Law Summary
General Objectives
- To achieve universal health care through a systemic approach with clear roles for agencies and stakeholders.
- Guarantee equitable access to quality, affordable health goods and services, protecting Filipinos from financial risks.
Key Definitions
- Defines terms such as abuse of authority, health care providers, emergency, essential health benefit package, fraudulent and unethical acts.
- Distinguishes between direct contributors (employed/self-employed) and indirect contributors (subsidized individuals).
- Clarifies concepts such as population-based vs. individual-based health services, and amenities.
Population and Service Coverage
- All Filipino citizens are automatically enrolled in the National Health Insurance Program (NHIP).
- Immediate access to preventive, curative, rehabilitative, and palliative medical, dental, mental, and emergency services.
- PhilHealth to implement comprehensive outpatient and emergency drug benefits within two years.
- Primary care providers shall serve as patient navigators; all Filipinos to register with a primary care provider.
Financial Coverage
- Population-based health services are government-funded and free at point of service.
- Individual-based services financed primarily through prepayment systems, including social health insurance and private insurance.
National Health Insurance Program Membership and Benefits
- Simplified membership categories: direct and indirect contributors.
- Members immediately entitled to health benefit packages without requiring PhilHealth ID.
- No co-payment for basic or ward accommodation; regulated co-payments for amenities.
- Premium non-payment doesn't bar benefit access but requires payment of missed contributions with interest.
Premium Contributions and Reserve Funds
- Premium rates progressively increase from 2.75% in 2019 to 5% in 2024, with income floor and ceiling adjustments.
- National government subsidizes indirect contributors.
- PhilHealth must maintain reserve funds limited to two years’ estimated expenditures, investing excess reserves.
- Establishment of funds for lifetime member benefits and optional supplemental benefits.
Administrative Expenses and Governance
- Administrative costs capped at 7.5% of total premiums collected.
- PhilHealth Board reconstituted with maximum 13 members including ex-officio government officials, experts, and sector representatives.
- Board members must undergo training in health financing and systems; non-compliance may lead to dismissal.
- President appoints PhilHealth President and CEO from qualified Board members.
Health Services Delivery
- DOH to contract province-wide and city-wide health systems for population-based services with surveillance and health promotion components.
- PhilHealth to contract health care provider networks delivering individual-based services with standards on quality, co-payments, and data submission.
- Adoption of performance-driven payment schemes and strong compliance audits.
Integration and Financing of Local Health Services
- LGUs to integrate local health systems into province-wide and city-wide systems overseen by Provincial and City Health Boards.
- Creation of Special Health Funds for financing health services and systems costs.
- Income from PhilHealth payments accrues to LGUs for health system improvements.
- Government grants to improve public health service competitiveness, prioritizing underserved areas.
Human Resources for Health
- Development and execution of a National Health Human Resource Master Plan addressing workforce needs.
- Priority deployment in geographically isolated and disadvantaged areas.
- Expansion of allied health programs, scholarship grants prioritized for underserved beneficiaries.
- Mandatory return service agreements for government-funded scholars.
Regulation of Health Services
- PhilHealth to implement a rating and incentive system to reward quality health facilities.
- DOH to establish licensing systems for stand-alone health facilities and set clinical care standards.
- Price regulation mechanisms including price negotiation boards and mandatory drug outlet disclosures.
- Coordination among insurers to complement the National Health Insurance Package.
Health Service Equity
- DOH to annually update underserved area lists to guide preferential licensing and contracting.
- Prioritization of GIDAs in health service distribution.
- Mandatory minimal bed capacity for basic or ward accommodations across government, specialty, and private hospitals.
Governance and Accountability
- Establishment of a Health Promotion Bureau to mainstream health literacy and preventive care.
- Integration of health promotion in school curricula with reciprocal DOH and DepEd reporting.
- LGUs mandated to enact and implement health literacy and promotion measures with annual reporting.
- Mandatory submission and public accessibility of health data to facilitate evidence-based policy.
- DOH and DOST to train policy systems researchers with service obligations.
- Health data recognized as public records with provisions for reproduction cost recovery.
Monitoring, Evaluation, and Assessment
- Philippine Statistics Authority to conduct annual health surveys initially.
- DOH to publish provincial disease burden estimates.
- Mandatory Health Impact Assessments for policies and programs affecting health.
- Institutionalization of Health Technology Assessment Council (HTAC) overseeing transparent, evidence-based prioritization of health technologies and benefits.
- HTAC composition and appointment procedures defined, with eventual transition to DOST attachment.
Ethics and Transparency
- Mandatory conflict of interest declarations.
- Public disclosure of financial relationships between health professionals and medical suppliers.
- Establishment of a public health ethics committee advising the Secretary of Health.
Health Information System
- Required maintenance of interoperable health information systems by providers and insurers.
- Systems funded and developed by DOH and PhilHealth with guaranteed patient privacy.
Appropriations
- Funding derived from sin tax incremental collections, PAGCOR and PCSO shares, premium contributions, and government appropriations.
- Allocation of funds managed under DOH and PhilHealth budgetary provisions.
- Potential for supplemental Congressional appropriations.
Penal Provisions
- Sanctions on health care providers for contract violations, fraud, unethical acts, and abuse of authority.
- Fines, suspension, and criminal penalties applicable depending on offenses.
- Employers penalized for failure to register employees, remit contributions, or illegal deductions.
- PhilHealth officials liable for misappropriation and unethical conduct.
- Continuation of pending cases despite cessation of provider operations.
Oversight and Monitoring
- Creation of a Joint Congressional Oversight Committee on Universal Health Care.
- Commissioning of studies validating Act's implementation.
- DOH tasked with establishing a Performance Monitoring Division.
Transitory and Miscellaneous Provisions
- Appointment of new PhilHealth Board and CEO within 30 days of effectivity.
- Continuity and protection of current PhilHealth personnel's rights and benefits.
- Phased integration of province-wide health systems with financial and managerial milestones.
- Temporary outsourcing and financial incentives during initial implementation years.
- Development of complementary co-payment systems with private insurers.
- Time-bound certification requirements for primary care provider eligibility.
- Provisions for PCSO fund transition to clear existing obligations.
- Emphasis on protecting current member benefits and resolving ambiguities in favor of Filipino health rights.
- Provisions for implementing rules and regulations issuance.
- Repeal and amendment of outdated laws to harmonize with this Act.
This summary highlights the comprehensive legal framework, institutional reforms, governance, financing, services delivery, regulatory mechanisms, and accountability measures established to implement universal health care in the Philippines as mandated by Republic Act No. 11223.