RA 7875 - National Health Insurance Act of 1995 (PhilHealth)

a. Allocation of National Resources for Health - the Program shall underscore the importance for government to give priority to health as a strategy for bringing about faster economic development and improving quality of life.

b. Universality - the Program shall provide all citizens with the mechanism to gain financial access to health services, in combination with other government health programs. the National Health Insurance Program shall give the highest priority to achieving coverage of the entire population with at least a basic minimum package of health insurance benefits;

c. Equity - the Program shall provide for uniform basic benefits. Access to care must be a function of a person's health needs rather than his ability to pay;

d. Responsiveness - the Program shall adequately meet the needs for personal health services at various stages of a member's life;

e. Social Solidarity - the Program shall be guided by community spirit. It must enhance risk sharing among income groups, age groups, and persons of differing health status, and residing in different geographic areas;

f. Effectiveness - the Program shall balance economical use of resources with quality of care;

g. Innovation - the Program shall adapt to changes in medical technology, health service organizations, health care provider payment systems, scopes of professional practice, and other trends in the health sector. It must be cognizant of the appropriate roles and respective strengths of the public and private sectors in health care, including people's organizations and community-based health care organizations;

h. Devolution - the Program shall be implemented in consultation with local government units (LGUs), subject to the overall policy directions set by the National Government;

i. Fiduciary Responsibility - the Program shall provide effective stewardship, funds management, and maintenance of reserves;

j. Informed Choice - the Program shall encourage members to choose from among accredited health care providers. the Corporation's local offices shall objectively apprise its members of the full range of providers involved in the Program and of the services and privileges to which they are entitled as members. This explanation, which the members may use as a guide in selecting the appropriate and most suitable provider, shall be given in clear and simple Filipino and in the local languages that is comprehensible to the member;

k . Maximum Community Participation - the Program shall build on existing community initiatives for its organization and human resource requirements;

l. Compulsory Coverage - All citizens of the Philippines shall be required to enroll in the National Health Insurance Program in order to avoid adverse selection and social inequity;

m. Cost Sharing - the Program shall continuously evaluate its cost sharing schedule to ensure that costs borne by the members are fair and equitable and that the charges by health care providers are reasonable;

n. Professional Responsibility of Health Care Providers - the Program shall assure that all participating health care providers are responsible and accountable in all their dealings with the Corporation and its members;

o.Public Health Services - the Government shall be responsible for providing public health services for all groups such as women, children, indigenous people, displaced communities and communities in environmentally endangered areas, while the Program shall focus on the provision of personal health services. Preventive and promotive public health services are essential for reducing the need and spending for personal health services;

p.Quality of Services - the Program shall promote the improvement in the quality of health services provided through the institutionalization of programs of quality assurance at all levels of the health service delivery system. the satisfaction of the community, as well as individual beneficiaries, shall be a determinant of the quality of service delivery,;

q. Cost Containment - the Program shall incorporate features of cost containment in its design and operations and provide a viable means of helping the people pay for health care services; and

r. Care for the Indigent - the Government shall be responsible for providing a basic package of needed personal health services to indigents through premium subsidy, or through direct service provision until such time that the program is fully implemented.

a. provide all citizens of the Philippines with the mechanism to gain financial access to health services;

b. create the National Health Insurance Program, hereinafter referred to as the Program, to serve as the means to help the people pay for health care services;

c. prioritize and accelerate the provision of health services to all Filipinos, especially that segment of the population who cannot afford such services; and

d. establish the Philippine Health Insurance Corporation, hereinafter referred to as the Corporation, that will administer the Program at central and local levels.

a. Beneficiary - Any person entitled to health care benefits under this Act.

b. Benefit Package - Services that the Program offers to its members.

c.Capitation - a payment mechanism where a fixed rate, whether per person, family, household, or group, is negotiated with a health care provider who shall be responsible for delivering or arranging for the delivery of health services required by the covered person under the conditions of a health care provider contract.

