NATIONAL HEALTH INSURANCE ACT OF 1995

[REPUBLIC ACT NO. 7875]

AN ACT INSTITUTING A NATIONAL HEALTH INSURANCE PROGRAM FOR ALL FILIPINOS AND ESTABLISHING THE PHILIPPINE HEALTH INSURANCE CORPORATION FOR THE PURPOSE.

SECTION 1. Short Title. - This Act shall be known as the "National Health Insurance Act of 1995."

ARTICLE I: GUIDING PRINCIPLES

SECTION 2. Declaration of Principles and Policies. - Section 11, Article XIII of the 1987 Constitution of the Republic of the Philippines declares that 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 children shall be recognized. Likewise, it shall be the policy of the State to provide free medical care to paupers.

In the pursuit of a National Health Insurance Program, this Act shall adopt the following guiding principles:

a) Allocation of National Resources for Health - The Program shall underscore the importance for government to give priority to health as a strategy for bringing about faster economic development and improving quality of life;

b) Universality - The Program shall provide all citizens with the mechanism to gain financial access to health services, in combination with other government health programs. The National Health Insurance Program shall give the highest priority to achieving coverage of the entire population with at least a basic minimum package of health insurance benefits;

c) Equity - The Program shall provide for uniform basic benefits. Access to care must be a function of a person’s health needs rather than his ability to pay;

d) Responsiveness - The Program shall adequately meet the needs for personal health services at various stages of a member’s life;

e) Social Solidarity - The Program shall be guided by community spirit. It must enhance risk-sharing among income groups, age groups, and persons of differing health status, and residing in different geographic areas;

f) Effectiveness - The Program shall balance economical use of resources with quality of care;

g) Innovation - The Program shall adopt to changes in medical technology, health service organizations, health care provider payments systems, scopes of professional practice, and other trends in the health sector. It must be cognizant of the appropriate roles and respective strengths of the public and private sectors in health care, including people’s organizations and community-based health care organizations;

h) Devolution - The Program shall be implemented in consultation with the local government units (LGUs), subject to the over-all policy directions set by the National Government;

i) Fiduciary Responsibility - The Program shall provide effective stewardship, funds management, and maintenance of reserves;

j) Informed Choice - The Program shall encourage members to choose from among accredited health care providers. The Corporation’s local offices shall objectively apprise its members of the full range of providers involved in the Program and of the services and privileges to which they are entitled as members. This explanation, which the member may use as a guide in selecting the appropriate and most suitable provider, shall be given in clear and simple Filipino and in the local language that is comprehensible to the members;

k) Maximum Community Participation - The Program shall build on existing community initiatives for its organization and human resource requirements.

l) Compulsory Coverage - All citizens of the Philippines shall be required to enroll in the National Health Insurance Program in order to avoid adverse selection and social inequity;

m) Cost Sharing - The Program shall continuously evaluate its cost-sharing schedule to ensure that the costs borne by the members are fair and equitable and that the charges by health care providers are reasonable;

n) Professional Responsibility of Health Care Providers - The Program shall assure that all participating health care providers are responsible and accountable in all their dealings with the Corporation and its members;

o) Public Health Services - The Government shall be responsible for providing public health services for all groups such as women, children, indigenous people, displaced communities in environmentally endangered areas, while the Program shall focus on the provision of personal health services. Preventive and promotive public health services are essential for reducing the need and spending for personal health services;

p) Quality of Services - The Program shall promote the improvement in the quality of health services provided through the institutionalization of programs of quality assurance at all levels of the health service delivery system. The satisfaction of the community, as well as individual beneficiaries, shall be a determinant of the quality of service delivery;

q) Cost Containment - The Program shall incorporate features of cost containment in its design and operations and provide a viable means of helping the people pay for health care services; and

r) Care for the Indigent - The government shall be responsible for providing a basic package of needed personal health services to indigents through premium subsidy, or through direct service provision until such time that the program is fully implemented.

SECTION 3. General Objectives. - This Act seeks to:

a) provide all citizens of the Philippines with the mechanism to gain financial access to health services;

b) create the National Health Insurance Program, hereinafter referred to as the Program, to serve as the means to help the people pay for health care services;

c) prioritize and accelerate the provisions of health services to all Filipinos, especially that segment of the population who cannot afford such services; and

d) establish the Philippine Health Insurance Corporation, hereinafter referred to as the Corporation, that will administer the Program at central and local levels.

