Core definitions for UHC operations
- “Abuse of authority” means an act of a person performing a duty or function beyond what is authorized by Republic Act No. 11223 and Republic Act No. 7875, otherwise known as the “National Health Insurance Act of 1995,” and their IRR, inimical to the public (Section 4).
- “Amenities” are comfort or convenience features of a health service, such as private accommodation, air conditioning, telephone, television, and choice of meals (Section 4).
- “Basic or ward accommodation” provides regular meal, bed in shared room, fan ventilation, and shared toilet and bath (Section 4).
- “Co-insurance” is a percentage of a medical charge paid by the insured, with the remainder paid by the health insurance plan (Section 4).
- “Co-payment” is a flat fee or predetermined rate paid at point of service (Section 4).
- “Direct contributors” include those who have capacity to pay premiums (gainfully employed with employer-employee relationship, or self-earning/professional practitioners, migrant workers and qualified dependents, and lifetime members) (Section 4).
- “Emergency” covers situations where immediate danger exists and delay in initial support and treatment may cause loss of life or permanent disability, including conditions for a pregnant woman involving permanent injury or loss of the unborn child, or a non-institutional delivery, based on objective findings of a prudent medical officer on duty (Section 4).
- “Entitlement” is any singular or package of health services for Filipinos to improve health (Section 4).
- “Essential health benefit package” is a set of individual-based entitlements under the NHIP that includes primary care; medicines, diagnostics and laboratory; and preventive, curative, and rehabilitative services (Section 4).
- “Fraudulent act” means misrepresentation or deception resulting in undue benefit or advantage, or means that deviate from normal procedure, for personal gain, resulting in damage and prejudice capable of pecuniary estimation (Section 4).
- “Health care provider” includes health facilities (public or private); licensed health professionals; community-based health care organizations; and pharmacies or drug outlets, laboratories, and diagnostic clinics (Section 4).
- “Health care provider network” is a group of primary to tertiary providers (public or private) offering people-centered and comprehensive integrated and coordinated care, with the primary care provider acting as navigator and coordinator (Section 4).
- “Health Maintenance Organization (HMO)” provides, offers, or covers designated health services for plan holders or members for a fixed prepaid premium (Section 4).
- “Health Technology Assessment (HTA)” is the systematic evaluation of health-related technologies (including devices, medicines, vaccines, procedures, and systems) using multidisciplinary evaluation of social, economic, organizational, and ethical issues (Section 4).
- “Indirect contributors” include all not in direct contributors, including qualified dependents subsidized by the national government, including those subsidized due to special laws (Section 4).
- “Individual-based health services” are services accessed within a health facility or remotely, traced to one recipient, with limited population-level effect and not altering the underlying cause of illness (e.g., ambulatory and inpatient care, medicines, laboratory tests, procedures) (Section 4).
- “Population-based health services” are interventions with population groups as recipients (e.g., health promotion, disease surveillance, vector control) (Section 4).
- “Primary care” is initial-contact, accessible, continuous, comprehensive, coordinated care available at the time of need, including services for all presenting conditions and the ability to coordinate referrals when necessary (Section 4).
- “Primary care provider” is a health care worker with defined competencies certified in primary care as determined by the DOH or a licensed and certified DOH health institution (Section 4).
- “Private health insurance” is coverage of defined health services financed through private premium payments to the insurer (Section 4).
- “Unethical act” includes actions or schemes against the NHIP such as overtoiling, upcasing, harboring ghost patients or recruitment practice, acts contrary to professional Code of Ethics, or similar acts that put or tend to put the NHIP integrity and effective implementation in disrepute (Section 4).
Universal inclusion and entitlement rules
- Every Filipino citizen is automatically included in the NHIP, referred to as the Program (Section 5).
- Every Filipino is granted immediate eligibility and access to preventive, promotive, curative, rehabilitative, and palliative care for medical, dental, mental, and emergency health services, delivered as either population-based or individual-based health services (Section 6(a)).
- Included goods and services must be determined through a fair and transparent HTA process (Section 6(a)).
- Within two (2) years from effectivity, PhilHealth must implement a comprehensive outpatient benefit including outpatient drug benefit and emergency medical services in accordance with HTAC recommendations under Section 34 (Section 6(b)).
- The DOH and LGUs must endeavor to provide a health care delivery system where every Filipino has a primary care provider that acts as navigator, coordinator, and initial and continuing point of contact (Section 6(c)).
