QuestionsQuestions (Republic Act No. 9241)
RA 9241 amends Section 4 by defining terms such as Beneficiary, Benefit Package, Capitation, Contribution, Coverage, Dependent (including specific categories and ages), Diagnostic Procedure, Emergency, Employee, Employer, Enrollment, Fee for Service, Global Budget, Health Care Provider (institutions, professionals, HMOs, and community-based health organizations), Health Insurance ID Card, Indigent, Inpatient Education Package, Member, Means Test, Medicare programs, National Health Insurance Program, and others like Utilization Review and Home Care and Medical Rehabilitation Services. These definitions control statutory interpretation—courts and the implementing agencies must apply the precise meanings when determining eligibility, obligations, accreditation, and what services are covered or excluded.
The law enumerates legal dependents: (1) legitimate spouse not a member; (2) unmarried unemployed children (legitimate/legitimated/illegitimate/acknowledged), plus legally adopted or step-children below 21; (3) children 21+ with congenital disability or disability acquired rendering them totally dependent; and (4) parents 60+ whose monthly income is below an amount to be determined by PhilHealth. Practically, member eligibility for dependents affects entitlement to benefits and compliance with documentary requirements.
Capitation is a negotiated fixed rate (per person/family/household/group) paid to a provider who is responsible for delivering or arranging required services under a contract. Fee for Service is a payment system where providers receive payment not exceeding their billed charge for each unit of service provided. The distinction affects provider payment incentives and cost management.
Global Budget is an approach to purchasing medical services where negotiations on cost of a specific package of medical benefits are based solely on a predetermined and fixed budget. It links provider contracting to budget ceilings rather than per-service billings.
Section 11 (Excluded Personal Health Services) excludes: (1) non-prescription drugs and devices; (2) alcohol abuse or dependency treatment; (3) cosmetic surgery; (4) optometric services; (5) fifth and subsequent normal obstetrical deliveries; and (6) cost-ineffective procedures defined by the Corporation. Inclusion requires actuarial studies, recommendation by the Corporation, and approval by the Board.
Actuarial studies must be done within three (3) years, and then periodically reviewed to determine financial sustainability of including the excluded services in the benefit package.
The Board includes: Secretary of Health; Secretary of Labor and Employment; Secretary of the Interior and Local Government; Secretary of Social Welfare and Development; President of the Corporation; representatives of labor sector, employers, SSS and GSIS (Administrator/General Manager and their reps), Vice Chairperson (basic sector) of the National Anti-Poverty Commission, overseas workers, self-employed sector, and health care providers (endorsed by national associations). The Secretary of Health is ex officio Chairperson, while the President of the Corporation is Vice Chairperson.
The President appoints Board members upon recommendation of the Chairperson and consultation with concerned sectors. Term is four (4) years, renewable for a maximum of two (2) years, except for members whose terms are co-terminous with their government positions. Vacancies are filled like the original appointment; the appointee serves only the unexpired term.
Regular meetings must be held at least once a month. Special meetings may be convened by the Chairperson or by a majority of Board members. Quorum is the presence of a majority of all members.
If violations consist of failure or refusal to deduct contributions from the employee’s compensation or to remit them, the penalty is: a fine of not less than P500 but not more than P1,000 multiplied by the total number of employees employed by the firm, and imprisonment of not less than six (6) months but not more than one (1) year.
Indigent contributions are subsidized partially by the LGU where the member resides. PhilHealth provides counterpart financing equal to the LGU subsidy. For fourth, fifth, and sixth class municipalities, the National Government provides up to 90% of the subsidy for indigents until upgraded to first, second, or third class municipalities. LGU share increases progressively until it equals the National Government’s share.
Health care providers operating for at least three (3) years may apply for accreditation. Those operating less than three (3) years may still qualify if they meet other accreditation requirements and satisfy conditions such as: managing health care professional has at least three (3) years experience in another accredited institution; it operates as a tertiary facility or equivalent; it operates in a locality where the accredited provider cannot adequately service the population; or other conditions determined by PhilHealth.
Congress conducts regular review of NHIP performance, impact, or accomplishments against its objectives/goals. Committees of the Senate and House with legislative jurisdiction undertake the review. NEDA, in coordination with NSO and UP’s National Institutes of Health, undertakes studies to validate accomplishments.
The budget required to undertake the studies comes from the income of PhilHealth.
The separability clause provides that if any part of the law is held unconstitutional or invalid, the remaining parts not affected continue in force. The repealing clause states that all inconsistent laws, decrees, orders, rules, and regulations or parts thereof are repealed, amended, or modified accordingly.
It takes effect fifteen (15) days after publication in at least three (3) national newspapers of general circulation. Publication is required to satisfy the constitutional/legal requirement of promulgation/notice so the public and concerned entities are deemed informed of the law.