ARTICLE II : DEFINITION OF TERMS

SECTION 4. Definition of Terms. - For the purpose of this Act, the following terms shall be defined as follows:

a) Beneficiary - Any person entitled to health care benefits under this Act.

b) Benefit Package - Services that the Program offers to its members.

c) Capitation - A payment mechanism where a fixed rate, whether per person, family, household, or group, is negotiated with the health care provider who shall be responsible for delivering or arranging for the delivery of health services required by the covered person under the conditions of a health provider contract.

d) Contribution - The amount paid by or in behalf of a member to the Program for coverage, based on salaries or wages in the case of formal sector employees, and on household earnings and assets, in the case of the self-employed, or on other criteria as may be defined by the Corporation in accordance with the guiding principles set forth in Article I of this Act.

e) Coverage - The entitlement of an individual, as a member or as a dependent, to the benefits of the Program.

f) Dependent - The legal dependents of a member are: 1) the legitimate spouse who is not a member; 2) the unmarried and unemployed legitimate, legitimated, illegitimate, acknowledged children as appearing in the birth certificate; legally adopted or stepchildren below twenty-one (21) years of age; 3) children who are twenty-one (21) years old or above but suffering from congenital disability, either physical or mental, or any disability acquired that renders them totally dependent on the member for support; 4) the parents who are sixty (60) years old or above whose monthly income is below an amount to be determined by the Corporation in accordance with the guiding principles set forth in Article I of this Act.

g) Diagnostic Procedure - Any procedure to identify a disease or condition through analysis and examination.

h) Emergency - An unforeseen combination of circumstances which calls for immediate action to preserve the life of a person or to preserve the sight of one or both eyes; the hearing of one or both ears; or one or two limbs at or above the ankle or wrist.

i) Employee - Any person who performs services for an employer in which either or both mental and physical efforts are used and who receives compensation for such services, where there is an employer-employee relationship.

j) Employer - A natural or juridical person who employs the services of an employee.

k) Enrollment - The process to be determined by the Corporation in order to enlist individuals as members or dependents covered by the Program.

l) Fee for Service - A reasonable and equitable health care payment system under which physicians and other health care providers receive a payment that does not exceed their billed charge for each unit of service provided.

m) Global Budget - An approach to the purchase of medical services by which health care provider negotiation concerning the costs of providing a specific package of medical benefits is based solely on a predetermined and fixed budget.

n) Government Service Insurance System - The Government Service Insurance System created under Commonwealth Act No. 186, as amended.

o) Health Care Provider - Refers to:

1) a health care institution, which is duly licensed and accredited and 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, or in need of obstretical or other medical and nursing care. It shall also be construed as any institution, building, or place where there are installed beds, cribs, or bassinets for twenty-four hour use or longer by patients in the treatment of diseases, injuries, deformities, or abnormal physical and mental states, maternity cases or sanitarial care; or infirmaries, nurseries, dispensaries, and such other similar names by which they may be designated; or

2) a health care professional, who is any doctor of medicine, nurse, midwife, dentist, or other health care professional or practitioner duly licensed to practice in the Philippines and accredited by the Corporation; or

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

4) a community-based health care organization, which is an association 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.

p) Health Insurance Identification (ID) Card - The document issued by the Corporation to members and dependents upon their enrollment to serve as the instrument for proper identification, eligibility verification, and utilization recording.

q) Indigent - A person who has no visible means of income, or whose income is insufficient for the subsistence of his family, as identified by the Local Health Insurance Office and based on specific criteria set by the Corporation in accordance with the guiding principles set forth in Article I of this Act.

r) Inpatient Education Package - A set of informational services made available to an individual who is confined in a hospital to afford him with knowledge about his illness and its treatment, and of the means available, particularly lifestyle changes, to prevent the recurrence or aggravation of such illness and to promote his health in general.

s) Member - Any person whose premiums have been regularly paid to the National Health Insurance Program. He may be a paying member, an indigent member, or a pensioner/retiree member.

t) Means Test - A protocol administered at the barangay level to determine the ability of individuals or households to pay varying levels of contributions to the Program, ranging from the indigent in the community whose contributions should be totally subsidized by government, to those who can afford to subsidize part but not all of the required contributions for the Program.

u) Medicare - The health insurance program currently being implemented by the Philippine Medical Care Commission. It consists of:

1) Program I, which covers members of the SSS and GSIS, including their legal dependents; and

2) Program II, which is intended for those not covered under Program I.