- Access to higher levels of care must be coordinated by the primary care provider, except in emergency or serious cases and when proximity is a concern (Section 6(c)).
- Every Filipino must register with a public or private primary care provider of choice (Section 6(d)).
- The DOH must promulgate guidelines on licensing of primary care providers and the registration of every Filipino to a primary care provider (Section 6(d)).
Financial coverage and NHIP funding design
- Population-based health services must be financed by the National Government through the DOH and provided free of charge at point of service for all Filipinos (Section 7(a)).
- The National Government must support LGUs in financing capital investments and provision of population-based interventions (Section 7(a)).
- Individual-based health services must be financed primarily through prepayment mechanisms such as social health insurance, private health insurance, and HMO plans (Section 7(b)).
- Program membership is simplified into two types: direct contributors and indirect contributors (Section 8).
Benefits, identification, and patient costs
- Every member must be granted immediate eligibility for health benefit package under the Program (Section 9).
- PhilHealth Identification Card must not be required in availment of any health service (Section 9).
- No co-payment may be charged for services rendered in basic or ward accommodation (Section 9).
- Co-payments and co-insurance for amenities in public hospitals must be regulated by the DOH and PhilHealth (Section 9).
- The current PhilHealth package for members must not be reduced (Section 9).
- PhilHealth must provide additional Program benefits for direct contributors, where applicable (Section 9).
- Failure to pay premiums must not prevent enjoyment of any Program benefits (Section 9).
- Employers and self-employed direct contributors must pay missed contributions with an interest compounded monthly of at least three percent (3%) for employers and not exceeding one and one-half percent (1.5%) for self-earning, professional practitioners, and migrant workers (Section 9).
Direct contributor premium schedule
- Premium rates for direct contributors must follow the schedule and income floor and ceiling (Section 10):
- 2019: 2.75%, income floor PHP 10,000.00, income ceiling PHP 50,000.00
- 2020: 3.00%, income floor PHP 10,000.00, income ceiling PHP 60,000.00
- 2021: 3.50%, income floor PHP 10,000.00, income ceiling PHP 70,000.00
- 2022: 4.00%, income floor PHP 10,000.00, income ceiling PHP 80,000.00
- 2023: 3.50%, income floor PHP 10,000.00, income ceiling PHP 90,000.00
- 2024: 5.00%, income floor PHP 10,000.00, income ceiling PHP 100,000.00
- 2025: 5.00%, income floor PHP 10,000.00, income ceiling PHP 100,000.00
- Indirect contributor premium subsidy must be gradually adjusted and included annually in the General Appropriations Act (GAA) (Section 10).
- Funds for indirect contributor subsidies must be released to PhilHealth (Section 10).
- The DOH, in coordination with PhilHealth, may request Congress to appropriate supplemental funding to meet targeted milestones of the Act (Section 10).
- For every increase in the rate of contribution of direct contributors and premium subsidy of indirect contributors, PhilHealth must provide for a corresponding increase in benefits (Section 10).
PhilHealth reserve limits and investments
- PhilHealth must set aside a portion of its accumulated revenues not needed for current year expenditures as reserve funds (Section 11).
- Total reserves must not exceed a ceiling equivalent to the actuarially estimated amount for two (2) years’ projected Program expenditures (Section 11).
- If actual reserves exceed the required ceiling at fiscal year end, the excess must be used to increase Program benefits and decrease members’ contributions (Section 11).
- Unused reserve fund portion not needed for current expenditures or the authorized programs must be placed in investments to earn an average annual income at prevailing rates of interest, called the Investment Reserve Fund (Section 11).
- Investment Reserve Fund must be invested in any or all of the following with limitations (Section 11):
- At least 50% in interest-bearing bonds, securities, or other evidence of indebtedness of the Government of the Philippines (Section 11(a))
- Up to 30% in debt securities and corporate bonds of prime/solvent corporations that have not defaulted on interest payments and meet issuer quality parameters (Section 11(b))
- Deposits/loans to or securities with domestic banks in the Philippines, subject to bank capacity limits and designation by the Monetary Board of Bangko Sentral ng Pilipinas (Section 11(c))
- Preferred stocks in solvent corporations/institutions listed on the stock exchange with proven track record/profitability over the last three (3) years and dividends for at least three (3) years immediately preceding investment (Section 11(d))
- Common stocks in solvent corporations/institutions listed on the stock exchange with high growth opportunities and earnings potentials (Section 11(e))
- Up to 10% in bonds/securities/promissory notes/evidences of indebtedness of accredited and financially sound medical institutions exclusively for construction, improvement, and maintenance of hospitals and medical facilities, with requirements on guarantee and triple ‘A’ ratings (Section 11(f))
- In debt instruments and other securities traded in secondary markets with intrinsic quality similar to Section 11(a) to (e), subject to PhilHealth Board approval (Section 11(g))
- No portion of the reserve fund or its income accrues to the general fund of the National Government or any of its agencies or instrumentalities, including government-owned or controlled corporations (Section 11).
