National Health Insurance Program (PhilHealth) Flashcards
Known as the National Health Insurance Act of 1995
“An Act Instituting a National Health Insurance Program for All Filipinos and Establishing the Philippine Health Insurance Corporation for the Purpose”
Approved February 14, 1995 by former President Fidel Ramos
Republic Act (RA) 7875
“An Act AMENDING RA 7875”
2004 amendment (1st amendment to NHA)
Added the Oversight Provision
Republic Act (RA) 9241
“An Act FURTHER AMENDING RA 7875”
2013 amendment (2nd amendment to NHA)
Added provision full national government subsidy
Added sections in accordance to RA 10361 (Kasambahay Law)
Republic Act (RA) 10606
Section and article of the 1987 Constitution of the Republic of the Philippines that reads:
“The State shall adopt an integrated and comprehensive approach to health development which shall endeavor to make essential goods, health, and other social services available to all the people at affordable cost. Priority for the needs of the underprivileged, sick, elderly, disabled, women, and other children shall be recognized. Likewise, it shall be the policy of the State to provide free medical care to paupers.”
Section 11, Article XIII
Program proposal made in 1963 by former DOH Secretary Francisco Quimson Duque under the administration of former President Diosdado Macapagal
National Health Service of the Philippines (or simply, the National Health Service)
The Philippine Medical Care Act of 1969
Signed by former President Ferdinand Marcos
Launched the Medicare Program (PHIC precursor)
Republic Act (RA) 6111
Medicare Program phase that started in 1972, targeting SSS/GSIS members
Phase I (Medicare Program Phase I)
Medicare Program phase that started in 1983, targeting the low-income and non-salary-based populations; promoted tie-ups with LGU’s and HMO’s
Phase II (Medicare Program Phase II)
1990s series of studies on social health insurance, funded by the USAID-MSH, crucial to the creation of PHIC
The Health Finance Development Project (HFDP)
The year Medicare’s GSIS and SSS services completely transferred over to PhilHealth
1997
First province to adopt PhilHealth’s indigent program (on October 1, 1997)
Abra
First region to process decentralization of claims (March 1999)
Region VI or the Western Visayas
(Provinces:
- Aklan
- Antique
- Capiz
- Guimaras
- Iloilo
- which at the time, included the provinces of NIR: Negros Occidental and Negros Oriental)
PHIC payment scheme launched October 1, 1999
Individually Paying Program for the Informal Sector
PHIC payment scheme launched July 2000
Capitation
First province to launch the OPD Package (July 2000)
Laguna
PHIC packages first introduced on April 1, 2003
Dialysis Package and the OPD Anti-TB/TB-DOTS Benefits Package
PHIC packages first introduced on May 1, 2003
Maternity Care Package for SVD and Maternity Care Package for SARS
Known as the Kasambahay Law of 2012
“An Act Instituting Policies for the Protection and Welfare of Domestic Workers”
Approved January 18, 2013 by former President Benigno Aquino III
Republic Act (RA) 10361
Amended by RA 10606, section that states the obligation to “ensure that PhilHealth membership of the household help or kasambahay is sustained”
Section 21: Obligations of the Employer of Household Help or Kasambahay
Amended by RA 10606, section that states that the “annual premium contributions of household helps shall be fully paid inaccodance with the provisions of RA 10361 of the ‘Kasambahay Law’”
Section 22: Premium Payment of Household Help
Concept in which the rich would subsidize the poor; the healthy would subsidize the sick
Social solidarity concept
A payment mechanism where a FIXED RATE, whether per person, family, household, or group, is negotioated with the health care provider who shall be responsible for delivering or arranging the delivery of health services required by the covered person under the conditions of a health provider contract
Capitation
A fee PRE-DETERMINED by PhilHealth for each service delivered by a health care provider based on the bill; payment system shall be based on PRE-NEGOTIATED schedule promulgated by the PHIC
Fee-for-service
A health care payment system in which the health care providers are given a FIXED AMOUNT for every SPECIFIC CASE diagnosed
Case payment
The entitlement of an individual as a member or as a dependent to the benefits of the NHIP
Coverage
The amount paid by or in behalf of a member to the NHIP for coverage, based on salaries/wages in the case of formal sector employees, and on household earnings and assets in the case of self-employed or non-formal sector employees, or on other criteria deemed fit by the PHIC in accordance with Act 1 of RA 7875
Premium contribution (or premium)
Foster Care Act of 2012
Defined foster children as legal dependents
Republic Act (RA) 10165
6 types of legal dependents
- Legitimate spouse who is not a member
- Unmarried, unemployed legitimate, legitimated, acknowledged, or illegitimate children and legally adopted or stepchildren BELOW 21
- Children 21 or above but suffering from congenital disability (physical/mental) or any disability acquired that would render them totally dependent on the member for support
- Foster children (RA 10165)
- Parents 60 or above not otherwise enrolled and whose monthly income is below an amount determined by the PHIC
- Parents with permanent disability regardless of age that renders them totally on the member for subsistence
An unforeseen combination of circumstances which calls for immediate action to preserve life, sight (one or both eyes), hearing (one or both ears), or one or two limbs at or above the ankle or wrist
