AGPAOA, BALTEZA, BUENCAMINO, CABITAC,

DIZON, LAMUG, SALVADOR, TENORIO

Universal Health
Care Act 2018
R.A. No. 11223
GENERAL
PROVISION
S
Policies and
Objectives
•Art.
II, Sec, 15 of the 1987
Constitution

•Access to affordable health care,

goods and services
Definition of terms
•Direct contributors
•Indirect contributors
•Health care provider
•Public Health Emergency
•Entitlement
•Essential health benefit package
ORGANIZATION OF LOCAL HEALTH
SYSTEMS
LOCAL HEALTH SYSTEMS

HEALTH SERVICES HEALTH PROFESSIONALS HEALTH FACILITIES

GOVERNING ENTITIES
HUMAN RESOURCES FOR
HEALTH
 National Health Human Resource Master Plan
- provide policies and strategies for the appropriate
health workforce based on population health needs.

- Provide guarantees of:

a) permanent employment and;
b) competitive salaries.

Plan Strategy
Sec. 25 Scholarship and Training Programs
Sec. 26 Return Service Agreement

- Return service for at least three (3) years for

recipients of government-funded scholarship
programs

- Provision of additional incentives for those rendering

additional two (2) years of service
GOVERNANCE AND
ACCOUNTABILITY
Health Promotion
● Transformation of Healthy Promotion and Communication
Service (HPCS) to Health Promotion Bureau

- Formulation of strategy

- Implementation of population-wide health needs

- Technical support to local development and research

Health Promotion
- DepEd schools to be designated as healthy settings

- Incorporation of health promotion in school curricula

What is its purpose?

- To intensify the fight against diseases and;

- To strengthen the effective promotion of healthy lifestyle

Evidence-Informed Sectoral Policy and Planning
for UHC
a) All health-related entities to submit health data to PhilHealth

b) DOH and DOST to develop a policy systems for researchers, experts and managers through training
grants.

c) All health-related survey data generated using public funds shall be considered as public records.

d) Action researches for health promotion and social mobilization as part of the national health research
agenda.
Monitoring and Evaluation
Who shall evaluate surveys of the effectiveness of health promotion?

- Conduct household
surveys for the first
(10) ten years of
implementation.

How do people be informed regarding diseases?

- Publish annual provincial

burden of disease.
What is Health Impact Assessment ?
Means of assessing the health impact of policies, programs and projects before, during and
after the implementation. (Section 33.1.a, Rule VIII, Universal Health Care Act)

- The HIA is conducted to manage the implementations of the plans and to provide practical
recommendations.

- The DOH shall review the development project and issue health impact clearance.
What is Health Technology Assessment ?
It is a mechanism for the development of policies and programs, regulations and the
determination of a range of entitlements such as drugs, medicines, pharmaceutical products,
and other devices, procedures and services. (Section 34, R.A. 11223).

Criteria in the conduct of HTA: (ReSaHoCA)

a) Responsiveness to Magnitude, Severity, and Equity.

b) Safety and Effectiveness.

c) Household Financial Impact

d) Cost-effectiveness

e) Affordability and Viability

 Health Technology Assessment Council (HTAC)

public health health sociologist or

epidemiologist economist citizen’s ethicist
anthropologist representative

CHAIRPERSON

Subcommittees to be constituted shall includes: -

Drugs
- Vaccines, clinical trial or research
- Clinical Equipment and Devices, public health medico-legal clinical epidemiologist or
methods expert
- Medical and Surgical Procedure, expert expert evidence-based
- Preventive and Promotive Health Services, medicine expert
- Traditional Medicine.
UNIVERSA
L HEALTH
CARE
 WHAT DOES THE LAW
PRIMARILY
In 2017, research shows only 2MEAN?
out of 3
Filipinos are covered by Philhealth.
Source: National Demographic and Health
Survey 2017
 WHAT DOES THE LAW
PRIMARILY MEAN?
In 2017, research shows only 2 out of 3 Filipinos are covered by
Philhealth.
Source: National Demographic and Health Survey 2017

UHC: Every Filipino citizen shall be automatically included into the

National Health Insurance Program (Section 5, R.A. 11223).
 How will the “inclusion” be implemented?
PhilHealth shall coordinate with other national government
agencies and health care facilities towards the inclusion of all
Filipinos in its database at no cost. (Section 5.2, Rule II, IRR,
Universal Health Care Act)

