PHILHEALTH

ROMEO R. ANDAYA, MD.MSCPD,PhD, FPAFP

Chair, DPMCH
RA 7875 : National Health Insurance Act of 1995

An Act instituting a National Health

Insurance Program for all Filipinos &
established the Philippine Health
Insurance Corporation (PHIC) for the
purpose.
RA 7875 : National Health Insurance Act of 1995

Main Functions of the PHIC:

1. Administersthe National Health
Insurance Program
2. Setpolicies, standards, rules &
regulations
3. Establish branch offices.
4. Manage the national Health
Insurance Fund
 RA 7875 : National Health Insurance
Act of 1995
Quasi-judicial Functions of the PHIC:
1. To conduct investigations
2. To
summon the parties to a
controversy
3. Tosuspend temporarily, revoke
permanently or restore accreditation of
a health care provider or the right to
benefits of a member &/or impose
fines after due notice & hearings.
 National Health Insurance Fund
SOURCES:
1. Contribution from Program members
2. Appropriations from local & national
government
3. Other appropriations:
 25% of the increment from total revenue
collected under RA 7654 (1995)
 25% of the incremental revenue from
increase in documentary stamp taxes RA
7660 (1996)
4. Donations & grant in aids
Philippine Health Insurance (PHILHEALTH)

The National Health Insurance Program (NHIP)

replaced the old MEDICARE program to:
1. Accelerate universal coverage
2. Enhance& expand the benefits to include
OPD services
3. Consolidatethe MEDICARE program
previously administered separately by SSS,
GSIS, & OWWA.
4. Ensurea sustainable National Health
Insurance for ALL.
General Objectives of PHILHEALTH

1.To gain financial access to

health services
2.To create the National Health
Insurance Program
3.To prioritize the provision of
health services
Who are Covered by the NHIP?

The program covers the following:

1.Employed sector- government &
private sectors
2.Individually paying members –
self-employed, OFWs, private
practitioners ( doctors, lawyers,
dentists, etc)
3.Non-paying members:
Who are Covered by the NHIP?
The program covers the following:
3. Non-paying members:
 Retirees & pensioners – entitled to life time
coverage provided they have paid at least 120
monthly contributions to the NHIP, & have reached
the age of 60 upon retirement
 Permanently & partial disability pensioners & death
pensioners ( survivorship) of the SSS prior to the
effectivity of the law in March 1995 are also
considered non-paying members. Optional retirees
( under RA1616) are NOT entitled to free coverage
until they reach the age of retirement.
Who are Covered by the NHIP?
The following can also enjoy coverage
through the member:
1. Legitimate spouse not an NHIP
member
2. Children
( legitimate , illegitimate,
adopted, step children ) below 21
years old, unmarried & unemployed
 Policies on Enrollment
1. MEDICARE Program I are automatically enrolled
2. Members of MEDICARE Program II are all enrolled.
3. Members of Local Health Insurance Plans
established by the Corporation
4. Members of other government initiated health
insurance programs, community based health care
organization cooperatives, or private non-profit
health insurance
5. Voluntary membership
6. indigent
Entitlement to PHILHEALTH Benefits

1. A member who have paid at least three (3) monthly

contributions within the immediate six (6) month
period prior to month of confinement
2. Confined in any accredited hospital for not less than
24 hours due to an illness or injury requiring
hospitalization
3. Minor surgical procedures, chemotherapy, radio
therapy, hemodialysis & cataract extraction are also
compensable on an out patient basis.
Entitlement to PHILHEALTH Benefits

• The 45 days allowance for room & board has

not been consumed yet.
• Principal members are entitled to the 45
days coverage each year while dependents
will share 45 days coverage.
• However, a member can avail of a new set
of benefits if succeeding confinements are of
different illness or condition.
 Benefit Package

1. In-patient hospital care

 Room & board
 Services of health care professionals
 Diagnostic, laboratory, &other medial
examination services
 Use of surgical &medical equipment facilities
 Prescription medicines & biological
 In patient education package
 Benefit Package

2. Out-patient care
 Services of health care
professionals
 Diagnostic, laboratory, &other
medial examination services
 Personal preventive services
 Prescription medicines & biological
 Benefit Package

3. Emergency & transfer services

4. Other health – care services that
the PHIC shall determine to be
appropriate & cost-effective
 Confinement in Non-accredited
Hospital

PHILHEALTH will not pay for

confinements in non-accredited
hospitals except for emergency
cases & the hospital or clinic is duly
licensed by the Department of
Health.
Excluded Personal Health Services

1. Non – prescription medicines & devices

2. Out-patient
psychotherapy & counselling for
mental disorders
3. Drug& alcohol abuse or dependency
treatment
4. Cosmetic surgery
5. Home rehabilitation services
6. Optometric services
7. Normal obstetrical delivery after the third birth
 Major Reforms

MEDICARE PROGRAM PHILHEALTH

1.COVERAGE
 Formal sector  All Filipinos
 Self employed
 Small portion of
informal sector
2. Benefit Packages  in-patient/.out-patient
- in-patient emergency & transfer services
& other cost effective &
appropriate services