PhilHealth Approves 50% Case Rate Adjustment for 2025

Amid the issues hounding its funding for 2025, the Philippine Health Insurance Corporation (PhilHealth) has approved a 50 percent adjustment in the case rates of selected medical benefits for its members. This move aims to lower the out-of-pocket expenses for its members and ensure effective delivery of high-quality health services.

In its Circular 2024-0037, PhilHealth issued the guidelines on the latest round of adjustments to its case rates. The circular applies to all accredited health facilities (HFs), PhilHealth regional offices, and all others concerned in implementing the adjustment.

Among the medical cases covered by the adjustments are urinary tract infection (UTI), acute gastroenteritis, and influenza. Additionally, benefit packages for cholecystectomy and craniotomy are also up for adjustments.

However, certain medical cases are excluded from the adjustments. These include Acute Stroke (Ischemic and Hemorrhagic), Pneumonia (high risk), Neonatal Sepsis, Bronchial Asthma in Acute Exacerbation, severe dengue, Ischemic Heart Disease-Acute Myocardial Infarction (IHD-AMI), and Covid-19, as they are being rationalized separately. Also excluded are Z Benefits packages that are being re-costed and are scheduled for adjustment, newly approved benefits packages starting 2023, cases identified to have a high risk for moral hazard and/or adverse incentives, and benefits packages paid through other provider payment mechanisms.

PhilHealth stated that these adjustments are necessary as the National Health Insurance Program (NHIP) covers less than 40 percent of total hospital service. The new case rate adjustments will take effect on hospital admissions starting January 1, 2025.

Earlier, the bicameral conference committee rejected PhilHealth’s proposed P74 billion subsidy budget for next year, suggesting the agency should utilize its P600 billion excess funds.

Reference: PhilHealth approves 50% case rate adjustment