals are prohibited from charging these members for medicines, diagnostics, or supplies.
Comparison of Common Case Rates
| Medical Case / Procedure | Case Rate Code | Total Coverage | Hospital Share | Doctor Fee Share |
|---|---|---|---|---|
| Normal Spontaneous Delivery (NSD) | 5611 | ₱5,000.00 | ₱3,500.00 | ₱1,500.00 |
| Caesarean Section (CS) | 5612 | ₱19,000.00 | ₱13,300.00 | ₱5,700.00 |
| Hemodialysis (per session) | 90935 | ₱4,000.00 | ₱2,800.00 | ₱1,200.00 |
| Acute Appendectomy | 47562 | ₱24,000.00 | ₱16,800.00 | ₱7,200.00 |
| Severe Dengue Fever | 9916 | ₱16,000.00 | ₱11,200.00 | ₱4,800.00 |
| Cataract Surgery (Single) | 66984 | ₱16,000.00 | ₱11,200.00 | ₱4,800.00 |
How to Avail of Double Coverage with Private HMOs
If you have a private Health Maintenance Organization (HMO) plan (e.g., Maxicare, Intellicare, Medicard), PhilHealth is always deducted first from your hospital bill. The remaining balance can then be passed to your HMO provider for coverage. Ensure both your PhilHealth MDR and HMO cards are presented at the billing section upon admission.
Thank you for this guide. I followed the online registration steps using the PMRF. It took exactly 1 day for my MDR to get generated in my online portal! Very accurate timeline detail.
Is it required to submit the marriage certificate if registering my wife as a dependent? My marriage is verified by PSA.
Hi Juan! Yes, a photocopy of your PSA Marriage Certificate is mandatory when updating your MDR to add your spouse. Make sure to attach it to your PMRF update form.