Declaration of Principles and Policies
- The State adopts an integrated and comprehensive approach to health development.
- Essential goods, health, and social services are to be made available at affordable costs.
- Free medical care is provided to paupers.
- A socialized health insurance program prioritizes the underprivileged, sick, elderly, PWDs, women, and children.
- Provision of free health care services to indigents.
Definitions
- Definitions cover critical terms like Dependents (including elderly parents with low income and permanently disabled parents), Fee-for-service, Indigent (as identified by DSWD), Member (paying, sponsored, or lifetime), Retiree, 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 Member, Formal and Informal Economy members, Migrant Workers, Sponsored Member.
Mandatory Coverage
- All Filipino citizens shall be covered by the National Health Insurance Program (NHIP).
- Coverage is compulsory nationwide regardless of existing LGU-based insurance programs.
- Collaboration among the Corporation, DOH, LGUs, NGOs, and NGAs to ensure access to quality and cost-effective health care.
Enrollment
- Enrollment categories include members in the formal economy, informal economy, indigents, sponsored members, and lifetime members.
- Enrollment involves identifying beneficiaries, issuing eligibility documentation, and specifying membership status.
Health Insurance Identification (ID) Card and ID Number
- Issued by the Corporation's local office upon enrollment.
- Used for identification, eligibility verification, and utilization recording.
- A member's right to benefits is not prejudiced by absence of the ID card.
- The card is recognized as a valid government ID.
Benefit Package
- Entitlements for members and dependents include:
- Inpatient hospital care (room and board, healthcare professional services, diagnostic and lab services, equipment use, prescription drugs, inpatient education).
- Outpatient care (services, diagnostics, preventive services, prescription drugs).
- Emergency and transfer services.
- Other appropriate and cost-effective services determined by the Corporation and DOH.
- Annual review for financial sustainability and relevance.
Excluded Personal Health Services
- Corporation excludes coverage of health services deemed cost-ineffective by health technology assessment.
- Additional exclusions/limitations may be instituted to protect objectives and financial sustainability.
Entitlement to Benefits
- Must have paid premium contributions for at least 3 months within 6 months before availment.
- Contributions must be regular and member not under legal penalties.
- Retirees/pensioners (SSS, GSIS) prior to this Act and lifetime members exempt from paying monthly contributions.
Powers and Functions of the Corporation
- Supervise health benefits provision, set standards and regulations.
- Negotiate and contract with healthcare providers and others.
- Conduct inspections and secure relevant records.
- Maintain operations and investment records.
- Develop and secure electronic member databases.
- Invest in IT systems.
- Conduct public information campaigns.
- Conduct post-audit on service quality.
- Establish offices/focal persons internationally for OFW claims.
- Impose interest/surcharges for delayed remittance.
- Support healthcare technology, ensure regulatory compliance.
- Mandate proof of membership in transactions involving national agencies and LGUs.
- Accredit pharmacies and drug outlets.
- Perform other appropriate acts for program enforcement.
Quasi-Judicial Powers
- Conduct investigations, render decisions, and manage disputes with due process.
- Suspend/revoke accreditation of providers and benefits of members, impose fines.
- Decisions can be executory immediately in public interest.
- Revoked providers barred from re-accreditation through any identity.
- Not bound by technical evidence rules.
Board of Directors Composition and Appointment
- Composed of key government secretaries, Corporation President/CEO, SSS, GSIS representatives, sectoral and independent representatives.
- Health Secretary is Chairperson; Corporation President/CEO is Vice Chairperson.
- Appointments by the President except ex officio members.
- Sectoral members appointed upon consultation.
- Terms follow GOCC Governance Act.
President of the Corporation
- Appointed by the President of the Philippines upon Board recommendation.
- One-year tenure following GOCC Governance Act.
Health Finance Policy Research Department
- Duties include quality assurance program submission, policy recommendation, client satisfaction surveys.
National Health Insurance Fund
- Composition: member contributions, government appropriations, donations/grants, accruals.
Financial Management
- Fund use subject to public fund rules and Board resolutions.
- Administration costs capped based on contributions, reimbursements, and investment earnings.
- Cost ceiling period up to five years following effectivity.