- PhilHealth may hire external local fund managers with valid trust licenses to manage reserve funds through public bidding and those managers must submit an annual report on investment performance to PhilHealth (Section 11).
- PhilHealth must set up separate funds (Section 11):
- A fund securing benefit payouts to members before becoming lifetime members
- A fund securing payouts to lifetime members
- A fund for optional supplemental benefits subject to additional contributions
- A portion of each fund must be identified as current and kept in liquid instruments; that portion must not be considered invested assets (Section 11).
- PhilHealth must allocate a portion of contributions to the lifetime members’ fund based on an actuary-determined allocation using a predetermined percentage with the current average age of members and current life expectancy and morbidity curve (Section 11).
- PhilHealth must manage the supplemental benefits and lifetime members’ funds in an actuarially sound manner, and the supplemental benefits fund in a way that meets minimum requirements to ensure supplemental benefit payments are secure (Section 11).
Administrative limits and governance structure
- Administrative costs for implementing the Program must not exceed seven and one-half percent (7.5%) of the actual total premium collected from direct and indirect contributors during the immediately preceding year (Section 12).
- The PhilHealth Board of Directors is reconstituted to have a maximum of thirteen (13) members, consisting of (Section 13):
- Five (5) ex-officio members: Secretary of Health, Secretary of Social Welfare and Development, Secretary of Budget and Management, Secretary of Finance, Secretary of Labor and Employment
- Three (3) expert panel members with expertise in public health, management, finance, and health economics
- Five (5) sectoral panel members representing direct contributors, indirect contributors, employers group, health care providers endorsed by their national associations of health care institutions and health care professionals, and elected local chief executives endorsed by the League of Provinces of the Philippines, League of Cities of the Philippines, and League of Municipalities of the Philippines
- At least one (1) expert panel member and at least two (2) sectoral panel members must be women (Section 13).
- Sectoral and expert panel members must be Filipino citizens of good moral character, and expert panel members must have recognized probity and independence with distinguished professional service, be in active practice for at least seven (7) years, and not be appointed within one (1) year after losing in the immediately preceding elections (regular or special) (Section 13).
- The Secretary of Health serves as an ex officio nonvoting Chairperson of the Board (Section 13(b)).
- Appointive Board members must undergo training in health care financing, health systems costing, and HTA prior to the start of their term; noncompliance is a ground for dismissal (Section 13(c)).
- Within thirty (30) days from effectivity, the Governance Commission for Government-Owned or -Controlled Corporations (GCG) must promulgate the nomination and selection process for appointive Board members under Republic Act No. 10149 with clear qualifications and sector recommendations (Section 13(c)).
CEO appointment and PhilHealth personnel rules
- Upon recommendation of the Board, the President must appoint the PhilHealth President and CEO from the Board’s non-ex-officio members (Section 14).
- The Board cannot recommend a PhilHealth President and CEO unless the nominee is a Filipino citizen with at least seven (7) years’ experience in public health, management, finance, and health economics (or a combination) (Section 14).
- All PhilHealth personnel must be classified as public health workers under Republic Act No. 7305 (Section 15).
PhilHealth powers and budgeting limits
- PhilHealth may fix reasonable compensation, allowances, and benefits of positions including its President and CEO, based on comprehensive job analysis and audit, subject to Presidential approval; the compensation plan must be comparable with government social security institutions and reviewed by the Board no more than once every four (4) years, without prejudice to merit reviews or productivity/efficiency-based increases (Section 16(a)).
- PhilHealth may establish organizational structure and staffing patterns for central and regional offices to cover provinces, cities and legislative districts including foreign countries, subject to Board approval, and inspect offices periodically (Section 16(b)).
- PhilHealth must maintain a Provident Fund consisting of contributions made by PhilHealth and its officials and employees and earnings thereon for benefits under terms set by the Board, subject to Presidential approval (Section 16(c)).
