Law Summary
Declaration of Principles and Policies
- The State adopts an integrated and comprehensive health development approach.
- Essential health goods and services should be affordable and accessible to all.
- Free medical care shall be provided to paupers.
- A socialized health insurance program prioritizes underprivileged groups including the sick, elderly, PWDs, women, and children.
Definitions Key to the National Health Insurance Program
- Dependent: Includes parents aged 60+ with income below a set amount and those with permanent disabilities.
- Fee-for-service: Pre-determined fees for each health service based on bills and schedules.
- Indigent: Persons with insufficient income identified by DSWD.
- Member: Those who regularly pay premiums, including paying, sponsored, and lifetime members.
- Retiree: Members retired by law or due to permanent disability.
- Other terms include abandoned children, case-based payment, health technology assessment, informal sector, other self-earning individuals, out-patient services, professional practitioners, traditional and alternative health care, lifetime members, members in formal and informal economy, migrant workers, and sponsored members.
Mandatory Coverage
- All Filipino citizens must be covered by the National Health Insurance Program (NHIP).
- Program implementation ensures coverage sustainability and quality services nationwide, including areas covered by LGU-based health insurance.
Enrollment Procedures
- The Corporation enrolls beneficiaries into categories: formal economy, informal economy, indigents, sponsored members, and lifetime members.
- Enrollment process includes beneficiary identification and issuance of eligibility documents.
Health Insurance ID Card
- The Corporation issues health insurance ID cards with corresponding numbers for identification and benefit verification.
- Absence of the ID card does not preclude benefit access.
- The ID card is recognized as valid government identification.
Benefit Package
- Minimum services include inpatient hospital care (room, professional services, lab exams, drugs) and outpatient care (professional services, diagnostics, preventive services, drugs).
- Emergency and transfer services plus other cost-effective health care services as determined by the Corporation and DOH.
- Annual review of benefits for financial sustainability and quality assurance.
Exclusions
- The Corporation excludes cost-ineffective health services as determined by health technology assessment.
- Additional reasonable exclusions and limitations may be imposed.
Entitlement to Benefits
- Members must pay premiums for at least 3 months within 6 months before availment.
- Retirees, pensioners before this Act's effectivity, and lifetime members need not pay monthly contributions.
Powers and Functions of the Corporation
- Supervise health benefits provision and set quality standards.
- Negotiate contracts on pricing, payment, and service delivery.
- Inspect health care facilities and records.
- Keep operational and investment records.
- Maintain secured electronic member databases.
- Promote health insurance information campaigns.
- Conduct audits and quality reviews.
- Establish overseas offices for OFW claims.
- Impose interest or surcharges on delayed employer contributions.
- Support technology use for health care delivery.
- Enforce compliance among regulatory agencies.
- Require proof of PhilHealth membership for business transactions.
- Accredit pharmacies and drug outlets.
- Perform other acts for objectives and enforcement.
Quasi-Judicial Powers
- Investigate and resolve disputes or grievances with due process.
- Conduct hearings in public or executive session.
- Suspend or revoke provider accreditation or member benefits.
- Decisions immediately executory if public interest requires.
- Not bound by technical rules of evidence.
Board of Directors Composition and Appointment
- Includes secretaries of Health, Labor, Interior, Social Welfare, Finance; PHIC President; SSS and GSIS representatives; sectoral representatives including migrant workers, informal/formal economy members, health providers, local chief executives, independent director.
- Secretary of Health as ex officio Chair, PHIC President as Vice-Chair.
- Appointed members serve terms under the GOCC Governance Act.
President of the Corporation
- Appointed by the President of the Philippines upon Board recommendation.
- One-year tenure.
Health Finance Policy Research Department
- Conducts quality assurance, utilization review, technology assessments.
- Recommends policy and operational improvements.
- Conducts client-satisfaction surveys and outcome assessments.
National Health Insurance Fund
- Composed of member contributions, government appropriations, donations, grants, and accruals.