v) National Health Insurance Program - The compulsory health insurance program of the government as established in this Act, which shall provide universal health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines.

w) Pensioner - An SSS or GSIS member who receives pensions therefrom.

x) Personal Health Services - Health services in which benefits accrue to the individual person. These are categorized into in-patient and out-patient services.

y) Philippine Medical Care Commission - The Philippine Medical Care Commission created under Republic Act No. 6111, as amended.

z) Philippine National Drug Formulary - The essential drugs list for the Philippines which is prepared by the National Drug Committee of the Department of Health in consultations with experts and specialists from organized professional medical societies, medical academe and pharmaceutical industry, and which is updated every year.

aa) Portability - The enablement of a member to avail of Program benefits in an area outside the jurisdiction of his Local Health Insurance Office.

bb) Prescription Drug - A drug which has been approved by the Bureau of Food and Drugs and which can be dispensed only pursuant to a prescription order from a physician who is duly licensed to do so.

cc) Public Health Services - Services that strengthen preventive and promotive health care through improving conditions in partnership with the community at large. These include control of communicable and non-communicable diseases, health promotion, public information and education, water and sanitation, environmental protection, and health related data collection, surveillance, and outcome monitoring.

dd) Quality Assurance - A formal set of activities to review and ensure the quality of services provided. Quality assurance includes quality assessment and corrective actions to remedy any beneficiaries identified in the quality of direct patient, administrative, and support services.

ee) Residence - The place where the member actually lives.

ff) Retiree - A member of the Program who has reached the age of retirement or who has retired on account of disability.

gg) Self-employed - a person who works for himself and is, therefore, both employee and employer at the same time.

hh) Social Security System - The Social Security System created under Republic Act No. 1161, as amended.

ii) Treatment Procedure - Any method used to remove the symptoms and cause of a disease.

jj) Utilization Review - A formal review of patient utilization or of the appropriateness of health care services, on a prospective, concurrent or retrospective basis.

ARTICLE III : THE NATIONAL HEALTH INSURANCE PROGRAM

SEC. 5. Establishment and Purpose. - There is hereby created the National Health Insurance Program which shall provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines, in accordance with policies and specific provisions of this Act. This social insurance program shall serve as the means for the healthy to help pay for the care of the sick and for those who can afford medical care to subsidize those who cannot. It shall initially consist of Programs I and II of Medicare and be expanded progressively to constitute one universal health insurance program for the entire population. The Program shall include a sustainable system of funds constitution, collection, management and disbursement for financing the availment of a basic minimum package and supplementary packages of health insurance benefits by a progressively expanding proportion of the population. The Program shall be limited to paying for the utilization of health services by covered beneficiaries or to purchasing health services in behalf of such beneficiaries. It shall be prohibited from providing health care directly, from buying and dispensing drugs and pharmaceuticals, from employing physicians and other professionals for the purpose of directly rendering care, and from owning or investing in health care facilities.

SEC. 6. Coverage. - All citizens of the Philippines shall be covered by the National Health Insurance Program. In accordance with the principles of universality and compulsory coverage enunciated in Section 2 (b) and 2 (1) hereof, implementation of the Program shall, furthermore, be gradual and phased in over a period of not more than fifteen (15) years: Provided, That the Program shall not be made compulsory in certain provinces and cities until the Corporation shall be able to ensure that members in such localities shall have reasonable access to adequate and acceptable health care services.

SEC. 7. Enrollment. - The Program shall enroll beneficiaries in order for them to be placed under coverage that entitles them to avail of benefits with the assistance of the financial arrangements provided by the Program. The process of enrollment shall include the identification of beneficiaries, issuance of appropriate documentation specifying eligibility to benefits, and indicating how membership was obtained or is being maintained. The enrollment shall proceed in accordance with these specific policies:

a) all persons currently eligible fro benefits under Medicare Program I, including SSS and GSIS members, retirees, pensioners and their dependents, shall immediately and automatically be made members of the National Health Insurance Program;

b) all persons eligible for benefits through health insurance plans established by local governments as part of Program II of Medicare or in accordance with the provisions of this Act, including indigent members, shall also be enrolled in the Program;

c) all persons eligible for benefits as members of local health insurance plans established by the Corporation in accordance with the implementing rules and regulations of this Act shall also be deemed to have enrolled in the Program. Enrollment of persons who have no current health insurance coverage shall be given priority by the Corporation; and

d) all persons eligible for benefits as members of other government-initiated health insurance programs, community-based health care organizations, cooperatives, or private non-profit health insurance plans shall be enrolled in the Program upon accreditation by the Corporation which shall devise and provide incentives to ensure that such accredited organizations will benefit from their participation in the program.

