Question & AnswerQ&A (Republic Act No. 7875)
The short title of Republic Act No. 7875 is the "National Health Insurance Act of 1995."
The main purpose of the National Health Insurance Program is to provide all citizens of the Philippines with the mechanism to gain financial access to health services and to establish a sustainable system for financing the availment of health insurance benefits.
Beneficiaries are any persons entitled to health care benefits under the Act, including members and their legal dependents.
Dependents include: 1) the legitimate spouse who is not a member; 2) unmarried and unemployed legitimate, legitimated, illegitimate, acknowledged children below 21 years old or disabled older children; 3) parents 60 years old or above with income below the amount set by the Corporation.
Guiding principles include Allocation of National Resources for Health, Universality, Equity, Responsiveness, Social Solidarity, Effectiveness, Innovation, Devolution, Fiduciary Responsibility, Informed Choice, Maximum Community Participation, Compulsory Coverage, Cost Sharing, Professional Responsibility of Health Care Providers, Public Health Services, Quality of Services, Cost Containment, and Care for the Indigent.
Benefits include inpatient hospital care (room, board, professional services, diagnostics, prescription drugs), outpatient care, emergency and transfer services, and other appropriate health services as determined by the Corporation, with priority on cost-effectiveness and reducing financial burden.
Retirees and pensioners of SSS and GSIS prior to the Act, members who reached retirement age with at least 120 monthly contributions, and enrolled indigents.
They may be fined between P10,000 and P50,000, and their accreditation may be suspended or revoked from three months to the entire accreditation term. Recidivists may no longer be accredited.
Violations may result in fines of P500 to P5,000 and imprisonment from six months to one year.
The Corporation administers the Program, formulates policies, manages funds, accredits health care providers, oversees quality assurance, and generally ensures the implementation and financial stability of the National Health Insurance Program.
The President is appointed for a non-renewable term of six years. Qualifications include Filipino citizenship, adequate training, and at least five years' experience in health care financing and corporate management.
Portability allows a member to avail of Program benefits in an area outside the jurisdiction of their Local Health Insurance Office.
The Board has 11 members including the Secretaries of Health, Labor, Interior, Social Welfare, the Corporation President, representatives of labor, employers, self-employed sector, health care providers, and the SSS and GSIS administrators or their representatives.
Complaints can be filed with the Local Health Insurance Office, which must rule within 90 days; appeals go to the Board within 30 days. The Board's decisions are final and executory, and a Grievance and Appeal Review Committee hears cases as provided in the Act.
Minimum requirements include conformity with DOH standards for human resources and facilities, acceptance of quality assurance and utilization review programs, agreed payment mechanisms, adoption of referral protocols, recognition of patient rights, and acceptance of information system requirements.
It consists of contributions from members, balances of SSS and GSIS Health Insurance Funds, appropriations from national and local government, donations, grants-in-aid, and all accruals thereof.
Contributions come from formal sector employees and employers, self-employed members based on household earnings and assets, government subsidies especially for indigents, and other appropriations as provided by law.
The Corporation shall maintain reserves not exceeding two years' projected expenditures, invest excess reserves in prescribed financial instruments, and adjust member contributions or benefits if reserves exceed the ceiling.
SSS and GSIS members are automatically enrolled; their Health Insurance Funds are transferred to the Corporation, and supplementary benefit funds for these groups are maintained but will merge into the basic fund within five years.