SAN BEDA UNIVERSITY

COLLEGE OF LAW
A.Y. 2021-2022

THE NATIONAL HEALTH INSURANCE PROGRAM

and
THE UNIVERSAL HEALTH CARE ACT
(RA 7875, as amended by RA 9241, RA 10606, RA 11223)

In Partial Fulfillment of the Requirements for the Course

Agrarian Law and Social Legislation

Cruz, Kyla Raine M.

Makilan, Hannah Angelica C.
Pua, Ernest Marlo V.
Valenzuela, Diane Faie O.
Block 2I - Group 5

Atty. Algie Kwillon B. Mariacos

Professor

June 21, 2022

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 Table of Contents

Summary of the Laws on the National Health Insurance Program 3

Salient Features of the National Health Insurance Program 4
Coverage of PhilHealth Insurance 5
Health Benefit Packages under PhilHealth 9
PhilHealth Identification Card and Number 12
Obligations and Premium Contributions 13
PhilHealth Claims 15
The Grievance System under RA 7875, as amended 17
The Philippine Health Insurance Corporation 18
Penalties 20
Jurisprudence on the National Health Insurance Program 22

List of Tables and Figures

Table(s):
Table 1: Premium Contributions Rate Schedule and Income Floor and Ceiling 13

Figure(s):
Figure 1: Identification Card with ID Number 13

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 Summary of the Laws on the National Health Insurance Program

RA 7875, otherwise known as the National Health Insurance Act of 2013, as amended by
RA 9241 and RA 10606, were enacted to 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 underprivileged, sick, elderly,
disabled, women and children, and provide free medical are to paupers. These laws aim to
achieve this objective through the National Health Insurance Program (NHIP). Thus, the NHIP is
a social health insurance scheme intended as a 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. This program
is administered by the Philippine Health Insurance Corporation (PhilHealth).

RA 11223, otherwise known as the Universal Health Care Act (UHCA), guarantees that
all Filipinos are guaranteed equitable access to quality and affordable health care goods and
services, and protected against financial risk expanded the coverage of the NHIP. Under the said
law, all Filipino Citizens are automatically covered by the NHIP, and every member shall be
granted immediate eligibility for health benefit package under the Program, without need to
present a PhilHealth Identification Card. Every Filipino should be able to access preventive,
promotive, curative, rehabilitative, and palliative health services, delivered either as
population-based or individual-based.

Since all Filipinos are now covered under the NHIP, they are now considered members of
PhilHealth. Families who are not yet registered/enlisted with PhilHealth will be assisted by their
health care provider with the next steps. However, this does not mean that all health services will
be free – at the very least, the prices of health goods and services will be predictable and
affordable. PhilHealth members still need to pay contributions, and they are categorized into two:
(1) direct contributors, who directly pay their own contributions; and (2) indirect contributors,
whose contributions are paid by the Government.

This paper shall extensively discuss the laws involved in the creation and enforcement of
the National Health Insurance Program, including its Implementing Rules and Regulations.

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 Salient Features of the National Health Insurance Program

What are the laws involving the National Health Insurance Program (NHIP)?
a. An Act Instituting a National Health Insurance Program for all Filipinos and Establishing
the Philippine Health Insurance Corporation for the Purpose, otherwise known as the
National Health Insurance Act of 2013 (RA 7875)
b. An Act Amending RA 7875, Otherwise Known as “An Act Instituting a National Health
Insurance Program for all Filipinos and Establishing the Philippine Health Insurance
Corporation for the Purpose” (RA 9241)
c. An Act Amending RA 7875, Otherwise Known as the “National Health Insurance Act of
1995”, as Amended, and for Other Purposes (RA 10606)
d. An Act Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the
Health Care System, and Appropriating Funds Therefor, otherwise known as the
Universal Health Care Act (RA 11223)

What are the policies behind the NHIP?

