Legal Basis and Amended Provisions
- Section 1 of Republic Act No. 9241 amends Section 4 of Republic Act No. 7875 (Definition of Terms).
- Section 2 of Republic Act No. 9241 amends Section 11 of Republic Act No. 7875 (Excluded Personal Health Services).
- Section 3 of Republic Act No. 9241 amends Section 18 of Republic Act No. 7875 (The Board of Directors).
- Section 4 of Republic Act No. 9241 amends Section 29 of Republic Act No. 7875 (Payment of Indigent Contributions).
- Section 5 of Republic Act No. 9241 amends Section 32 of Republic Act No. 7875 (Accreditation Eligibility).
- Section 6 of Republic Act No. 9241 amends the third paragraph of Section 44 (Penal Provisions) of Republic Act No. 7875 (Employer non-deduction/non-remittance penalty).
- Section 7 of Republic Act No. 9241 amends Section 54 of Republic Act No. 7875 (Oversight Provision).
- Sections 8–9 provide separability and repealing rules, and Section 10 sets the effectivity date.
Defined Terms: Core NHIP Concepts
- Section 4 of Republic Act No. 7875 defines Beneficiary as any person entitled to health care benefits under the Act.
- Section 4 defines Benefit Package as the services the Program offers to its members.
- Section 4 defines Capitation as a fixed-rate payment mechanism per person, family, household, or group negotiated with a health care provider, who is responsible for delivering or arranging delivery of required services under a health care provider contract.
- Section 4 defines Contribution as the amount paid by or in behalf of a member to the Program for coverage, based on salaries or wages for formal sector employees, and on household earnings and assets for self-employed persons, or other criteria defined by the Corporation in line with the guiding principles in Article I of Republic Act No. 7875.
- Section 4 defines Coverage as the entitlement of an individual, as a member or dependent, to the Program benefits.
- Section 4 defines Dependent to include specific categories and age/disability/income qualifications, including: the legitimate spouse not a member; unmarried and unemployed legitimate/legitimated/illegitimate/acknowledged children as appearing in the birth certificate; legally adopted or step-children below twenty-one (21) years of age; children twenty-one (21) years old and above with congenital or acquired disability rendering them totally dependent; and parents aged sixty (60) and above with monthly income below an amount to be determined by the Corporation in accordance with the guiding principles in Article I.
- Section 4 defines key operational terms including Diagnostic Procedure, Emergency, Employee, Employer, Enrollment, Fee for Service, Global Budget, Government Service Insurance System, Health Care Provider, Health Insurance Identification (ID) Card, Indigent, Inpatient Education Package, Member, Means Test, Medicare, National Health Insurance Program, Pensioner, Personal Health Services, Philippine Medical Care Commission, Philippine National Drug Formulary, Portability, Prescription Drug, Public Health Services, Quality Assurance, Residence, Retiree, Self-employed, Social Security System, Treatment Procedure, Utilization Review, Rehabilitation Center, and Home Care and Medical Rehabilitation Services.
Excluded Personal Health Services
- Section 11 provides that the benefits granted under the Act do not cover expenses for the enumerated Excluded Personal Health Services, unless the Corporation recommends inclusion after actuarial studies and the Board approves.
- The excluded services are non-prescription drugs and devices.
- The excluded services are alcohol abuse or dependency treatment.
- The excluded services are cosmetic surgery.
- The excluded services are optometric services.
- The excluded services are fifth and subsequent normal obstetrical deliveries.
- The excluded services are cost-ineffective procedures, defined by the Corporation.
- Section 11 requires actuarial studies to be done within three (3) years and then periodically reviewed to determine the financial sustainability of including the excluded personal health services in the benefit package under Section 10 of the Act.
Governance: Board Composition and Meetings
- Section 18 establishes that the Corporation is governed by a Board of Directors composed of: the Secretary of Health; the Secretary of Labor and Employment (or representative); the Secretary of the Interior and Local Government (or representative); the Secretary of Social Welfare and Development (or representative); the President of the Corporation; a representative of the labor sector; a representative of employers; the SSS Administrator (or representative); the GSIS General Manager (or representative); the Vice Chairperson for the basic sector of the National Anti-Poverty Commission (or representative); a representative of Filipino overseas workers; a representative of the self-employed sector; and a representative of health care providers endorsed by national associations of health care institutions and medical health professionals.
