PhilHealth case rates: how much PhilHealth pays for a hospital stay

A case rate is a fixed amount PhilHealth pays for one illness or procedure during a hospital stay. It covers the hospital’s charges and the doctors’ fees together, and the hospital takes it off your bill before you leave. The amount is set in PhilHealth’s circulars, it is the same whatever the actual bill comes to, and you can look it up in PhilHealth’s Case Rates Search. In a basic or ward room, the law says the hospital may not charge you more than PhilHealth pays.

How a case rate comes off your bill

PhilHealth’s benefits page says the case rate “shall be deducted by the Health Facility from the member’s total bill, which shall include professional fees of attending physicians, prior to discharge”. The hospital then files the claim with PhilHealth.

• One amount for the hospital and the doctors. PhilHealth pays the whole case rate to the hospital, which passes the doctors’ share on. Under Circular No. 35, s. 2013, which the 2025 and 2026 circulars still apply, the doctors’ share is 30% of a medical case rate. For a procedure it is worked out from the procedure itself, so the share differs; for the appendectomy and caesarean rates below it is 40%.
• Fixed, whatever the bill. Circular No. 2024-0037 calls the list “a list of fixed rates per case … irrespective of the actual individual charges per admission”.
• Two conditions in one stay. If two conditions are treated in the same stay, the hospital may claim a second case rate. PhilHealth pays the full rate for the main condition and 50% of the rate for the second, except for a few listed treatments, such as dialysis, chemotherapy and blood transfusion, that are paid in full (Circular No. 35, s. 2013). Only conditions and procedures on PhilHealth’s second case rate list (Annex D of Circular No. 2024-0037) qualify, and common illnesses such as pneumonia and dengue are not on it. The hospital maternity case rates of Circular No. 2026-0005 and the cataract package cannot be claimed as a second case rate.
• The rest of the bill. The first case rate plus the amount paid for any second one comes off the total. Circular No. 35, s. 2013 says the remainder is paid by the patient, except where no balance billing applies (see below).

Looking up a case rate

PhilHealth’s Case Rates Search lets you search by the name of the illness or procedure, its ICD-10 code, or its RVS code (the code for a procedure). Each result shows the case rate, the hospital and doctors’ shares, whether it can be a second case rate, and the date the rate took effect. On 20 October 2026 it already showed rates that took effect in 2026.

The full lists behind it are the annexes of Circular No. 2024-0037: medical case rates and procedure case rates. Later circulars have changed some rows, so check the search tool for the current figure.

A few examples, as the Case Rates Search showed them on 20 October 2026, for hospital stays (Levels 1 to 3):

Scroll the table sideways for more

Amounts are in Philippine pesos. Severe dengue has its own, higher rate. These are what PhilHealth pays the hospital; they say nothing about what a stay will cost.

Recent changes

• 50% rise, January 2025. Circular No. 2024-0037 raised many case rates by 50% for admissions from 1 January 2025. Packages PhilHealth had already re-costed, such as stroke, high-risk pneumonia, severe dengue and asthma, were left out, along with cataract surgery and hemodialysis.
• Cataract surgery, January 2025. Circular No. 2025-0001 set a new package: PHP 28,300 for one eye with a standard (monofocal) lens, with other amounts for other lens types.
• Maternity, April 2026. Circular No. 2026-0005 set new hospital rates from 30 April 2026, including PHP 29,000 for a normal delivery and PHP 58,000 for a caesarean section, up from PHP 37,050.
• Leptospirosis, July 2026. Circular No. 2026-0008 set PHP 63,000 for moderate to severe leptospirosis from 15 July 2026, up from PHP 21,450.
• Day limits lifted. The 45-day yearly limit on hospital days was lifted (Circular No. 2025-0007), and so was the rule that blocked a second claim for the same illness within 90 days (Circular No. 2025-0015).

PhilHealth is also testing a different way of paying hospitals, called diagnosis-related groups, through “shadow billing” (Circular No. 2026-0012). Until PhilHealth says otherwise, case rates are what it pays. Our guide to PhilHealth benefits covers the other recent changes.

No balance billing

The Universal Health Care Act says “no co-payment shall be charged for services rendered in basic or ward accommodation” (RA 11223, Sec. 9). A basic or ward room means a shared room, regular meals, a fan and a shared toilet and bath (Sec. 4). Circular No. 2024-0037 says that since the 50% rise, every PhilHealth beneficiary is entitled to no co-payment in a ward, in public and private hospitals.

In a semi-private or private room, the hospital may charge you the difference. The 2026 maternity circular adds a cap on that difference for a normal delivery in a semi-private room. Our guide to the PhilHealth maternity benefit has the figure.

If a hospital charges you in a ward for something PhilHealth covers, you can raise it with PhilHealth’s Action Center at actioncenter@philhealth.gov.ph (PhilHealth Advisory No. 2026-0016).

What you may still pay

A case rate does not promise to cover everything. Circular No. 2024-0037 says case rates “shall not need to provide full coverage for the cost of care beyond the minimum standards in basic or ward accommodation”, and that costs above the case rate may be met from other funds or out of pocket. What usually adds to the bill:

• A room above ward level, and extra amenities or upgrades.
• Care that costs more than the case rate, outside the ward.
• Anything not covered by the package.

Legal discounts, such as the senior citizen and PWD discounts, come off the bill together with PhilHealth, before anything else (Circular No. 2024-0037). Private insurance or an HMO then adds to what PhilHealth pays. Our guide to HMOs and health insurance explains the difference.

PhilHealth’s 2025 and 2026 package circulars (Nos. 2025-0001 and 2026-0005) say claims “shall not require a printed copy of the member data record (MDR)”: the hospital checks eligibility and deducts PhilHealth’s share on discharge. Bring a valid ID: Circular No. 2022-0013 says you may need one to prove who you are. Our guide to the PhilHealth Member Data Record explains when a copy still helps. Everything else about PhilHealth for OFWs and their families is on our PhilHealth guide.