National Health Insurance Act

Provide all Filipinos with mechanisms for financial access to health services.
Create the National Health Insurance Program as a payment means for health care.
Prioritize health services for those who cannot afford them.
Establish the Philippine Health Insurance Corporation to administer the Program centrally and locally.

Defines key terms such as Beneficiary, Benefit Package, Capitation, Contribution, Coverage, Dependent, Diagnostic Procedure, Emergency, Employee, Employer, Enrollment, Fee for Service, Global Budget, Health Care Provider, ID Card, Indigent, Member, Means Test, Medicare, National Health Insurance Program, Pensioner, Personal Health Services, Portability, Prescription Drug, Public Health Services, Quality Assurance, Residence, Retiree, Self-employed, Social Security System, Treatment Procedure, and Utilization Review.

Creation of the National Health Insurance Program to provide coverage and affordable health services.
The Program works as social insurance to redistribute costs among different population groups.
Initially incorporates Medicare Programs I and II, expanding towards universal coverage.
It manages financing systems for a basic minimum package and supplementary benefits.
Prohibited from direct provision of health care and ownership of medical facilities.

All Filipino citizens shall be covered.
Implementation is phased over 15 years allowing local readiness.
Enrollment includes automatic inclusion of current Medicare beneficiaries and prioritization of unenrolled individuals.
Issuance of Health Insurance ID cards for eligibility verification.
Procedures for member’s change of residence to maintain proper local coverage.

Benefits include inpatient hospital care, outpatient services, emergency and transfer services, and other determined health services.
An initial basic minimum package is guaranteed during the first five years.
Supplemental benefits are provided for contributory members.
No reduction or interruption of benefits currently enjoyed by Medicare members.

Non-prescription drugs, outpatient psychotherapy, drug treatment, cosmetic surgery, home and rehab services, optometry, normal delivery, and cost-ineffective procedures unless approved later.

A tax-exempt government corporation attached to the Department of Health.
Powers include administering the program, policy formulation, contracting, fund management, accreditation, supervision, appointments, reporting, and legal actions.
Quasi-judicial powers to conduct investigations, hearings, enforce sanctions, and issue subpoenas.

Board comprises 11 members from government, labor, employers, social security, self-employed, and health provider sectors.
Terms, meetings, allowances, and appointment procedures are specified.
President appointed for six years, must have qualifications in healthcare financing and management, acts as CEO, and prohibited from conflicts of interest.

Health Finance Policy Research Department develops national health finance plans and conducts program impact assessments.
Office of Actuary conducts actuarial studies on premiums and investments.

Established per province or city to decentralize services.
Responsible for member recruitment, premium collection, accreditation, payment of claims, referral system establishment, and grievance redressal.
Support community health workers and local government units.

Sources include member contributions, existing health funds from SSS and GSIS, government appropriations, donations, and accruals.
Composed of Basic Benefit Fund (for minimum package) and Supplementary Benefit Funds (for enhanced coverage).
Financial management subject to public fund rules; administration costs capped at 12% of contributions.
Reserve Fund created with limitations and invested in government securities, banks, or corporation stocks meeting standards.

All members contribute based on salary, earnings, or household assets with caps on maximum contributions.
Contributions for indigents subsidized jointly by local government units and the National Government with gradual LGU increase.

Members have free choice among accredited providers within jurisdiction and appropriateness constraints.
Accreditation requires at least three years operation and compliance with standards, payment methods, referral protocols, rights recognition, and information systems.
Provider payment mechanisms include fee-for-service, capitation, combination, or global budget.
Quality assurance programs mandatory including utilization review and technology assessment.
Safeguards against overuse, underuse, and inappropriate referrals are enforced; penalties apply for false claims.

Establishes procedure for members, dependents, or providers to file grievances for violations including rights violations, neglect, delays, or other detriments.
Complaints filed first with Local Office then appealable to the Board; decisions final subject to Supreme Court review on legal questions.
Grievance and Appeal Review Committee operates hearings, evidence review, and issues recommendations.
Quasi-judicial powers include issuing subpoenas and imposing sanctions.

Fines and accreditation suspension or revocation for health providers committing violations.
Fines and potential imprisonment for members failing contribution payments.
Employers failing to remit contributions face fines, imprisonment, and presumed misappropriation charges.
Officers or employees misappropriating funds face severe penalties including imprisonment and fines.

Initial funding from remaining budget of Philippine Medical Care Commission and unappropriated government funds.
Annual appropriations include incremental portions from national revenue and documentary stamp taxes.
Supplemental appropriations may be requested from Congress for program milestones.

Appointment of Board and President within 30 days.
Rule formulation and promulgation within prescribed timeframes.
Merger of Philippine Medical Care Commission functions within 60 days after rules issuance.
Transfer of SSS and GSIS Health Insurance Funds and Medicare functions to the Corporation within set periods.
Employees of SSS and GSIS Medicare departments prioritized for absorption.