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 govt 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, semiannually 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.