All indigents not enrolled in the Program shall have priority in the use and availment of the services and facilities of government hospitals, health care personnel, and other health organizations: Provided, however, That such government health care providers shall ensure that said indigents shall subsequently be enrolled in the Program.

SEC. 8. Health Insurance ID Card - In conjunction with the enrollment provided above, the Corporation through its local office shall issue a health insurance ID which shall be used for purposes of identification, eligibility verification, and utilization recording. The issuance of this ID card shall be accompanied by a clear explanation to the enrollee of his rights, privileges and obligations as a member. A list of health care providers accredited by the Local Health Insurance Office shall likewise be attached thereto.

SEC. 9. Change of Residence. - A citizen can be under only one Local Health Insurance Office which shall be located in the province or city of his place of residence. A person who changes residence, becomes temporarily employed, or for other justifiable reasons, is transferred to another locality, should inform said Office of such transfer and subsequently transfer his Program membership.

SEC. 10. Benefit Package. - Subject to the limitations specified in this Act and as may be determined by the Corporation, the following categories of personal health services granted to the member or his dependents as medically necessary or appropriate, shall include:

a) Inpatient hospital care:

1) room and 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; subject to the limitations stated in Section 37 of this Act;

6) inpatient education packages;

b) Outpatient care:

1) services of health care professionals;

2) diagnostic, laboratory, and other medical examination services;

3) personal preventive services; and

4) prescription drugs and biologicals, subject to the limitations described in Section 37 of this Act;

c) Emergency and transfer services; and

d) Such other health care services that the Corporation shall determine to be appropriate and cost-effective: Provided, That the Program, during its initial phase of implementation, which shall not be more than five (5) years, shall provide a basic minimum package of benefits which shall be defined according to the following guidelines:

1) the cost of providing said packages is such that the available national and local government subsidies for premium payments of indigents are sufficient to extend coverage to the widest possible population.

2) the initial set of services shall not be less than half of those provided under the current Medicare Program I in terms of overall average cost of claims paid per beneficiary household per year.

3) the services included are prioritized, first, according to its cost-effectiveness and, second, according to its potential of providing maximum relief from the financial burden on the beneficiary: Provided, That, in addition to the basic minimum package, the Program shall provide supplemental health benefit coverage to beneficiaries of contributory funds, taking into consideration the availability of funds for the purpose from said contributory funds: Provided, further, That the Program progressively expand the basic minimum benefit package as the proportion of the population covered reaches targeted milestone so that the same benefits are extended to all members of the Program within five (5) years after the implementation of this Act. Such expansion will provide for the gradual incorporation of supplementary health benefits previously extended only to some beneficiaries into the basic minimum package extended to all beneficiaries: and Provided, finally, That in the phased implementation of this Act, there should be no reduction or interruption in the benefits currently enjoyed by present members of Medicare.

SEC. 11. Excluded Personal Health Service. - The benefits granted under this Act shall not cover expenses for the services enumerated hereunder except when the Corporation, after actuarial studies, recommend their inclusion subject to the approval of the Board:

a) non-prescription drugs and devices;

b) out-patient psychotherapy and counseling for mental disorders;

c) drug and alcohol abuse or dependency treatment;

d) cosmetic surgery;

e) home and rehabilitation services;

f) optometric services;

g) normal obstetrical delivery; and

h) cost ineffective procedures which shall be defined by the Corporation.

SEC. 12. Entitlement to Benefits. - A member whose premium contributions for at least three (3) months have been paid within six (6) months prior to the first day of his or his availment, shall be entitled to the benefits of the Program: Provided, That such member can show that he contributes thereto with sufficient regularity, as evidenced in his health insurance ID card: and Provided, further, That he is not currently subject to legal penalties as provided for in Section 44 of this Act.

The following need not pay the monthly contributions to be entitled to the Program’s benefits:

a) Retirees and pensioners of the SSS and GSIS prior to the effectivity of this Act;

b) Members who reach the age of retirement as provided for by law and have paid at least one hundred twenty (120) contributions; and

c) Enrolled indigents.

SEC. 13. Portability of Benefits. - The Corporation shall develop and enforce mechanisms and procedures to assure that benefits are portable across Offices.