Law Summary
Coverage and Scope
- NBB Patients: Includes Indigent (as identified by DSWD), Sponsored members (contributions paid by others), Household Help per RA 10361, and Group Gold members under existing Group Policy Contracts (GPCs)
- Benefits Covered: All case-based payments including specified case rates, special packages (Leptospirosis, TB-DOTS, Malaria, Animal Bite, Voluntary Surgical Contraception), outpatient packages, and IUD insertion
- Health Care Institutions Covered: Accredited government facilities and specified accredited private institutions such as contracted Z benefit hospitals, ambulatory surgical clinics, dialysis centers, TB DOTS centers, birthing homes, infirmaries, and dispensaries with specific conditions on NBB applicability
General Policies
- Preferential access for NBB patients to social welfare funds for augmenting benefits
- Health care institutions responsible for patient care quality and access without denial
- Provision of complete medical and non-medical services including drugs, diagnostics, meals, and special accommodations at no additional cost
- Ward accommodations guaranteed or next higher accommodation provided for free; private accommodations excluded from NBB
- No charge for professional fees for care providers
- Sourcing medicines and supplies externally only as last resort and at institution's cost
Enabling Mechanisms
- Membership Verification: Mandatory real-time eligibility verification via IHCP Portal for government facilities
- Proof of membership accepted through Member Data Record, PhilHealth Number Card, or 4Ps ID Card treated with presumptive validity
- Alternative verification systems coordinated with PhilHealth CARES and LHIOs if portal unavailable
Quality of Care and Resource Availability
- Ensuring cost-effective clinical care without compromising quality, monitored via post-audit system
- Access to basic patient comforts aligned with prescribed NBB bed standards
- Hospital formulary maintained by Therapeutics Committee for drug availability
- Use of consignment agreements for procuring drugs and supplies discouraged with conflict of interest
- Physician responsibility to prescribe generic PNF drugs and consider alternatives if unavailable
- Full diagnostic services mandatory, with referral and free transport if tests unavailable
Professional and Referral Services
- No additional professional fees charged by salaried or non-salaried physicians for ward accommodations
- Referrals discouraged unless necessary, with arrangements made for patient transport and accommodation at no cost
Hospital NBB Packages and Claims
- Encouragement for hospitals to develop predefined NBB packages covering all necessary resources
- Fast-tracking claims payment within 30 days for facilities compliant with NBB rules
Information Dissemination
- Orientation of qualified NBB patients on policy and case rates upon admission
- Use of IEC materials for education and communication of accommodation choices
Monitoring and Evaluation
- Regular monitoring by PhilHealth Standards and Monitoring Dept.
- Exit interviews conducted among patients; violations documented and followed up
- Post-audit claims evaluation and on-site validation for suspected violations
Grievance Mechanisms
- PhilHealth CARES designated to receive reports of NBB violations within facilities
- SMS hotline and other contact channels provided for reporting violations
- Reports validated by regional offices and anti-fraud teams for appropriate action
Penalties
- Violations subject to penalties per RA 7875, its IRR, and related regulations including signed performance commitments
Separability Clause
- Portions of circular invalidated by law remain without affecting validity of remaining provisions
Effectivity
- Circular effective 15 days after publication in a newspaper of general circulation
- Copy to be deposited with the Office of the National Administrative Register, University of the Philippines Law Center