- PhilHealth must adopt and approve annual and supplemental budgets of receipts and expenditures, including salaries, allowances, and early retirement, and authorize capital and operating expenditures and disbursements for effective management, subject to budget limitations under Section 12, and corporate budget submission to DBM is for information purposes only (Section 16(d)).
Population-based and individual-based delivery
- The DOH must endeavor to contract province-wide and city-wide health systems for population-based health services (Section 17).
- Province-wide and city-wide health systems for population-based services must have minimum components (Section 17):
- Primary care provider network with patient records accessible throughout the health system
- Accurate, sensitive, and timely epidemiologic surveillance systems
- Proactive and effective health promotion programs or campaigns
- PhilHealth must endeavor to contract public, private, or mixed health care provider networks for individual-based health services (Section 18(a)).
- Member access to services must not be compromised by the contracted networks (Section 18(a)).
- Networks must agree to service quality, co-payment/co-insurance, and data submission standards (Section 18(a)).
- During transition, PhilHealth and DOH must incentivize health care providers that form networks (Section 18(a)).
- Apex or end-referral hospitals as determined by the DOH may be contracted by PhilHealth as stand-alone providers (Section 18(a)).
- PhilHealth must endeavor to shift to performance-driven, close-end, prospective payments based on disease or diagnosis related groupings using validated costing methodologies without differentiating facility and professional fees (Section 18(b)).
- PhilHealth must develop differential payment schemes considering service quality, efficiency, and equity, and institute strong surveillance and audit mechanisms to ensure network compliance (Section 18(b)).
Local health system integration and funds
- DOH, DILG, PhilHealth, and LGUs must endeavor to integrate health systems into province-wide and city-wide health systems (Section 19).
- Provincial and City Health Boards oversee and coordinate integration of health services, composed of municipal and component city health systems and city-wide health systems in highly urbanized and independent component cities, respectively (Section 19).
- Provincial and City Health Boards manage the Special Health Fund under Section 20 and provide administrative and technical supervision over health facilities and health human resources within territorial jurisdiction (Section 19).
- Municipalities and cities included in the integrated health systems are entitled to a representative in the appropriate Provincial or City Health Board (Section 19).
- The province-wide or city-wide health system must pool and manage resources through a special health fund for finance of population-based and individual-based health services, health system operating costs, capital investments, and remuneration of additional health workers and incentives for all health workers (Section 20).
- The DOH, in consultation with DBM and LGUs, must develop guidelines for the use of the Special Health Fund (Section 20).
- All income derived from PhilHealth payments must accrue to the Special Health Fund and be allocated by LGUs exclusively for improvement of the LGU health system (Section 21).
- PhilHealth payments must be credited to the LGU annual regular income (ARI) (Section 21).
- The National Government must provide commensurate matching grants (financial and non-financial, including capital outlay, human resources for health, and health commodities) to improve functionality of province-wide and city-wide health systems (Section 22).
- Underserved and unserved areas must be prioritized in grants allocation (Section 22).
- Grants must follow approved province-wide and city-wide health investment plans, accounting for complementation of public and private providers and public or private health sector investments (Section 22).
Health workforce planning and incentives
- The DOH must ensure formulation and implementation of a National Health Human Resource Master Plan covering policies and strategies for generation, recruitment, retraining, regulation, retention, and reassessment of the health workforce based on population health needs (Section 23).
- All health professionals and health care workers must be guaranteed permanent employment and competitive salaries to ensure continuity of health programs and services (Section 23).
- A national health workforce support system must be created to support local public health systems in addressing human resource needs, with priority deployment to Geographically Isolated and Disadvantaged Areas (GIDAs) (Section 24).
- CHED, TESDA, PRC, and DOH must plan the expansion of existing and new allied and health-related degree and training programs including community-based health care workers, and must regulate the number of enrollees based on health needs of the population, especially underserved areas (Section 25(a)).
- CHED and DOH must expand scholarship grants for allied and health-related undergraduate and graduate programs, based on needed cadre of national and local health managers and health professionals (Section 25(b)).
- Scholarships for bona fide residents of unserved or underserved areas or members of indigenous peoples must be given priority (Section 25(b)).
- PRC and DOH, in coordination with duly-registered medical and allied health professional societies, must set up a registry of medical and allied health professionals indicating current number of practitioners and location of practice (Section 25(c)).
- CHED, PRC, and DOH must reorient medical and allied professional education and health professional certification and regulation toward producing health workers with competencies for primary care services (Section 25(d)).
