Group 7 PHILHEALTH

What is PHILHEALTH?

Philippine Health Insurance Corporation (PhilHealth) exists to create universal health

coverage for the Philippines.

A government-owned and government-controlled corporation (GOCC) of the Philippines,
it is exempted on paying tax, and is attached to the Department of Health (DOH).

WHAT IS ITS GOALS?

- The goals of PhilHealth are as follows:
1) to provide health insurance coverage for all Filipinos,
2) to ensure affordable and quality health care services, and
3) to manage its resources economically. If Filipinos will support and enroll in PhilHealth, our
country may well be on its way to giving adequate healthcare to an estimated 50 percent of
Filipinos living with meager incomes.
Categories of Enrollees for PhilHealth:
1. Formal Economy
Government Employee
o An employee of the government, who renders services in any of the
government branches, military or police force, political subdivisions, agencies
or
instrumentalities,
including
government-owned
and-controlled
corporations.
Private Employee
i. Corporations, partnerships, or single proprietorships, NGOs, cooperatives, nonprofit organizations, social, civic, or professional or charitable institutions, organized
and based in the Philippines including those foreign owned;
ii. Foreign business organizations based abroad with agreement with the Corporation
to cover their Filipino employees in PhilHealth.
2. Informal Economy
Migrant Workers
- documented or undocumented Filipinos who are engaged in a remunerated
activity in another country of which they are not citizens
Informal Sector
- includes among others, street hawkers, market vendors, pedicab and tricycle
drivers, small construction workers, and home-based industries and services.
Self-Earning Individuals
- individuals who render services or sell goods as a means of livelihood outside
of an employer-employee relationship or as a career. These include professional
practitioners including but not limited to doctors, lawyers, engineers, artists,
architects and the like, businessmen, entrepreneurs, actors, actresses and other
performers, news correspondents, professional athletes, coaches, trainers, and
such other individuals.
Filipinos With Dual Citizenship
- Filipinos who are also citizens of other countries.

Naturalized Filipino Citizens

- those who have become Filipino citizens through naturalization as governed by
Commonwealth Act No. 473 or the Revised Naturalization Law.
Citizens of other countries working and/or residing in the Philippines
- foreign citizens with valid working permits and/or Alien Certificate of
Registrations (ACRs), working and/or residing in the Philippines
Indigent Members
- To this category belong persons who have no visible means of income, or whose
income is insufficient for family subsistence, as identified by the Department of
Social Welfare and Development (DSWD), based on specific criteria. All indigents
identified by the DSWD under the National Household Targeting System (NHTS)
for Poverty Reduction and other such acceptable methods, shall automatically be
enrolled and covered under the Program. The female spouse of the families
identified by DSWD may be designated as the primary member of the Program.
Sponsored Members
- This category includes members whose contributions are being paid for by another
individual, government agencies, or private entities.
- Orphans, abandoned (children who have no known family willing and capable to take
care of them and are under the care of the DSWD, orphanages, churches and other
institutions) and abused minors, out-of-school youths, street children, persons with
disability (PWD), senior citizens and battered women under the care of the DSWD,
or any of its accredited institutions run by NGOs or any non-profit private
organizations, whose premium contributions shall be paid for by the DSWD;
- Barangay health workers, nutrition scholars, barangay tanods, and other barangay
workers and volunteers, whose premium contributions shall be fully borne by the
LGUs concerned; and
Lifetime Members
Individuals aged 60 years and above and have paid at least 120 monthly
contributions with PhilHealth and the former Medicare Programs of SSS and GSIS;
Uniformed personnel aged 56 years and above and have paid at least 120 monthly
contributions with PhilHealth and the former Medicare Programs of SSS and GSIS;
SSS underground miner-retirees aged 55 years above and have paid at least 120m
monthly contributions with PhilHealth and the former Medicare Programs of SSS and
GSIS;
SSS and GSIS pensioners prior to March 4, 1995
Senior Citizens
- Filipino citizens who are residents of the Philippines, aged sixty (60) years or above
and are not currently covered by any membership category of PhilHealth.

3.

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6.

Philhealth Law: [REPUBLIC ACT No. 7875].

AN ACT INSTITUTING A NATIONAL HEALTH INSURANCE PROGRAM FOR ALL FILIPINOS.
SEC. 1. Short Title known as the National Health Insurance Act of 1995

PHILHEALTH (definition of terms)

Beneficiary Any person entitled to health care benefits under this Act.
Benefit Package Services that the Program offers to its members.
Indigent A person who has no visible means of income
Pensioner An SSS or GSIS member who receives pensions there from.
Philippine Medical Care Commission The Philippine Medical Care Commission created
under Republic Act No. 6111, as amended.
Portability the enablement of a member to avail of Program benefits in an area outside the
jurisdiction of his Local Health Insurance Office.
Article V: PHILHEALTH LOCAL HEALTH INSURANCE OFFICE
Sec. 22 Establishment - referred to as the Office, in every province or chartered city.
Functions - Each office has its powers and functions
a) To administer the National Health Insurance Program;
b) To formulate and promulgate policies for the sound administration of the Program;
c) To supervise the provision of health benefits and to set standards, rules and regulations
necessary to ensure quality of care, appropriate utilization of services, fund viability, member
satisfaction, and overall accomplishment of Program objectives;
d) To formulate and implement guidelines on contributions and benefits; portability of benefits,
cost containment and quality assurance; and health care provider arrangements, payment,
methods, and referral systems;
e) To establish branch offices of PhilHealth
Article VIII: HEALTH CARE PROVIDERS
Free Choice of Health Facility, Medical or Dental Practitioner
- Beneficiaries requiring treatment of confinement shall be free to choose from
accredited health care providers
Authority to Grant Accreditation
- The Corporation shall have the authority to grant to health care providers
accreditation
Accreditation Eligibility
- All health care providers and operating for at least three (3) years may apply for
accreditation
Provider Payment Mechanisms
Fee-for-service Payments and Payment in General
- May be made separately for professional fees and hospital charges, or both, based
on arrangements with health care providers.
Capitation Payments
- May be paid to public or private providers according to rates of capitation payments
Quality Assurance
- Health care providers shall take part in programs of quality assurance, utilization
review, and technology assessment
Safeguards Against Over and Under Utilization
- It is incumbent upon the Corporation to set up a monitoring mechanism to be
operationalized through a contract with health care providers.