National health insurance act of 1995

Rationale behind the enactment of R.A. 7875 It was enacted to implement Section 11, Article 13 of the 1987

constitution which provides :

“The state shall adopt an integrated and comprehensive approach to health development and to make essential goods, health and other social services available to all the people at affordable cost, with priority for the needs of the under-privileged, sick elderly, Disabled, women, and children, and provide free medical care to paupers.

The National Health Insurance Program (NHIP)

Intended to answer for the utilization or purchase of health services by covered beneficiaries.

Consisted initially of programs I & II NHIP is prohibited from: 1) providing direct health care 2) O/I in health care facilities 3)buying &dispensing drugs & pharmaceuticals 4) Employing physicians and other professionals for the purpose of

directly rendering care.

Coverage of the NHIP

All citizens of the Philippines Compulsory Except cities and municipalities when: When PHC is able to ensure that members have access to

adequate and acceptable health care services

Enrollment of beneficiaries in the NHIP

Beneficiary must be enrolled with the NHIP in accordance with these policies:

A) Persons eligible for benefits under medicare program I –Automatically enrolled in NHIP

B)Members of LHIP established by PHIC – deemed enrolled in NHIP

C)Persons eligible for benefits under the health insurance plans established by LGU as part of program II of medicare, including indigent members. –deemed enrolled

D)Persons eligible for benefits as members of other gov’t initiated HIPs, community based health care organizations, cooperatives or private non-profit health insurance plans – deemed enrolled with accreditation by PHIC

Enrollment Requirements A) PhilHealth membership registration B)Birth Certificate C)Baptismal Certificate D)GSIS/SSS ID E)Passport F)Any other valid id/doc acceptable to the PHIC Takes effect upon payment of premium contribution.

Declaration of Dependents

Requirements for registrants declaring dependents: Dependent Spouse – Marriage Certificate(MC) Dependent Legitimate Child – MC and Birth/Baptismal Certificate

(B/BS) Dependent Illegitimate child – B/BC Dependent Adopted Child – adoption papers or court resolution Dependent parents – B/BC of registrant Dependent step children – MC of parent and Step Father/Step

Mother and Baptismal Certificate of the dependent step children. Premium Contributions Employees and Employers shall pay monthly contributions

determined by the PHIC. Self-employed members shall pay their contributions based on

household earnings and assets. Contributions made in behalf of indigent members shall not exceed

the min. contributions set for employed members. The premium contribution of individually paying members shall be at

a minimum of P75.00 per month & can be paid quarterly, semi-annually or annually.

OFWs enrolled with the NHIP shall pay an annual contribution in an amount to be set by the Corporation.

Persons not obliged to pay premium contributions

Retirees & pensioners of the SSS & GSIS prior to the effectivity of the NHIA

Members who have reached the age of majority and have paid at least 120 monthly contributions; and

Enrolled indigents

Benefits under the NHIP

A) Inpatient hospital care: 1) room & board 2)services of health care professionals 3)diagnostic, laboratory and other medical examination services 4)use of surgical or medical equipment and facilities 5)prescription drugs and biologicals 6)inpatient education packages

B)Outpatient care: 1)services of health care professionals 2) diagnostic, laboratory and other medical examinations 3)personal preventive services; and 4)prescription drugs and biological

C)emergency & transfer services; and D)such other health care services that the PHIC shall determine to be appropriate and cost-effective.

Health services not covered by the NHIP A) non- prescription drugs and devices B) alcohol abuse or dependency treatment C)cosmetic surgery D)optometric services

E)fifth and subsequent normal obstetrical deliveries F)cost-ineffective producers G) outservice psychotherapy and counseling for mental disorders. H)home and rehabilitation services

Conditions for entitlement of benefits: Must suffer illness or injury Paid premium for at least 3 months within the 6 month period to the

first day of his or her dependents’ availment. He must not be currently subject to penal sanctions under the law.

Members/dependents can avail of benefits while they are outside the country provided they submit: 1)official receipt of payment or statement of account. 2) certification of the attending physician as to the final diagnosis,

period of confinement and services rendered.

Health care providers refer to: A) a duly licensed health care institution devoted primarily to the

maintenance and operation of facilities for health promotion, prevention, diagnosis, treatment and care of individuals suffering from illness, disease, injury, disability or deformity, drug addiction or in need of obstetrical or other medical and nursing care.

B) a health care professional

C) a health maintenance organization which provides, offers or arranges offers coverage of designated health services needed by plan members for a fixed prepaid premium; or

D) a community-based health care organization of indigenous members of the community organized for the purpose of improving the health status of that community through preventive, promotive and curative health services.

Health care providers should be accredited

Health care provider must apply and qualify for accreditation with the ff. requirements: A) managing health care professional must have 3 year work

experiences with an accredited health care institution. B) operates s an tertiary facility or equivalent; or

C) operates in a LGU where accredited HCP cannot adequately or fully services its population.

Payment of claims of Health Care Providers A) fee for services B) capitation of health care professionals, institutions or networks of

the same, including maintenance organizations, medical cooperatives and other legally form health service groups;

C) such other mechanisms as may hereafter be determined by the PHIC

Direct payment to the member is not allowed except: A) if member/dependent is confined abroad. B) if drugs, medicines and other medical supplies were bought and

used by the member within the confinement period with supporting official receipts.

C) if member advanced payment because of failure to submit the required documents;

D) if the member paid the professional fees directly.

Grounds for denial or reduction of claims: A) over-utilization and under-utilization of services B) unnecessary diagnostic and therapeutic procedures and

intervention C) irrational medication and prescriptions D) fraud E) gross, unjustified deviations from currently accepted standards of

practice and/or treatment protocols F) inappropriate referral practices

G) use of fake, adulterated or misbranded pharmaceuticals or unregistered drugs; or

H) use of drugs other than those recognized in the latest PNDF and those for which exemptions were granted by the board.

Compensability of confinement for less than 24 hours are not compensable except: A) when the patient died B) when the patient is transferred to another health care institution;

or

C) in emergency cases.

The Philippine Health Insurance Corporation

Is tax exempt Attached to the DOH Administers the NHIC Vested with administrative and quasi-jidicial powers Its decisions are immediately executory, even pending appeal, when

public interest so requires.