Emergency
4 types of health care providers
- Health care institution, duly licensed/accredited
- Health care professional (doctor of medicine, nurse, midwife, dentist, pharmacist, other health care professionals duly licensed to practice in the Philippines or or accredited/recognized by the PHIC
- Health maintenance organizations (HMOs)
- A community-based health care organizations (CBHCOs)
An entity that provides, offers, or arranges for coverage of designated health services needed by plan members for a fixed pre-paid premium
Health maintenance organization (HMO)
An association of members of the community organized for the purpose of improving the health status of that community through preventive, promotive, and curative health services
Community-based health care organization (CBHCO)
A person who has no visible means of income, or whose income is insufficient for family subsistence (as identified by the DSWD)
Indigent
Essential drugs list of the Philippines (as prepared by the DOH)
Philippine National Formulary
A health facility that has been granted advanced participation for beyond compliance with PhilHealth policies, demonstrated higher financial risk protection, excellent quality of care, and better service satisfaction to its clients/patients
Preferred Health Care Institution
NHIP’s designated responsibility on health services (as opposed to that of the government)
Personal health services
The government’s designated responsibility on health services (as opposed to that of the NHIP)
Public health services (for all groups, such as wmoen, children, indigenous, displaced communities, indigents, environmentally endangered areas)
Protocol administered at the barangay level to determin the ability of individuals/households to pay varying levels of contributions to the NHIP
Means test
Series of successive confinements for the SAME illness/injury, not separated from each other by more than 90 days
Single period of confinement
Maximum allowance period given by the PHIC for a single period of confinement
45 days
Percent goal of the population in KALASUGAN PANGKAHALATAN (or universal coverage)
85%
End-goal of the NHIP
“Bawat Pilipino, miyembro; bawat miyembro, protektado; kalasugan natin segurado”
DSWD program whose registered families are automatically covered by PhilHealth (2013)
National Household Targeting System for Poverty Reduction (NHTS-PR)
4 prohibited actions for the PHIC
- Cannot provide health care directly
- Cannot purchase/dispense drugs and pharmaceuticals
- Cannot employ physicians and other professionals for the purpose of directly rendereding care
- Owning/investing in health care facilities
(Note: PHIC cannot engage in public health services, only personal health services)
Type of corporation the PHIC is, making it exempt from tax
Government-owned-and-controlled corporation (GOCC)
Feature of the PHIC that allows it to issue its own subpoenas, investigations, and decide upon complaints; can sue and be sued; NOT bound by the technical rules of evidence
Quasi-judicial powers
Maximum period of time EMPLOYERS must enroll their employees into the NHIP after hiring
30 days
2 documents required for confinement outside the country
- Official receipt from the health care institution
2. Certification of the attending physician as to the final diagnosis, period of confinement, and services rendered
Section of RA 9241 that provides the “Oversight Provision”
“Government shall conduct a regular review of the NHIP which shall entail a systemic evaluation of the NHIP’s performance, impact/accomplishments with respect to its objectives/goals. Such a review shall be undertaken by the Committees of the Senate and the House of Representatives which have legislative jurisdiction over the NHIP. The NEDA, in coordination with the NSO and the National Institutes of Health of the University of the Philippines shall undertake studies to validate the accomplishments of the program. The budget required to understand such study shall come from the income of PhilHealth”
Section 54
The research group created by Dr. Jimmy Galvez-Tan and Dr. Ramon Paterno to fulfill the Oversight Provision, in partnership with NEDA and NSO (with NEDA as the head agency)
The PhilHealth Research Study Group
Appointed by the president to lead the PHIC, each to serve a 4-year tenure renewable for a maximum of 2 years (except for Cabinet secretaries), mandated to hold meetings at least ONCE A MONTH, each to receive a PER DIEM for every meeting attended
The PhilHealth Board of Directors
4 sources of PhilHealth funding
- Premiums
- Grants and donations
- Investment earnings
- Sin taxes
17 members that compose the Board of Directors
- Ex Officio Chairperson (DOH Secretary) - DR. PAULYN UBIAL
- Vice Chairperson (PHIC President/CEO) - DR. CELESTINA DELA SERNA
- DOLE Secretary or representative - ATTY. SILVESTRE BELLO III
- DILG Secretary or representative - ENG. CATALINO CUY
- DSWD Secretary or representative - PROF. JUDY TAGUIWALO
- DOF Secretary or representative - CARLOS DOMINGUEZ III
- SSS Administrator (SSS President/CEO) or representative - ATTY. EMMANUEL DOOC
- GSIS General Manager (GSIS GM/President) or representative - ATTY. NORA SALUDARES
- Vice Chairperson of the Basic Sector of the National Anti-Poverty Commission or representative - RUPERTO ALEROZA
- CSC Chairperson or representative - ALICIA BALA
- Filipino Migrant Workers representative - NONE
- Informal Economy representative - DR. HILDEGARDES DINEROS
- Formal Economy representative - DR. ROBERTO SALVADOR, JR.
