Health coverage gap methodology
How the calculator estimates your out-of-pocket exposure.
Demystifying the Math
The math behind health coverage shouldn't be a black box. Here we outline the exact logic, data sources, and assumptions the Gap Engine uses.
Gross Hospital Cost − PhilHealth − Employer HMO − Other Coverage = Your Gap
Hospital Tier Classification
PGH, East Avenue, provincial DOH hospitals. Zero Balance Billing: active PhilHealth members in basic ward pay ₱0. Source: DOH ZBB policy; PGH published rates.
CGHMC, UST Hospital, Manila Doctors, Cardinal Santos, Chong Hua. Room rates ₱1,200–₱4,300/day. Source: Chong Hua published room rates; ClinicFinderPH.
St. Luke's (BGC/QC), MakatiMed, The Medical City, Asian Hospital. 3–5× mid-range. Room rates ₱5,500–₱25,000+/day. Source: MakatiMed price list; ClinicFinderPH St. Luke's guide.
Singapore, Bangkok, Hong Kong, Japan. Philippine coverage provides zero offset. Informational only — no peso estimates generated.
Scenario Definitions
4 consultations, routine labs (CBC, lipid, FBS, HbA1c, UA), chest X-ray, 2 prescriptions. Sources: PGH published rates, Hi-Precision Diagnostics, St. Luke's estimates via ClinicFinderPH.
Dengue, pneumonia, or appendectomy. Room, PFs, labs, imaging, meds. PhilHealth case rate applied as a fixed peso offset regardless of hospital tier.
Cholecystectomy, C-section with complications, or cardiac procedure. Includes ICU days, multiple specialist PFs, advanced imaging. Z-Benefits up to ₱600,000 for qualifying conditions.
PhilHealth Offsets
Fixed peso amount per diagnosis from PhilHealth Circular 2024-0037. Applied regardless of hospital tier or room choice. Outpatient (Konsulta) assumed ₱0 — conservative, as uptake is limited.
At DOH hospitals, basic ward = ₱0 for active members regardless of income. Over 1.3 million patients paid nothing in 2025 under this policy.
Cancer: up to ₱175,000. Cardiac surgery (Z-MORPH): up to ₱575,000. Kidney transplant: up to ₱600,000. Dialysis: ₱4,000/session. Highest applicable benefit used per confinement (they do not stack).
Healthcare Inflation Context
Philippines: 17.9% (2023), 19.3% (2024), 18.3% projected (2025). Second highest in APAC. Driven by utilization rebound, rising hospital costs, and PF negotiations (80–150% increases proposed).
Total health expenditure: ₱1.87 trillion (+15.1% YoY). Per capita: ₱15,223. Government share: 46.5%. Household out-of-pocket: 41.2%. Voluntary (HMO/insurance): 12.3%.
Gap Engine uses 15% — the conservative end of the observed 15–19% range — compounded annually for 3- and 5-year horizons. Labelled "illustration only."
Cost estimates are 2026 figures. PhilHealth rates from Circular 2024-0037. Hospital costs from PGH, MakatiMed, Chong Hua, and ClinicFinderPH. Lab costs from Hi-Precision. Inflation data from WTW Global Medical Trends Survey 2025. Health spending from PSA National Health Account 2025. Rates and policies change — confirm with your hospital and insurer.