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PhilHealth Benefits: What Is Covered in 2026 and How to Claim

Understand what PhilHealth coverage pays for, how case rates work and how to make sure your record is claim-ready.
✓ Last reviewed: [DATE]8 min readIndependent guide
What PhilHealth helps pay
Inpatient
Hospital stays
Outpatient
Primary care
Maternity
Mother and baby
Z Benefits
High-cost illness
Quick answer
PhilHealth benefits pay a fixed amount toward many medical costs, including inpatient care, outpatient and primary care (Konsulta), maternity care and high-cost illnesses (Z Benefits). The amount depends on the condition, the case rate and the facility, and it usually does not cover the entire bill.†

Who has PhilHealth coverage?

The Universal Health Care Act (Republic Act 11223) automatically includes all Filipinos in the National Health Insurance Program. Employed members, self-earning members, OFWs, senior citizens, persons with disability and indigent or sponsored members each have a membership category, and qualified dependents share the member’s coverage.†

Types of PhilHealth benefits

Inpatient benefits

Room, medicines, laboratory, operating room and professional fees for confinement, paid through case rates.

Outpatient and Konsulta

Primary care consultations, screening, selected tests and medicines through registered Konsulta providers.

Maternity benefits

Prenatal, delivery and newborn-related packages at accredited facilities.†

Z Benefits

Package rates for selected high-cost illnesses such as certain cancers and heart or kidney conditions.†

Special packages

Dialysis, chemotherapy, radiotherapy and other programs offered through accredited facilities.†

Claims

Filed by the hospital on your behalf. Ask for a breakdown of what PhilHealth paid.

How PhilHealth case rates work

PhilHealth pays a case rate, a fixed amount for a specific diagnosis or procedure, instead of paying every line item. The rate is split between the hospital’s charges and professional fees. If the bill is higher than the case rate, the difference is your balance, unless a no-balance-billing rule applies to you.†
Ask the hospital’s PhilHealth desk before discharge how the case rate will be applied and whether you qualify for no-balance-billing.

PhilHealth Konsulta: primary care for members

PhilHealth Konsulta is a primary care package that covers consultations, selected screening and laboratory tests and medicines through registered providers.†
  1. 1Log in to the Member Portal and choose a Konsulta provider. See PhilHealth login.
  2. 2Register yourself and any dependents with the provider.
  3. 3Visit the provider for a consultation and availed services.
  4. 4Follow the provider’s guidance for follow-ups.

PhilHealth Z Benefits for high-cost illnesses

Z Benefits are package payments for selected catastrophic conditions. Each package has eligibility rules and must be availed at an accredited facility. Ask the hospital’s PhilHealth desk or your Local Health Insurance Office to confirm whether your diagnosis is covered.†

No balance billing and sponsored members

PhilHealth’s no balance billing (NBB) policy has applied to indigent, sponsored and certain other members admitted in basic accommodation at government facilities, meaning they should not pay a balance beyond the covered amount.† Confirm your category before admission.

PhilHealth benefit eligibility and your contributions

  • ✓Keep your PIN and personal details consistent across your MDR and hospital records.
  • ✓Check that your payments have posted. See PhilHealth contribution 2026 for the amounts and how to pay online for the steps.
  • ✓Declare dependents early so they can be covered. See the documents you need.
  • ✓Confinement day limits have historically existed each year, including days shared among dependents. Verify the current limit.†

How to use your PhilHealth benefits at the hospital

  1. 1Bring your PIN or MDR and a valid ID for you and any dependent.
  2. 2Tell the admitting desk you are a PhilHealth member and ask for the PhilHealth desk.
  3. 3The hospital checks your eligibility and prepares the claim. Sign required forms.
  4. 4Ask for a statement of account showing the PhilHealth deduction.
  5. 5Keep copies of receipts and forms.

Why PhilHealth claims get delayed

  • Records with mismatched names or birthdates
  • Unposted or unpaid contributions
  • Treatment at a non-accredited facility or by a non-accredited provider
  • Missing documents or unsigned forms
  • Unregistered dependents

PhilHealth inpatient benefits in detail

PhilHealth inpatient benefits help pay for hospital confinement. They cover categories such as room and board, drugs and medicines, laboratory and diagnostics, operating room fees and professional fees, subject to the case rate for your condition.†
  • ✓Coverage is per case, and packages differ by illness or procedure.
  • ✓The hospital normally computes and deducts the benefit from your bill before discharge.
  • ✓Ask for a detailed statement showing the PhilHealth amount for hospital charges and professional fees.

PhilHealth outpatient benefits

PhilHealth outpatient benefits are mainly delivered through primary care packages such as Konsulta, and through selected outpatient services offered by accredited facilities. They may include consultations, screening, some laboratory tests and medicines, depending on the package and provider.†

PhilHealth maternity benefits

PhilHealth maternity benefits support prenatal care, childbirth and newborn care in accredited facilities. Requirements can include registration of the mother and the correct member category. Ask your obstetric provider and the hospital’s PhilHealth desk what applies to you.†

Coverage for dependents

Qualified dependents can use your coverage, provided they are declared and your record is in order. Keep documents such as marriage and PSA birth certificates ready. See the requirements for dependents.

What PhilHealth usually does not cover

  • ✓Balances above the case rate, unless a no-balance-billing rule applies
  • ✓Cosmetic or other excluded procedures†
  • ✓Services from non-accredited facilities or providers†
  • ✓Costs not included in the case rate, such as private room upgrades†

How the PhilHealth claim timeline works

Step 1

Admission

Present your PIN and IDs
Step 2

Eligibility

Hospital verifies your record
Step 3

Treatment

Case rate applied
Step 4

Discharge

Benefit deducted
Step 5

Follow-up

Keep statements and forms

PhilHealth Konsulta registration in more detail

  1. 1Confirm that your PIN and record are valid in the Member Portal.
  2. 2Choose a registered Konsulta provider near you.
  3. 3Register yourself and dependents with that provider.
  4. 4Attend the first consultation, where the provider assesses your health and recommends screening or tests.
  5. 5Return for follow-ups and for medicines covered under the package.†

How a case rate works: an illustrative example

Imagine a hospital bill of ₱40,000. If the case rate for the condition is ₱15,000, PhilHealth pays ₱15,000 and the balance is ₱25,000, unless a no-balance-billing rule applies to your membership category or facility. The numbers here are illustrative only. Ask the hospital for the actual case rate for your diagnosis.†

PhilHealth benefit eligibility checklist before admission

  • PIN and MDR match your IDs
  • Payments posted in your Member Portal
  • Dependents declared in your record
  • Admission at an accredited facility with an accredited doctor
  • Knowledge of your membership category, especially for indigent or sponsored members

Where to check current PhilHealth benefit packages

Benefit amounts and packages change through PhilHealth circulars. Check the official PhilHealth website or ask your hospital’s PhilHealth desk for the current case rates for your diagnosis. This site explains how benefits work but does not list official payment tables.†

PhilHealth benefits: common questions

Usually not. It pays a set amount per case, and the balance depends on the hospital and your category.

Some are, particularly through Konsulta. Availability depends on the provider and your registration.

Yes, if they are properly declared in your PMRF.

Overseas confinement claims have been possible with documents submitted within a set period. Check the current rules.†

No. They require a qualifying diagnosis, an accredited facility and an approved package.

Verify before you act. Rates, forms and procedures change. Details marked † should be confirmed on philhealth.gov.ph. This site cannot access or change your account.
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Independent guide. Not affiliated with PhilHealth. Official services: philhealth.gov.ph

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