This health information system shall be developed and funded by

DOH and Philhealth.
 What kinds of services does the law
● cover?
Immediate Eligibility and Access
● Comprehensive Outpatient Benefits
● Provision of Primary Care Providers
SERVICE COVERAGE IN
SUM
● “Comprehensive Outpatient Benefits” is foreseen to be
similar to a Primary Care Benefit Package.
● An individual or a family need not get sick first before they
may avail the benefits of Philhealth.
SERVICE COVERAGE IN SUM
● The law mandates, among others, that the individual or family must be
checked regularly by a physician at NO COST, including entitlement to
diagnostic services, laboratory services, preventive and promotive services,
etc., depending on the physician’s recommendation and advice.
HOW WILL HEALTH SERVICES BE
FUNDED? SOURCE OF FUNDS
TYPE OF HEALTH SERVICE

POPULATION-BASED SERVICES National Government (through the

DOH).

The National Government shall support

LGUs in the financing of capital
investments and provision of population-
based health services.

INDIVIDUAL-BASED SERVICES Primarily through pre-payment mechanisms

(Social Health Insurance, Private Health
Insurances, HMOs)
PROGRAM MEMBERSHIP
Program Membership
Simplified into two (2) types:
1. Direct contributors
2. Indirect contributors
Who are the members of direct contributors?

● Employees w/ formal employment, existence of an employer-employee

relationship. ( workers in government and private sector)
● Kasambahays
● All other workers not covered by formal contracts (no Er-Ee relationship)
- Self-earning individuals; and professional practitioners;
● OFW (Migrant Workers Act)
- Sea-based or land based Filipino workers
Who are the members of direct contributors?
● Filipinos living abroad;
● Filipinos with dual citizenship;
● Lifetime members (National Health Insurance Act);
● All Filipinos aged 21 years and above who have the capacity to pay
premiums.
Who are the self-earning individuals?

Who render services or sell goods as a means of livelihood or a career

(outside of an employer-employee relationship)
Who is a lifetime member?
A member who has reached the age of retirement and has paid at least 120
monthly premium contributions.
1. Retirees/ Pensioners from the Government Sector;
2. Retirees/ Pensioners from the Private Sector;
3. Uniformed Members of the AFP, PNP, BJMP and BFP and;
4. Members of PhilHealth who have reached the age of retirement and
who paid premium contributions of at least 120 months.
Who is a sponsored member?
Contribution being paid by another individual, government agency, or
private entity.
Direct Contributors
Shall register and/or update their records and premium contributions with
PhilHealth.
Who are the members of indirect contributors?
● Indigents identified by the DSWD;
● Beneficiaries of 4Ps/MCCT;
● Senior citizens not covered by the Program
● PWD
Who are the members of indirect
contributors?
● All Filipinos, 21 years old and above without the capacity to pay
premiums;
● Sangguniang Kabataan officials
● Those identified at point-of-service (POS) or during registration
Who is an indigent person?
A person who has no visible means of income,
or whose income is insufficient for family
subsistence.
What are the criteria to become eligible for the
4Ps?
● Residents of the poorest municipalities (NSCB)
● Households whose economic condition is equal to or below the provincial poverty
threshold
● Households that have children 0-18 years old and/or have a pregnant woman at the
time of assessment
● Households that agree to meet conditions specified in the program
Who determine those who are financially
incapable to pay premiums?

- The DSWD or social welfare officers of the LGUs authorized by PhilHealth.

Who are the qualified dependents
of direct and indirect
contributors?
● Legal spouse who is not an active member;
● Unmarried and unemployed legitimate, illegitimate children, and
legally adopted or step-children below 21 years of age.
● Foster children (RA 10165)
● Parents who are 60 years old and above, not an enrolled member
PREMIUM
CONTRIBUTIO
NS
Year Premium Rate Income Floor Income Ceiling
2019 2.75% ₱10,000.00 ₱50.000.00