- Section 18 makes the Secretary of Health the ex officio Chairperson and makes the President of the Corporation the Vice Chairperson of the Board.
- Section 18 provides that the President of the Philippines appoints Board members upon recommendation of the Chairman of the Board and in consultation with the sectors concerned.
- Section 18 sets a Board term of four (4) years each, renewable for a maximum of two (2) years, except that members whose terms are co-terminous with their respective government positions.
- Section 18 provides that vacancies are filled in the same manner as original appointment, and the appointee serves only the unexpired term.
- Section 18 requires regular meetings at least once a month, allows special meetings upon call of the Chairperson or by a majority of Board members, and provides that the presence of a majority of all the members constitutes quorum.
- Section 18 provides that when the Chairperson and Vice Chairperson are absent, a temporary presiding officer is designated by the majority of the quorum.
- Section 18 provides that Board members receive a per diem for every meeting actually attended, subject to pertinent budgetary laws, rules, and regulations on compensation, honoraria, and allowances.
Indigent Subsidy Funding Rules
- Section 29 provides that contributions for indigent members are subsidized partially by the local government unit where the member resides.
- Section 29 requires the Corporation to provide counterpart financing equal to the LGU subsidy for indigents.
- Section 29 provides a national government subsidy cap for fourth, fifth and sixth class municipalities: the National Government provides up to ninety percent (90%) of the subsidy for indigents until those municipalities are upgraded to first, second or third class municipalities.
- Section 29 requires the LGU share to be progressively increased until it becomes equal to the National Government share.
Accreditation Eligibility for Providers
- Section 32 provides that all health care providers enumerated in Section 4(o) and operating for at least three (3) years may apply for accreditation.
- Section 32 allows a health care provider that has not operated for at least three (3) years to apply and qualify for accreditation if it complies with all other accreditation requirements and meets any of the following conditions.
- A qualifying condition is that its managing health care professional has worked in another accredited health care institution for at least three (3) years.
- A qualifying condition is that it operates as a tertiary facility or its equivalent.
- A qualifying condition is that it operates in a local government unit where the accredited health care provider cannot adequately or fully service its population.
- A qualifying condition is that it meets other conditions determined by the Corporation.
Employer Non-Deduction and Non-Remittance Penalties
- Section 44 (Penal Provisions) provides that when violations consist of failure or refusal to deduct contributions from the employee’s compensation or to remit the same to the Corporation, the penalty is a fine of not less than PHP 500 but not more than PHP 1,000, multiplied by the total number of employees employed by the firm.
- Section 44 (Penal Provisions) provides that the same violations are punished by imprisonment of not less than six (6) months but not more than one (1) year.
Congressional Oversight and NHIP Studies
- Section 54 requires Congress to conduct regular review of the National Health Insurance Program through systematic evaluation of Program performance, impact, and accomplishments with respect to objectives or goals.
- Section 54 provides that the review is undertaken by Senate and House committees with legislative jurisdiction over the Program.
- Section 54 requires the National Economic and Development Authority, in coordination with the National Statistics Office and the National Institutes of Health of the University of the Philippines, to undertake studies to validate Program accomplishments.
- Section 54 provides that the Budget required for such studies comes from the income of PhilHealth.
Separability, Repealing, and Effectivity Rules
- Section 8 establishes separability: if any part or provision of Republic Act No. 9241 is held unconstitutional or invalid, other unaffected provisions remain in full force and effect.
- Section 9 provides repealing authority: all laws, presidential decrees, executive orders, rules and regulations, or parts thereof inconsistent with Republic Act No. 9241 are repealed, amended, or modified accordingly.
- Section 10 provides that Republic Act No. 9241 takes effect fifteen (15) days after publication in at least (3) national newspapers of general circulation.