Financial Management
- Subject to public fund rules and Board resolutions.
- Administration costs capped by percentage of contributions, reimbursements, and investment earnings.
- Cost ceiling to be implemented within five years.
Reserve Fund
- Portion of accumulated revenues set aside up to a ceiling for two years' projected expenditures.
- Excess reserved for benefits enhancement, contribution reduction, and health facilities support.
- Investment reserve fund to be invested in government bonds, debt securities of rated institutions, banks, preferred stocks, and bonds of medical institutions under specified conditions and limits.
- External fund managers may be hired.
- Funds segmented for pre-lifetime member benefits, lifetime member payouts, and optional supplemental benefits.
- Managed actuarially sound.
Contribution Guidelines
- Formal economy members and employers pay based on salary not exceeding 5%, with government appropriations included in annual budgets.
- Informal sector contributions based on household earnings/assets with subsidies for lowest income.
- Indigent contributions capped at employed members' minimum.
- Lifetime member monthly premium requirements may be increased based on actuarial studies.
Payment for Indigent Contributions
- Fully subsidized by the national government with amounts appropriated through DOH.
Payment for Sponsored Members' Contributions
- Contributions for vulnerable groups under DSWD care paid by DSWD.
- Barangay health and nutrition workers’ contributions paid by LGUs.
- House helpers' contributions fully paid by employers.
Coverage for Women About to Give Birth
- Premiums for unenrolled pregnant women fully borne by national government, LGUs, or sponsors.
Accreditation Eligibility for Health Providers
- Providers operating at least 3 years may apply.
- New providers may qualify if certain criteria met (experienced management, tertiary facility, underserved LGU areas).
- Providers guilty of violations disqualified from accreditation renewal.
Provider Payment Mechanisms
- Allowed mechanisms: fee-for-service, capitation, case-based payment, global budget, other approved mechanisms.
- Local offices may recommend payment mechanisms, favoring remote/underserved areas.
Payment Guidelines for Provider Services
- No charges to indigent patients beyond NHIP coverage.
- Salaried public providers retain payments at facility level, used for operating costs excluding salaries.
Claims Reimbursement and Filing Period
- Claims filed within 60 days of patient discharge; extensions allowed by Corporation.
Role of Local Government Units (LGUs)
- Provide basic health services and manage capitation funds for health facilities and services.
- Capitation payments placed in trust funds for mandated health purposes.
Grievance and Appeal Procedures
- Complaints filed with Corporation for Grievance and Appeal Review Committee resolution within 60 days.
- Appeals filed with Board within 30 days.
Grievance and Appeal Review Committee Composition
- Five members including a representative of accredited health providers.
Penal Provisions
- Accredited providers fined P50,000-P100,000 or suspended; recidivists barred from accreditation.
- Members fined P5,000 or suspended 3-6 months for false claims.
- Employers fined P5,000 per employee for failure to register/deduct/remit contributions or unlawful deductions.
- Corporation employees misappropriating funds fined P10,000-P20,000.
- Other violations fined P5,000-P20,000.
- Proceedings continue despite cessation of provider operations.
- Decisions on fines and claims immediately executory.
License or Permit Issuance or Renewal Requirement
- Government agencies must require proof of PhilHealth contributions before issuing or renewing professional/business licenses or permits.
Joint Congressional Oversight Committee
- Composed of 10 members (5 Senate, 5 House), co-chaired by health committees from both chambers.
- Conducts regular reviews and validation studies on NHIP performance.
- Annual report and study funding sourced at 0.001% of the Corporation's previous year income.
Implementing Rules and Regulations
- To be issued within 60 days of the Act’s effectivity by the Corporation in coordination with DOH.
Separability Clause
- Invalid parts of the law do not affect remaining provisions.
Repealing Clause
- Inconsistent laws, issuances, or parts are repealed or modified accordingly.
Effectivity
- The Act takes effect 15 days after publication in the Official Gazette or two newspapers of general circulation.