2020 3.00 % ₱10,000.00 ₱60,000.00

2021 3.50% ₱10,000.00 ₱70,000.00

2022 4.00 % ₱10,000.00 ₱80,000.00

2023 4.50 % ₱10,000.00 ₱90,000.00

2024 5.00 % ₱10,000.00 ₱100,000.00

2025 5.00 % ₱10,000.00 ₱100,000.00

 Employee A Employee C

90, 000/ month 8,500/month

60, 000 * .03 = 1, 800 Employee B 10, 000 * .03 – 300/ month
55,000/ month

55, 000 * .03 = 1, 650

 members
&
Sea-based
OFWs
● Equal share for Er and Ee
● Schedule of payment:
○ PENs ending 0-4; every 11th-15th
day
○ PENs ending 5-9; every 16th-20th
day
Kasambahay
● Employer: < P 5,000
● Equal share: ≥ P 5,000
Self-earning individuals
Practicing Professionals
Land-based migrant
workers
Other direct
contributors
● 100%
✓ Acceptable proof of actual income
❌ Rate based on the income ceiling
● Monthly, quarterly, semi-annual,
annual
● ≥ 21 y/o
○ based on PhilHealth guideline
 Indirect
Contributors
● Subsidized by the government
● PWD + income
✓ employer + government
● Lifetime members & seniors +
income
✓ premium for membership type
Benefits
 Benefits
“ Essential health benefit package” (PMDL)
● Rule on Admissions in basic and non-basic
accommodations.
Government – 90%
Specialty Hospital – 70%
Private Hospitals – 10%
 What are the benefits under
hilHealth
1. Inpatient benefit
2. Outpatient (BDRP)
3. Z Benefit (Cancer)
4. Sustainable Development Goals (SDG)
5. Maternity Benefits
Requirement: 6MC-P-3MQC-w/ 12
PPFDC
Health Services Delivery
1. Population-based Health Services
- Population
- Public health emergency
2. Individual-based Health Services
REGULATI
ON
Safety and Quality
• How does the Department of
Health determine the safety
and quality of health care
facilities?
• Stand-alone healthcare
facilities
• Standards for clinical care
AFFORDABILITY
OF HEALTHCARE
•REMEMBER “DPAGS”

• DOH owned healthcare

providers…
• Price negotiation board
• Availability of information
• Generic medicine
• Standard policies
Equity, Equality of Healthcare for All

Bed capacities of hospitals

● Government Hospitals
● Specialty Hospitals
● Private Hospitals
 2CNN IN ACTION
PENAL PROVISIONS
OFFENSES OF HEALTH CARE PROVIDERS OF POPULATION-BASED HEALTH SERVICES

● Shall be penalized by its respective contracts without prejudice to the right

PENAL PROVISIONS
of the government to institute any criminal or civil action before the judicial
body.
PENAL PROVISIONS
OFFENSES OF HEALTH CARE PROVIDERS OF INDIVIDUAL-BASED HEALTH SERVICES

● Shall be penalized by a fine of two hundred pesos (Php 200,000) for each
count, or suspension of contract up to three (3) months or the remaining
period of its contract or accreditation whichever is shorter, or both, at the
discretion of the PhilHealth, taking into consideration the gravity of the
offense.
OFFENSES OF MEMBERS
● Jed, a member of PhilHealth was accused by Kenn for fraudulently claiming
the benefits of his brother Philip.
OFFENSES OF EMPLOYERS: FAILURE OR REFUSAL
TO REGISTER EMPLOYEES

● It was reported in our station that Henry, who is the employer of Karen,
refused to register her contributions in PhilHealth.
OFFENSES OF EMPLOYERS: FAILURE OR REFUSAL
TO DEDUCT CONTRIBUTIONS

● Wabalaks went to our station and stated that his employer, Kapitantanan,
failed to deduct his contributions from his compensation.
OFFENSES OF EMPLOYERS: FAILURE OR
REFUSAL TO ACCURATELY AND TIMELY
REMIT CONTRIBUTIONS
● Complainant Reino reported in our office, and stated that his employer
Princess, did not exert any effort to accurately and timely remit his
contributions in his compensation
OFFENSES OF EMPLOYERS: FAILURE OR REFUSAL
TO SUBMIT REPORT
● Pedro went to our station and complained that his employer, Judas refused
to submit the report of his contributions to PhilHealth.
OFFENSES OF EMPLOYERS: UNLAWFUL
DEDUCTION
● Shanti, the employee of Dudut, went to our office and is complaining that
his compensation was deducted by his employer to pay for his own
contribution on behalf of Shanti.
OFFENSES OF DIRECTORS, OFFICERS, OR EMPLOYEES
OF PhilHealth
● Members of PhilHealth were complaining and reported that Director Henry
kept Php 15,000,000 of funds which is to be delivered to PhilHealth for his
own personal use.
OFFENSES OF DIRECTORS, OFFICERS, OR EMPLOYEES
OF PhilHealth

● A complaint against Director Henry of PhilHealth was issued, it states that

Director Henry is the mastermind of the ghost claims and padded receipts
for the dialysis of kidney patients based.
END