d.Contribution - the amount paid by or in behalf of a member to the Program for coverage, based on salaries or wages in the case of formal sector employees, and on household earnings and assets, in the case of the self-employed, or on other criteria as may be defined by the Corporation in accordance with the guiding principles set forth in Article I of this Act.

e.Coverage - the entitlement of an individual, as a member or as a dependent, to the benefits of the Program.

f.Dependent - the legal dependents of a member are: 1) the legitimate spouse who is not a member; 2) the unmarried and unemployed legitimate, legitimated, illegitimate, acknowledged children as appearing in the birth certificate; legally adopted or stepchildren below twenty-one (2 1) years of age; 3) children who are twenty-one (2 1) years old or above but suffering from congenital disability, either physical or mental, or any disability acquired that renders them totally dependent on the member for support; 4) the parents who are sixty (60) years old or above whose monthly income is below an amount to be determined by the Corporation in accordance with the guiding principles set forth in Article I of this Act.

g.Diagnostic Procedure - Any procedure to identify, a disease or condition through analysis and examination.

h.Emergency - An unforeseen combination of circumstances which calls for immediate action to preserve the life of a person or to presense the sight of one or both eyes; the hearing of one or both ears; or one or two limbs at or above the ankle or wrist.

i.Employee - Any person who performs services for an employer in which either or both mental and physical efforts are used and who receives compensation for such services, where there is an employer-employee relationship.

j. Employer - a natural or juridical person who employs the services of an employee.

k. Enrollment - the process to be determined by the Corporation in order to enlist individuals as members or dependents covered by the Program.

l. Fee for Service - a reasonable and equitable health care payment system under which physicians and other health care providers receive a payment that does not exceed their billed charge for each unit of service provided.

m. Global Budget - An approach to the purchase of medical services by which health care provider negotiations concerning the costs of providing a specific package of medical benefits is based solely on a predetermined and fixed budget.

n. Government Service Insurance System - the Government Service Insurance System created under Commonwealth Act No. 186, as amended.

o. Health Care Provider - Refers to:

p. Health Insurance Identification (ID) Card- the document issued by the Corporation to members and dependents upon their enrollment to sense as the instrument for proper identification, eligibility verification, and utilization recording.

q. Indigent - a person who has no visible means of income, or whose income is insufficient for the subsistence of his family, as identified by the Local Health Insurance Office and based on specific criteria set by, the Corporation in accordance with the guiding principles set forth in Article I of this Act;

r. Inpatient Education Package - a set of informational services made available to an individual who is confined in a hospital to afford him with knowledge about his illness and its treatment, and of the means available, particularly lifestyle changes, to prevent the recurrence or aggravation of such illness and to promote his health in general.

s. Member - Any person whose premiums have been regularly paid to the National Health Insurance Program. He may be a paying member, an indigent member, or a pensioner/retiree member.

t. Means Test - a protocol administered at the barangay level to determine the ability of individuals or households to pay varying levels of contributions to the Program, ranging from the indigent in the community whose contributions should be totally subsidized by government, to those who can afford to subsidize part but not all the required contributions for the Program.

u. Medicare - the health insurance program currently being implemented by the Philippine Medical Care Commission. It consists of:

v. National Health Insurance Program - the compulsory health insurance program of the government as established in this Act, which shall provide universal health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines.

w. Pensioner - An SSS or GSIS member who receives pensions therefrom.

x. Personal Health Services - Health services in which benefits accrue to the individual person. These are categorized into impatient and outpatient services.

y. Philippine Medical Care Commission - the Philippine Medical Care Commission created under Republic Act No. 6111, as amended.

z. Philippine National Drug Formulary - the essential drugs list for the Philippines which is prepared by the National Drug Committee of the Department of Health in consultation with experts and specialists from organized professional medical societies, medical academe and the pharmaceutical industry, and which is updated every year.

