QuestionsQuestions (Republic Act No. 11223)
The short title is the “Universal Health Care Act.” It institutes universal health care for all Filipinos by prescribing health care system reforms and appropriating funds to implement universal coverage, service access, and financial risk protection.
The State shall protect the right to health and adopt: (a) an integrated and comprehensive approach; (b) a health care model providing access to quality and cost-effective services without financial hardship and prioritizing those who cannot afford care; (c) a whole-of-system/whole-of-government/whole-of-society framework for policy development and evaluation; and (d) a people-oriented service delivery approach centered on needs and well-being.
Primary care is initial-contact, accessible, continuous, comprehensive, coordinated care available at the time of need, covering all presenting conditions, and coordinating referrals when necessary. It is the foundation for access and navigation/referral coordination.
“Emergency” refers to a condition based on objective findings of a prudent medical officer where immediate danger exists and delay may cause loss of life/permanent disability, or for pregnant women permanent injury/loss of unborn child, or a non-institutional delivery. It matters because emergency situations affect eligibility and access to services under the Act’s coverage rules.
Every Filipino citizen is automatically included into the NHIP (the Program).
Every Filipino must have access to preventive, promotive, curative, rehabilitative, and palliative care for medical, dental, mental, and emergency health services. Goods and services included must be determined through a fair and transparent HTA process.
Every Filipino shall register with a public or private primary care provider of choice. The DOH shall promulgate guidelines on licensing primary care providers and registration of every Filipino to a primary care provider.
Population-based services are financed by the National Government through the DOH and provided free of charge at point of service for all Filipinos. Individual-based services are financed primarily through prepayment mechanisms such as social health insurance, private health insurance, and HMO plans.
Membership is simplified into two types: direct contributors and indirect contributors. Indirect contributors’ premiums are subsidized by the national government (including those subsidized due to special laws).
PhilHealth identification card shall not be required to avail of any health service; no co-payment for basic/ward accommodation; co-payments/co-insurance for amenities in public hospitals are regulated by DOH and PhilHealth; and the current PhilHealth package shall not be reduced. Failure to pay premiums shall not prevent enjoyment of Program benefits (with rules on missed contributions for direct contributors).
Failure to pay premiums shall not prevent enjoyment of Program benefits. Employers and self-employed direct contributors must pay missed contributions with interest: at least 3% compounded monthly for employers, and not exceeding 1.5% for self-earning/professional practitioners and migrant workers.
PhilHealth must set aside reserve funds not needed for the current year, with total reserves not exceeding an actuarial estimate for two years of projected expenditures. If actual reserves exceed the required ceiling at fiscal year end, the excess shall be used to increase Program benefits and decrease members’ contributions.
No more than 7.5% of the actual total premium collected from direct and indirect contributors during the immediately preceding year may be allotted for administrative cost of implementing the Program.
The Board has a maximum of 13 members: 5 ex-officio members (Secretaries of Health, DSWD, Budget and Management, Finance, Labor and Employment); 3 expert panel members; and 5 sectoral panel members (representing direct contributors, indirect contributors, employers, health care providers, and elected local chief executives). At least one expert panel and at least two sectoral panel members must be women.
Upon recommendation of the Board, the President of the Philippines appoints the PhilHealth President and CEO. The Board cannot recommend unless the candidate is a Filipino citizen and has at least seven years of experience in public health, management, finance, and health economics or a combination of these.
They must include: (a) a primary care provider network with accessible patient records throughout the system; (b) accurate, sensitive, and timely epidemiologic surveillance systems; and (c) proactive and effective health promotion programs/campaigns.
Province-wide or city-wide health systems must pool and manage resources through a special health fund to finance population-based and individual-based health services, health system operating costs, capital investments, and remuneration/incentives for additional health workers, subject to DOH guidelines.
Providers must make accessible to the public and submit to DOH and PhilHealth up-to-date information on prices of health services and goods/services offered. Drug outlets must carry generic equivalents of all drugs in the Primary Care Formulary and provide customers with a list of therapeutic equivalents and corresponding prices when fulfilling prescriptions or in any transaction.
Investments on any health technology or development of any benefit package by DOH and PhilHealth must be based on positive recommendations from the HTA process.
For contracted providers: unethical acts, abuse of authority, or fraudulent acts may result in a fine of PHP 200,000 per count, contract suspension up to three months or remaining contract/accreditation period (whichever is shorter), or both (PhilHealth discretion, considering gravity), and may also be a criminal violation punishable by imprisonment from 6 months and 1 day up to 6 years depending on court discretion. For members: violations or knowingly cooperating/agreeing to a provider/employer violation (including filing fraudulent claims) may result in a fine of PHP 50,000 per count, suspension from Program benefits for at least 3 months but not more than 6 months, or both at PhilHealth discretion.