It is the policy of the State to protect and promote the right to health of all Filipinos and instill
health consciousness among them. Towards this end, the State shall adopt:
a. An integrated and comprehensive approach to ensure that all Filipinos are health literate,
provided with healthy living conditions, and protected from hazards and risks that could
affect their health;
b. A health care model that provides all Filipinos access to a comprehensive set of quality
and cost-effective, promotive, preventive, curative, rehabilitative and palliative health
services without causing financial hardship, and prioritizes the needs of the population
who cannot afford such services;
c. A framework that fosters a whole-of-system, whole-of government, and whole-of-society
approach in the development, implementation, monitoring, and evaluation of health
policies, programs and plans; and
d. A people-oriented approach for the delivery of health services that is centered on people's
needs and well-being, and cognizant of the differences in culture, values, and beliefs.
(Sec. 2, RA 11223)

What is the purpose of the NHIP?

a. The NHIP is a social health insurance scheme intended as a 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.
b. The laws institutionalizing the NHIP were enacted to 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 underprivileged, sick, elderly, disabled, women and children, and provide
free medical are to paupers.
c. Explanatory Note Senate Bill No. 1458 (Senate counterpart of the bill which was later
enacted as RA 11223):
i. “This bill will make it possible for every Filipino to enjoy the benefits of a
Universal Health Care, where preventive, creative and rehabilitative health
services are guaranteed to everyone. It will unburden poor families from financial

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 difficulties when paying for these services. It will improve our people’s
health-seeking behavior and guarantee affordable medical attention for everyone
at home, at work, in school or anywhere in the country as government agencies,
Local Government Units, and the private sector create more cooperation and
synergy to fund and improve basic health care service delivery in government and
private hospitals own to the health center at community level.
ii. A Universal Health Care law banishes healthcare as an entitlement and as a
privilege of the few because more health coverage is provided for those in the
formal employed sector and informal economy. It will provide more health care
services to children and young people and provide better coverage for senior
citizens and persons with disability (PWDs)”

Coverage of PhilHealth Insurance

Who are covered by the NHIP?

a. All Filipino citizens are automatically covered by the National Health Insurance
Program. Every Filipino shall register with a public or private primary care provider of
choice. (Sec. 5 and Sec. 9, RA 11223)
b. All persons with disability and senior citizens are automatically covered by the NHIP.
Premium contributions of persons with disability, as well as senior citizens (who were
previously not covered by the NHIP), shall be paid by the national government. However,
premium contributions for persons with disability in the formal economy shall be shared
equally by their employees and the national government. (Sec. 20-A, Magna Carta for
Persons with Disability, as amended, and Sec. 5(h)(2), Senior Citizens Act, as amended)

What are the categories of Members in the NHIP?

a. Direct Contributors: Those who have the capacity to pay premiums, are gainfully
employed and are bound by an employer-employee relationship, or are self-earning,
professional practitioners, migrant workers, including their qualified dependents, and
lifetime members. (Sec. 4(f), RA 11223)

Direct Contributors, including their qualified dependents, shall include:

1. Employees with formal employment characterized by the existence of an
employer-employee relationship, including workers in the government and private
sector, whether regular casual or contractual, occupying either elective or
appointive position, regardless of the status, whose premium contributions are
equally shared by the employee and employer
2. Kasambahays
3. All workers not covered by formal contracts or agreements who have no
employee-employer relationship and premium contributions are self-paid and with
capacity to pay premiums including self-earning individuals, professional
practitioners
4. Overseas Filipino Worker, sea based and land based
5. Filipinos living abroad
6. Filipinos with dual citizenship
7. Lifetime Members of the National Health Insurance Act

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 i. 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
ii. 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
iii. 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
iv. SSS and GSIS pensioners prior to March 4, 1995
8. All Filipinos aged 21 and above with capacity to pay premium

b. Indirect Contributors: All others not included as direct contributors, as well as their
qualified dependents, whose premium shall be subsidized by the national government
including those who are subsidized under special laws. (Sec. 4(o), RA 11223)

Indirect Contributors, including qualified dependents, shall include:

1. Indigents identified by the DSWD
2. Beneficiaries of Pantawid Pamilyang Pilipino Program,
3. Senior citizen not covered by the program
4. Persons with disability
5. All Filipinos aged 21 years old and above without capacity to pay premiums
6. Sangguniang Kabataan Officials
7. Previously identified at point of service or during registration, sponsored by the
LGU who are not yet in the Philhealth database

PhilHealth shall authorize the DSWD or social welfare officers of the LGUs to determine
those who are financially incapable to pay premiums (Sec. 8.5, IRR RA 11223)

Who are the qualified dependents?

