AN ACT AMENDING REPUBLIC ACT NO. 7875

Case Overview and Summary

Summary of Republic Act No. 10606 (National Health Insurance Act of 2013)

Principles and Policies (Section 2)
- Declares the policy of the State to adopt an integrated and comprehensive approach to health development, providing essential goods, health and social services to all people at affordable cost, and free medical care to paupers.
- Prioritizes the health care needs of the underprivileged, sick, elderly, persons with disabilities, women, and children, and provides free health care services to indigents.

Definitions (Section 4)
- Defines key terms such as dependent, fee-for-service, indigent, member, 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, members in the formal economy, members in the informal economy, migrant workers, and sponsored member.

Mandatory Coverage (Section 6)
- All citizens of the Philippines shall be covered by the National Health Insurance Program.

Enrollment (Section 7)
- The Corporation shall enroll beneficiaries under the following categories: members in the formal economy, members in the informal economy, indigents, sponsored members, and lifetime members.

Health Insurance ID Card and ID Number (Section 8)
- The Corporation shall issue a health insurance ID card and ID number for identification, eligibility verification, and utilization recording.
- The ID card shall be recognized as a valid government identification.

Benefit Package (Section 10)
- Members and their dependents are entitled to inpatient hospital care, outpatient care, emergency and transfer services, and other health care services determined by the Corporation and the DOH.
- The services and packages shall be reviewed annually.

Excluded Personal Health Services (Section 11)
- The Corporation shall not cover expenses for health services considered cost-ineffective through health technology assessment.

Entitlement to Benefits (Section 12)
- Members whose premium contributions for at least three (3) months have been paid within six (6) months prior to the first day of availment, including those of the dependents, shall be entitled to the benefits.
- Retirees, pensioners, and lifetime members need not pay monthly contributions.

Powers and Functions of the Corporation (Section 16)
- The Corporation shall have various powers and functions, including supervising the provision of health benefits, negotiating contracts with health care providers, visiting and inspecting facilities, keeping records, establishing an electronic database, conducting information campaigns, conducting post-audit on quality of services, establishing offices or focal persons in Philippine Consular Offices abroad, imposing interest and surcharges for delayed remittance of contributions, supporting the use of technology in health care delivery, monitoring compliance by regulatory agencies, mandating proof of PhilHealth membership for transactions with private individuals or groups, and accrediting independent pharmacies and retail drug outlets.

Quasi-Judicial Powers (Section 17)
- The Corporation shall be vested with quasi-judicial powers, including conducting investigations, rendering decisions, orders, or resolutions, and suspending or revoking the accreditation of health care providers or the right to benefits of members.

Board of Directors (Section 18)
- The Corporation shall be governed by a Board of Directors composed of representatives from various government agencies, sectors, and stakeholders.
- The Secretary of Health shall be the ex officio Chairperson, and the President and CEO of the Corporation shall be the Vice Chairperson.

President of the Corporation (Section 19)
- The President of the Philippines shall appoint the President and CEO of the Corporation, who shall have a tenure of one (1) year.

Health Finance Policy Research (Section 20)
- The Corporation shall establish a Health Finance Policy Research Department with duties and functions related to policy research, quality assurance, utilization review, technology assessment, and client-satisfaction surveys.

National Health Insurance Fund (Section 24)
- A National Health Insurance Fund is created, consisting of contributions from Program members, appropriations from national and local governments, donations and grants-in-aid, and all accruals thereof.

Financial Management (Section 26)
- The use, disposition, investment, disbursement, administration, and management of the National Health Insurance Fund shall be governed by applicable laws and resolutions of the Board of Directors.
- The total annual costs for administration, monitoring, marketing, research, audit, and other necessary activities shall not exceed specified percentages of premium contributions, reimbursements, and investment earnings.

Reserve Fund (Section 27)
- The Corporation shall set aside a portion of its accumulated revenues as reserve funds, not exceeding a ceiling equivalent to the amount actuarially estimated for two (2) years' projected Program expenditures.
- Excess reserves shall be used to increase benefits, decrease member contributions, and augment the health facilities enhancement program of the DOH.
- The Investment Reserve Fund shall be invested in various instruments, including government securities, corporate bonds, bank deposits, preferred stocks, and bonds of medical institutions.