Reserve Fund
- Portion of revenues set aside as reserve - up to actuarial value for two years' expenditures.
- Excess to be used to improve benefits, reduce contributions, and support DOH facilities.
- Investment Reserve Fund established with specified investment vehicles and limits.
- Investment management may be outsourced to licensed institutions.
- Separate funds for benefit payouts, lifetime members, supplemental benefits.
- Actuarial management required.
Contributions
- Members who can pay shall contribute as per actuarial studies.
- Formal economy contributions capped at 5% of salaries.
- Government must budget premium payments.
- Informal economy contributions based on earnings/assets; lowest income groups subsidized by LGUs or cost-sharing.
- Indigent contributions capped at minimum-employed member contribution.
- Lifetime member contribution requirements may be increased based on actuarial study.
Payment for Indigent Contributions
- Fully subsidized by the national government.
- Funding included in DOH appropriations.
Payment for Sponsored Members
- Premiums for orphans, abandoned minors, PWDs, seniors, battered women under DSWD care paid by DSWD.
- Barangay health workers' premiums paid by LGUs.
- House helpers' premiums paid by employers per Kasambahay Law.
Coverage of Women About to Give Birth
- Premiums for unenrolled women about to give birth paid by national government, LGUs, or legislative sponsors via means testing.
Accreditation Eligibility
- Health care providers with at least 3 years operation may apply for accreditation.
- Providers with less experience may qualify if meeting certain criteria (experienced managing professional, tertiary facility, underserved LGU, other Corporation criteria).
- Providers guilty of violations are ineligible for renewal.
Provider Payment Mechanisms
- Allowed mechanisms: fee-for-service, capitation, case-based payment, global budget, others as approved.
- Local offices recommend appropriate mechanisms.
- Special considerations for remote areas.
Other Provider Payment Guidelines
- No additional fees for indigent patients per Corporation guidelines.
- Payments to salaried public providers retained by facilities for operating costs and quality improvement.
Reimbursement and Claims Filing Period
- Claims to be filed within 60 calendar days after patient discharge.
- Extensions allowed for reasonable causes.
Role of Local Government Units (LGUs)
- LGUs provide basic health care services.
- Capitation payments to LGUs to be invested in health infrastructure, equipment, professional fees.
- Capitation funds placed in special trust fund and used for mandated healthcare purposes.
Grievance and Appeal Procedures
- Complaints filed with Corporation and referred to Grievance and Appeal Review Committee.
- Committee issues resolution within 60 calendar days.
- Appeals to Board within 30 days from resolution receipt.
Grievance and Appeal Review Committee
- Composed of five members including an accredited health care provider representative.
- Responsible for recommending action on complaints related to the Act.
Penal Provisions
- Accredited providers violating the Act face fines (P50,000-P100,000), suspension, or revocation.
- Members committing violations face fines (min P5,000), suspension, or both.
- Employers failing to register/deduct/remit contributions fined P5,000 per employee; misappropriation presumed if contributions not remitted timely.
- Unlawful deductions by employers fined P5,000 per affected employee.
- Corporation employees misappropriating funds fined P10,000-P20,000.
- Other violations fined P5,000-P20,000.
- Continued proceedings despite cessation of provider operation or practice termination.
- Decisions on fines and claims immediately executory.
License or Permit Issuance or Renewal Requirement
- Proof of PhilHealth premium payment required before issuance or renewal of professional/business licenses.
Oversight Provision
- Joint Congressional Oversight Committee (5 Senators, 5 House members) to review NHIP regularly.
- Chaired by Senate and House Health Committee Chairpersons.
- NEDA, NSO, UP NIH conduct validation studies on Program performance and enrollee satisfaction.
- Corporation to allocate 0.001% of prior year's income for studies.
Implementing Rules and Regulations
- Corporation, with DOH, to issue necessary rules within 60 days of Act's effectivity.
Separability Clause
- If any part declared unconstitutional, other provisions remain effective.
Repealing Clause
- All inconsistent laws and issuances are repealed or modified accordingly.
Effectivity
- The Act takes effect 15 days after publication in the Official Gazette or two newspapers of general circulation.