a. all persons currently eligible for benefits under Medicare Program 1, including SSS and GSIS members, retirees, pensioners and their dependents, shall immediately and automatically be made members of the National Health Insurance Program;

b. all persons eligible for benefits through health insurance plans established by local governments as part of Program II of Medicare or in accordance with the provisions of this Act, including indigent members, shall also be enrolled in the Program;

c. all persons eligible for benefits as members of local health insurance plans established by the Corporation in accordance with the implementing rules and regulations of this Act shall also be deemed to have enrolled in the Program. Enrollment of persons who have no current health insurance coverage shall be given priority by the corporation; and

d. all persons eligible for benefits as members of other government initiated health insurance programs, community-based health care organizations, cooperatives, or private non-profit health insurance plans shall be enrolled in the Program upon accreditation by the Corporation which shall devise and provide incentives to ensure that such accredited organizations will benefit from their participation in the program.

a. Inpatient hospital care:

b. Outpatient care: -

c. Emergency and transfer services; and

d. Such other health care services that the Corporation shall determine to be appropriate and cost-effective: Provided, that the Program, during its initial phase of implementation, which shall not be more than five (5) years, shall provide a basic minimum package of benefits which shall be defined according to the following guidelines:

a. non-prescription drugs and devices;

b. outpatient psychotherapy and counseling for mental disorders;

c. drug and alcohol abuse or dependency treatment;

d. cosmetic surgery;

e. home and rehabilitation services;

f. optometric services;

g. normal obstetrical delivery; and

h. cost-ineffective procedures which shall be defined by the Corporation.

a. Retirees and pensioners of the SSS and GSIS prior to the effectivity of this Act;

b. Members who reach the age of retirement as provided for by law and have paid at least one hundred twenty (120) monthly contributions; and

c. Enrolled indigents.

a. to administer the National Health Insurance Program;

b. to formulate and promulgate policies for the sound administration of the Program;

c. to set standards, rules, and regulations necessary to ensure quality of care, appropriate utilization of services, fund viability, member satisfaction, and overall accomplishment of Program objectives;

d. to formulate and implement guidelines on contributions and benefits; portability of benefits, cost containment and quality assurance; and health care provider arrangements, payment methods, and referral systems;

e. to establish branch offices as mandated in Article V of this Act;

f. to receive and manage grants, donations, and other forms of assistance;

g. to sue and be sued in court;

h. to acquire property, real and personal, which may be necessary or expedient for the attainment of the purposes of this Act;

i. to collect, deposit, invest, administer, and disburse the National Health Insurance Fund in accordance with the provisions of this Act;

j. to negotiate and enter into contracts with health care institutions, professionals, and other persons, juridical or natural, regarding the pricing, payment mechanisms, design and implementation of administrative and operating systems and procedures, financing, and delivery of health services;

k. to authorize Local Health Insurance Offices to negotiate and enter into contracts in the name and on behalf of the Corporation with any accredited government or private sector health provider organization, including but not limited to health maintenance organizations, cooperatives and medical foundations, for the provision of at least the minimum package of personal health services prescribed by the Corporation;

l. to determine requirements and issue guidelines for the accreditation of health care providers for the Program in accordance with this Act;

m. to supervise the provision of health benefits with the power to inspect medical and financial records of health care providers and patients who are participants in or members of the Program, and the power to enter and inspect accredited health care institutions, subject to the rules and regulations to be promulgated by the Corporation;

n. to organize its office, fix the compensation of and appoint personnel as may be deemed necessary and upon the recommendation of the president of the Corporation;

o. to submit to the President of the Philippines and to both Houses of Congress its Annual Report which shall contain the status of the National Health Insurance Fund, its total disbursements, reserves, average costings to beneficiaries, any request for additional appropriation, and other data pertinent to the implementation of the Program and publish a synopsis of such report in two (2) newspapers of general circulation;

p. to keep records of the operations of the Corporation and investments of the National Health Insurance Fund; and

q. to perform such other acts as it may deem appropriate for the attainment of the objectives of the Corporation and for the proper enforcement of the provisions of this Act.