Contributions (Section 28)
- All members who can afford to pay shall contribute to the Fund according to a reasonable, equitable, and progressive contribution schedule determined by the Corporation.
- Members in the formal economy and their employers shall continue paying the same monthly contributions, not exceeding 5% of their monthly salaries.
- Contributions from members in the informal economy shall be based on household earnings and assets, with subsidies from LGUs or other sponsors for the lowest income segment.
- Contributions for indigent members shall not exceed the minimum contributions for employed members.
- The required number of monthly premium contributions to qualify as a lifetime member may be increased by the Corporation.

Payment for Indigent Contributions (Section 29)
- Premium contributions for indigent members shall be fully subsidized by the national government through appropriations for the DOH.

Payment for Sponsored Members' Contributions (Section 29-A)
- The premium contributions of orphans, abandoned and abused minors, out-of-school youths, street children, PWDs, senior citizens, and battered women under the care of the DSWD or accredited institutions shall be paid by the DSWD.
- The premium contributions of barangay health workers, nutrition scholars, and other barangay workers and volunteers shall be fully borne by the LGUs.
- The annual premium contributions of househelpers shall be fully paid by their employers.

Coverage of Women About to Give Birth (Section 29-B)
- The annual required premium for the coverage of unenrolled women who are about to give birth shall be fully borne by the national government, LGUs, or legislative sponsors, determined through the DSWD's means testing protocol.

Accreditation Eligibility (Section 32)
- All health care providers operating for at least three (3) years may apply for accreditation, with exceptions for providers meeting certain conditions.
- A health care provider found guilty of any violation of this Act shall not be eligible to apply for the renewal of accreditation.

Provider Payment Mechanisms (Section 34)
- The following payment mechanisms shall be allowed: fee-for-service payments, capitation of health care professionals and facilities, case-based payment, global budget, and other mechanisms determined by the Corporation.

Other Provider Payment Guidelines (Section 34-A)
- No other fee or expense shall be charged to the indigent patient, subject to the Corporation's guidelines.
- Payments for professional services rendered by salaried public providers shall be retained by the health facility and pooled for distribution among health personnel.

Reimbursement and Period to File Claims (Section 35)
- All claims for reimbursement or payment for services rendered shall be filed within sixty (60) calendar days from the date of discharge of the patient, with possible extension for reasonable causes.

Role of Local Government Units (LGUs) (Section 36)
- LGUs shall provide basic health care services and invest the capitation payments from the Corporation on health infrastructures, equipment, professional fees, drugs, supplies, information technology, and database, ensuring basic health care services, especially for maternal, infant, and child health.

Grievance and Appeal Procedures (Section 41)
- A member, dependent, or health care provider may file a complaint for grievance, which shall be ruled on by the Grievance and Appeal Review Committee within sixty (60) calendar days.
- Appeals from the Committee's decision must be filed with the Board within thirty (30) calendar days.

Grievance and Appeal Review Committee (Section 42)
- The Board shall create a Grievance and Appeal Review Committee to receive and recommend appropriate action on complaints from members and health care providers.

Penal Provisions (Section 44)
- Violations by accredited health care providers, members, employers, and employees of the Corporation shall be subject to fines, suspension of accreditation or benefits, or other penalties, depending on the nature and severity of the violation.

Requisites for Issuance or Renewal of License or Permits (Section 56)
- All government agencies issuing professional or business licenses or permits shall require applicants to submit proof of payment of PhilHealth premium contributions prior to issuance or renewal.

Oversight Provision (Section 54)
- A Joint Congressional Oversight Committee is created to conduct regular reviews of the NHIP's performance, impact, and accomplishments.
- The National Economic and Development Authority, in coordination with the National Statistics Office and the National Institutes of Health of the University of the Philippines, shall undertake validation studies on the Program's accomplishments and enrollees' satisfaction.

Implementing Rules and Regulations (Section 49)
- The Corporation, in coordination with the DOH, shall issue the necessary rules and regulations for the effective implementation of this Act within sixty (60) days from its effectivity.