- Graduates of allied and health-related courses receiving government-funded scholarships must serve in priority public sector areas for at least three (3) full years, with compensation, under DOH supervision (Section 26).
- Graduates who serve for additional two (2) years must be provided additional incentives as determined by DOH (Section 26).
- Graduates from state universities and colleges and private schools are encouraged to serve in these priority areas (Section 26).
- DOH must coordinate with CHED and PRC and establish guidelines for noncompliance (Section 26).
Regulation: quality, licensing, affordability
- PhilHealth must establish a rating system under an incentive scheme to acknowledge and reward facilities providing better service quality, efficiency, and equity; PhilHealth must recognize third-party accreditation mechanisms and may use them as basis for incentives (Section 27(a)).
- DOH must institute a licensing and regulatory system for stand-alone health facilities, including those providing ambulatory and primary care services, and other modes of health service provision (Section 27(b)).
- DOH must set standards for clinical care through development, appraisal, and use of clinical practice guidelines with professional societies and the academe (Section 27(c)).
- DOH-owned health care providers must procure drugs and devices using price reference indices guided by centrally negotiated prices, sell them using prescribed maximum mark-ups, and submit a price list of procured and sold drugs/devices to DOH (Section 28(a)).
- An independent price negotiation board composed of DOH, PhilHealth, DTI, and others must negotiate prices on behalf of DOH and PhilHealth, guided by parameters including new technology, innovator drugs, and single supplier sourcing (Section 28(b)).
- Negotiated framework contract prices must apply for all health care providers under DOH (Section 28(b)).
- The price negotiation board must adhere to guidelines issued by the Government Procurement Policy Board (Section 28(b)).
- Health care providers and facilities must make readily accessible to the public and submit to DOH and PhilHealth pertinent, relevant, up-to-date information regarding prices of health services and all offered goods and services (Section 28(c)).
- Drug outlets must carry the generic equivalent of all drugs in the Primary Care Formulary and must provide customers a list of therapeutic equivalents and corresponding prices when fulfilling prescriptions (Section 28(d)).
- DOH, PhilHealth, HMOs, and life and non-life private health insurance (PHIs) must develop standard policies/plans complementing the Program’s benefit schedule, and a coordination mechanism between PhilHealth, PHIs, and HMOs must ensure no benefits are unnecessarily dropped (Section 28(e)).
- DOH must annually update the list of underserved areas as basis for preferential licensing of health facilities and contracting of health services (Section 29(a)).
- DOH must develop frameworks and guidelines to determine appropriate bed capacity and number of health care professionals for public health facilities (Section 29(a)).
- The government must guarantee equitable distribution of health services and benefits by prioritizing GIDAs (Section 29(b)).
- All government hospitals must operate at least ninety percent (90%) of bed capacity as basic or ward accommodation (Section 29(c)).
- Specialty hospitals must operate at least seventy percent (70%) of bed capacity as basic or ward accommodation (Section 29(c)).
- Private hospitals must operate at least ten percent (10%) of bed capacity as basic or ward accommodation (Section 29(c)).
- Government hospitals, specialty hospitals, and private hospitals must regularly submit reports on the allotment/percentage of basic or ward accommodation to DOH, and DOH must issue necessary guidelines for immediate implementation (Section 29(c)).
Health promotion, data, monitoring, and HIA/HTA
- DOH must strengthen national efforts as overall steward for health care with comprehensive coordinated approach emphasizing scaling up health promotion and preventive care (Section 30).
- DOH must transform its Health Promotion and Communication Service into a full-fledged Health Promotion Bureau to improve health literacy and mainstream health promotion and protection (Section 30).
- The Health Promotion Bureau must formulate a framework strategy for health promotion serving as basis for DOH programs, increase health literacy to reduce non-communicable diseases, implement population-wide health promotion programs across social determinants of health, coordinate policies across government instrumentalities, and promote technical support to local R&D programs/projects (Section 30).
- Within two (2) years from effectivity, the cost of implementing health promotion programs must be at least one percent (1%) of DOH total budget appropriations (Section 30).
- DepEd schools are designated as healthy settings for the Act; DepEd, in coordination with DOH, must formulate programs and modules on health literacy and rights integrated into existing curricula, to intensify the fight against communicable diseases and increase prevalence reduction of non-communicable diseases through healthy lifestyle, physical activity, proper nutrition, and prevention of smoking and alcohol consumption among students (Section 30).
- DepEd and DOH must submit annual reports on health promotion and literacy programs implemented (including impact assessment) to the President, Senate President,