a. to conduct investigations for the determination of a question, controversy, complaint, or unresolved grievance brought to its attention, and render decisions, orders, or resolutions thereon. It shall proceed to hear and determine the case even in the absence of any party who has been properly served with notice to appear. It shall conduct its proceedings or any part thereof in public or in executive session; adjourn its hearings to any time and place; refer technical matters or accounts to an expert and to accept his reports as evidence; direct parties to be joined in or excluded from the proceedings; and give all such directions as it may deem necessary or expedient in the determination of the dispute before it;

b. to summon the parties to a controversy, issue subpoenas the attendance and testimony of witnesses or the production of documents and other materials necessary to a just determination of the under investigation;

c. to suspend temporarily, revoke permanently, or restore the accreditation of a health care provider or the right to benefits of a member and/or impose fines after due notice and hearing. the decision shall immediately be executory, even pending appeal, when the public interest so requires and as may be provided for in the implementing rules and regulations. Suspension of accreditation shall not exceed twenty-four (24) months. Suspension of the rights of members shall not exceed six (6) months.

The Secretary of Health;

The Secretary of Labor and Employment or his representative;

The Secretary of the Interior and Local Government or his representative;

The Secretary of Social Welfare and Development or his representative;

The President of the Corporation;

A representative of the labor sector;

A representative of employers;

a. Appointment and Tenure - the President of the Philippines shall appoint for a non-reneavable term of six (6) years the President of the Corporation, hereinafter referred to as the President, upon the recommendation of the Board. the President shall not be removed from office except in accordance with existing laws.

b. Duties and Functions - the President shall have the duty of advising the Board and carrying into effect its policies and decisions. His functions are as follows:

c. Qualifications - the President must be a Filipino citizen and must adequate and appropriate training and at least five (5) years experience in the field of health care financing and corporate management.

d. Salary - the President shall receive a salary to be fixed by the Board, with the approval of the President of the Philippines, payable from the funds of the Corporation.

e. Prohibition - to avoid conflict of interest. the President must not care institution as owner or member of its board.

a. development of broad conceptual framework for implementation of the Program through a national health finance master plan to ensure sustained investments in health care, and to provide guidance for addition appropriations from the National Government;

b. conduct of researches and studies toward the development of policies necessary to ensure the viability, adequacy and responsiveness of the Program;

c. review, evaluation, and assessment of the Program's impact on to access to, as well as the quality and cost of, health care in the country;

d. periodic review of fees, charges, compensation rates, capitation rates, medical standards, health outcomes and satisfaction of members, benefits, and other matters pertinent to the operations of the Program;

e. comparison in the delivery, quality, use, and cost of health care services of the different Offices;

f. submission for consideration of program of quality assurance, utilization review, and technology assessment; and

g. submission of recommendations on policy and operational issues that will help the Corporation meet the objectives of this Act.

a) to consult and coordinate, as needed, with the local government units within its jurisdiction in the implementation of the Program;

b) to recruit and register members of the Program from all areas within its jurisdiction;

c) to collect and receive premiums and other payment contributions to the Program;

d) to maintain and update the membership eligibility list at community levels;

e) to supervise the conduct of means testing which shall be based on the criteria set by the Corporation and undertaken by the Barangay Captain in coordination with the social welfare officer and community-based health care organizations to determine the economic status of all households and individuals, including those who are indigent;

f) to issue health insurance ID cards to persons whose premiums have been paid according to the requirements of the Office and the guidelines issued by the Board;

g) to recommend to the Board premium schedules that provide for lower rates to be paid by members whose dependents include those with reduced probability of utilization, as in fully immunized children;