- Employers Sector representative - DR. ROY FERRER
- Health Care Providers Sector representative endorsed by national associations of health care institutions and medical health professionals - DR, JOAN LAREZA
- Local Chief Executives endorsed by League of Provinces, League of Cities, and League of Municipalities - DR. EDDIE DOROTAN
- Independent Director appointed by Monetary Board - DR. ANTHONY LEACHON
3 components of the National Health Insurance Fund (NHIF)
- basic benefit funds
- supplementary benefit funds
- reserve funds
Component of the NHIF that shall finance the basic minimum package to be enjoyed by ALL members
Basic benefit funds
Component of the NHIF that shall finance the extension and availing of ADDITIONAL BENEFIt not included in the basic minimum package but approved by the Board
Supplementary benefit funds
Component of the NHIF to be invested in interest-bearing bonds, securities, deposits/loans/securities to any domestic band and stocks of corporations
Reserve funds
Rules for the total annual revenue of PhilHealth
- should not exceed the sum total of 4% of the total premium contributions during the immediately preceding year
- should not exceed 5% of total reimbursements
- should not exceed 5% of investment earnings generated during the immediately preceding year
Type of member that encompasses the following:
- government employee
- private sector employee (including household help and SEA-BASED OFWs)
- individually-paying member (including LAND-BASED OFWs)
Paying member
Type of member who has reached the age of retirement and has made at least 120 monthly contributions
Lifetime member (or covered member)
4 types of current PhilHealth members
- paying
- indigent
- privately-sponsored
- lifetime/covered
5 requirements for membership registration
(Any 1)
- birth certificate
- baptismal certificate
- GSIS/SSS ID
- passport
- any other valid ID/document accepted by the PHIC
8 requirements for declaration of dependents
- marriage contract/certificate
- birth/baptismal certificate
- court order on adoption
- birth/baptismal certificate of the member and dependent parents
- marriage contract of parent and step-parent and birth certificate of step-children
- joint affidavit of two disinterested persons
- DSWD or Barangay certificate (to attest fact of relationship)
- any other valid ID/document accepted by the PHIC
4 requirements for registration of employers
(Any 1 plus business permit of the license to operate)
- DTI registration (for single proprietorships
- SEC registration (for partnerships and corporations, foundations, and non-profit organizations)
- CDA registrations (for cooperatives)
- Barangay certification or City permit (for backyard industries/ventures and micro-business enterprises)
Minimum years of operation for a health care institution to acquired PhilHealth accreditation
3 years
(Waived in the following situations:
- managing health care professional has had prior experience in another accredited health care institution; or a graduate of hospital administration or any related degree
- operates a tertiary facility
- operates in an LGU where the accredited health care provider cannot adequately/fully serve the population
- service capabiity is not currently available in the LGU
Fee for accreditation for professionals and institutions
Php 0
No accreditation fee; no certificate of good standing is required
A field of science that investigates the value of health technology (as defined in RA 10606)
Health technology assessment
Type of exclusion to TB-DOTS coverage where the patient, on treatment, is sputum smear-positive at 5 months or later during the course of treatment
Treatment failure case (or failure case)
Type of exclusion to TB-DOTS coverage where the patient, previously treat for TB and declared cured or treatment completed, is diagnosed with bacteriologically-positive (smear or culture) TB
Relapse case
Type of exclusion to TB-DOTS coverage where a patient who returns to treatment with positive bacteriology, following interruption of treatment for 2 months or more
Return-after-default (RAD) case
Feature in NHIP where no other fee/expense shall be charged to indigents in government health care institutions
No-Balance Billing
Percent maximum amount of premium contribution (shared by employee and employer) respective to monthly salary
5%
(The amount of premium contribution paid shall not exceed 5% of the members’ respective monthly salaries to be shared equally by the employer and employee)
Maximum period from discharge date of the patient that doctors should file their claim
60 days (with an extension of additional 60 days in the setting of natural calamities or other fortuitous events)
Can health care institutions charge for PhilHealth forms and processing fees?
No
PhilHealth will only pay for drugs included in this list, as assembled by the DOH
Philippine National Drug Formulary (PNDF)
Confinements of less than 24 hours are not compensated, unless in the case of 1 of these 3 exceptions.
- Patient TRANSFER to another institution
- EMERGENCY cases
- Patient DIES
Claims cannot be made in non-accredited health care institutions, unless in the case of 1 of these 3 exceptions
- Health care institution has DOH LICENSE
- EMERGENCY case
- Physical TRANSFER/REFERRAL to accredited institution is IMPOSSIBLE
Penalty for PhilHealth MEMBER fraudulently claiming benefit
Fine: P5000-10000 and/or membership suspension for 3-6 months
Penalty for employer who does not deduct or remit contribution
Fine: not less than P5000 x number of employees involved