h) to recommend to the Board a contribution schedule which specifies contribution levels by individuals and households, and a corresponding uniform package of personal health service benefits which is at least equal to the minimum package of such benefits prescribed by the Board as applying to the nation;

i) to grant or deny accreditation to health care providers in their area of jurisdiction, subject to the rules and regulations to be issued by the Board;

j) to process, review and pay the claims of providers, within a period not exceeding sixty (60) days whenever applicable in accordance with the rules and guidelines of the Corporation;

k) to pay fees, as necessary, for claims review and processing when such are conducted by the central office of the Corporation or by any of its contractors;

l) to establish referral systems and network arrangements with other Offices, as may be necessary and following the guidelines set by the Corporation;

m) to establish mechanisms by which private and public sector health facilities and human resources may be shared in the interest of optimizing the use of health resources;

n) to support the management information system requirements of the Corporation;

o) to serve as the first level for appeals and grievance cases;

p) to tap community-based volunteer health workers and barangay officials, if necessary, for member recruitment, premium collection and similar activities, and to grant such workers incentives according to the guidelines set by the Corporation and in accordance with applicable laws. However, the incentives for the barangay officials shall accrue to the barangay and not to the said officials.

q) to participate in information and education activities that are consistent with the government's priority programs on disease prevention and health promotion; and

r) to prepare an annual report according to guidelines set by the Board and to submit the same to the central office of the Corporation.

a) Contributions from Program members;

b) Current balances of the Health Insurance Funds of the SSS and the GSIS collected under the Philippine Medical Care Act of 1969, as amended, including arrearages of the Government of the Philippines with the GSIS for the said Fund;

c) Other appropriations earmarked by the national and local governments purposely for the implementation of the Program;

d) Subsequent appropriations provided for under Sections 46 and 47 of this Act;

e) Donations and grants-in-aid; and

f) All accruals thereof.

a) The Basic Benefit Fund. This Fund shall finance the availment of the basic minimum benefit package by eligible beneficiaries. All liabilities associated with the extension of entitlement to the basic minimum benefit package to the enrolled population shall be home by the basic benefit fund. It shall be constituted and maintained through the following process:

b) Supplementary Benefit Funds. These are separate and distinct supplementary benefit funds created by the Corporation as eligible for use to provide supplementary coverage to various groups of the population enjoying the basic benefit coverage as are affordable by their respective funding sources. Each supplementary benefit fund shall finance the extension and availment of additional benefits not included in the basic minimum benefit package but approved by the Board. Such supplementary benefits shall be financed by whatever amounts are available after deducting the costs of providing the basic minimum benefit package, including costs of direct benefit payments, all costs of administration, and provision of adequate reserves. All liabilities associated with the extension of supplementary benefits to the defined group of enrollees shall be come exclusively by the respective supplementary benefit fund. Upon the implementation of this Act, the following supplementary benefit funds shall be established:

In accordance with the principles of equity and social solidarity, as enunciated in Section 2 of this Act, the above supplementary benefit funds shall be maintained for not more than five (5) years, after which, such funds shall be merged into the basic benefit fund.

a) All funds under the management and control of the Corporation shall be subject to all rules and regulations applicable to public funds.

b) The Corporation is authorized to charge the various funds under its control for the costs of administering the Program. Such costs may include administration, monitoring, marketing and promotion, research and development, audit and evaluation, information services, and other necessary activities for the effective management of the Program. the total annual costs for these shall not exceed twelve percent (12%) of the total contributions, including government contributions to the Program and not more than three percent (3%) of the investment earnings collected during the immediately preceding year.

a) In interest-bearing bonds, securities or other evidences of indebtedness of the Government of the Philippines, or in bonds, securities, promissory notes and other evidences of indebtedness to which full faith and credit and unconditional guarantee of the Republic of the Philippines is pledged;

b) In interest-bearing deposits and loans to or securities in any domestic bank doing business in the Philippines: Provided, That in the case of such deposits, this shall not exceed at any time the unimpaired capital and surplus or total private deposits of the depository bank, whichever is smaller: Provided, further, That said bank shall first have been designated as a depository for this purpose by the Monetary Board of the Bangko Sentral ng Pilipinas; and

c) In preferred stocks of any solvent corporation or institution created or existing under the laws of the Philippines: Provided, That the issuing, assuming, or guaranteeing entity or its predecessor has paid regular dividends upon its preferred or guaranteed stocks for a period of at least three (3) years immediately preceding the date of investment in such preferred or guaranteed stocks: Provided, further, That if the stocks are guaranteed the amount of stocks so guaranteed is not in excess of fifty percent (50%) of the amount of the preferred common stocks as the case may be of the issuing corporations: Provided, furthermore, That if the corporation or institution has not paid dividends upon its preferred stocks, the corporation or institution has sufficient retained earnings to declare dividends for at least two (2) years on such preferred stocks and in common stocks option or warrants to common stocks of any solvent corporation or institution created or existing under the laws of the Philippines in the stock exchange with proven track record of profitability and payment of dividends over the last three (3) years or in common stocks of a newly organized corporation about to be listed in the stock exchange: Provided, finally, That such duly organized corporations shall have been rated 'A', double 'A's or triple 'A's by authorized accredited domestic rating agencies or by the Corporation or in mutual funds including allied investments.

a) Formal sector employees and current medicare members and their employers shall continue paying the same monthly contributions as provided for by law until such time that the Corporation shall have determined the contribution schedule mentioned herein: Provided, That their monthly contribution shall not exceed three percent (3%) of their respective monthly salaries.

b) Contributions from self-employed members shall be based primarily on household earnings and assets; their total contributions for one year shall not, however, exceed three percent (3%) of their estimated actual net income for the preceding year.

c) Contributions made in behalf of indigent members shall not exceed the minimum contributions set for employed members.

a) human resource, equipment and physical structure in conformity with the standards of the relevant facility, as determined by the Department of Health;

b) acceptance of formal program of quality assurance and utilization review;

c) acceptance of the payment mechanisms specified in the following section;

d) adoption of referral protocols and health resources sharing arrangements;

e) recognition of the rights of patients; and

f) acceptance of information system requirements and regular transfer of information.

a) Fee-for-service based on mechanisms established by the Corporation;

b) Capitation of health care professionals and facilities, or networks of the same including HMOS, medical cooperatives, and other legally formed health service groups;

c) A combination of both; and

d) Any or all of the above, subject to a global budget.

a) to ensure that the quality of personal health services delivered, measured in terms of inputs, process, and outcomes, are of reasonable quality in the context of the Philippines over time;

b) to ensure that the health care standards are uniform within the Office's jurisdiction and eventually throughout the nation; and

c) to see to it that the acquisition and use of scarce and expensive medical technologies and equipment are consistent with actual needs and standards of medical practice, and that:

a) over-utilization of services;

b) unnecessary diagnostic and therapeutic procedures and intervention;

c) irrational medication and prescriptions;

a) any violation of the rights of patients;

b) a willfull neglect of duties of Program implementors that results in the loss or non-enjoyment of benefits by members or their dependents;

c) unjustifiable delay in actions on claims;

d) delay in the processing of claims that extends beyond the period agreed upon; and

e) any other act or neglect that tends to undermine or defeat the purposes of this Act.

a) A complaint for grievance must be filed with the Office which shall rule on the complaint within ninety (90) calendar days from receipt thereof.

b) Appeals from Office decisions must be filed with the Board within thirty (30) days from receipt of notice of dismissal or disallowance by the Office.

c) The Offices shall have no jurisdiction over any issue involving the suspension or revocation of accreditation, the imposition of fines, or the imposition of charges on members or their dependents in case of revocation of their entitlement.

d) All decisions by the Board as to entidement to benefits of members or to payments of health care providers shall be considered final and executory.