Sec. 8, IRR RA 11223 enumerates the legal dependents of a member to wit:
a. The legal spouse who is not an active member
b. Unmarried and unemployed legitimate, illegitimate children, and legally adopted or step
children below 21 years of age
c. Foster children as defined in RA 10165
d. Parents who are sixty (60) years old or above, not otherwise an enrolled member

What is the coverage of services under the NHIP?

a. Services under the NHIP covers preventive, promotive, curative, rehabilitative, and
palliative care for medical, dental, mental, and emergency health services, delivered
either as population-based or individual-based health services: Provided, That the
goods and services to be included shall be determined through a fair and transparent
Health Technology Assessment (HTA) process (Sec. 6, RA 11223)
i. HTA refers to the systematic evaluation of properties, effects, or impact of
health-related technologies, devices, medicines, vaccines, procedures, and all
other health-related systems developed to solve a health problem and improve the

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 quality of lives and health outcomes, utilizing a multidisciplinary process to
evaluate the social, economic, organizational, and ethical issues of a health
intervention or health technology. (Sec. 4 (l), RA 11223)
ii. Individual-based health services refer to services which can be accessed within
a health facility or remotely that can be definitively traced back to 1 recipient, has
limited effect at a population level, and does not alter the underlying cause of
illness such as ambulatory and inpatient care, medicines, laboratory tests and
procedure (Sec. 4(p), RA 11223)
iii. Population-based health services refer to interventions such as health
promotion, disease surveillance, vector control, which have population groups as
recipients (Sec. 4(q), RA 11223)
1. Health services shall be classified as population-based health services if
they fulfill any of the following criteria:
a. Intended to be received by populations or identified groups of
people, of which outcomes contribute to the general public health,
safety and protection; and
b. Rendered in response to a public health emergency or disaster or
any circumstance of equal magnitude, such as diseases for
elimination, that has affected, or can potentially affect, a
population. (Sec. 17, IRR RA 11223)

b. Every Filipino shall register with a public or private primary care provider of choice.
with due consideration to proximity and ease of travel of those seeking care, absorptive
capacity of the provider for quality care, and provider capability to deliver the required
services, among others. (Sec. 6.6, IRR RA 11223)
1. Primary care provider (PCP): A health care worker, with defined competencies,
who has received certification in primary care as determined by the DOH or any
health institution that is licensed and certified by the DOH. (Sec. 4(s), RA 11223)
i. The DOH and local government units (LGUs) shall endeavor to provide a
health care delivery system that shall afford every Filipino a primary care
provider (Sec. 6.4, IRR RA 11223)
ii. The primary care provider shall act as the navigator, initial and continuing
point of contact in the health care delivery system; provided, that except in
emergency or serious cases and when proximity is a concern, access to
higher levels of care shall be coordinated by the primary care provider.
(Sec. 6.5, IRR RA 11223)
2. Primary care refers to initial-contact, accessible, continuous, comprehensive, and
coordinated care that is accessible at the time of need, including a range of
services for all presenting conditions, and the ability to coordinate referrals to
other health care providers in the health care delivery system, when necessary.
(Sec. 4(r), RA 11223)

Will all health services be free through UHC?

NO, health services will not be free. However, one of the goals of the UHC Act is to decrease the
out-of-pocket expenses of families. This means that some health services may become more
affordable, but not everything will be free. At the very least, the prices of health goods and

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services will be predictable and affordable. Depending on the available budget, such as
additional revenue from tobacco, alcohol, and sugar-sweetened beverage taxes, and the
value-based decisions of health technology assessment, DOH and PhilHealth will design benefits
for this.

What is the financial coverage of PhilHealth?

a. Population-based health services shall be financed by the National Government through
the DOH and provided free of charge at point of service for all Filipinos.

The National Government shall support LGUs in the financing of capital investments and
provision of population-based interventions. (Sec. 7, RA 11223)
1. The DOH shall finance population-based health services and provide support in
financing capital investments, human resources for health capacity building,
health systems development, among others, to complement local government
resources for health. (Sec. 17.6, IRR RA 11223)

b. Individual-based health services shall be financed primarily through prepayment

mechanisms such as social health insurance, private health insurance, and HMO plans to
ensure predictability of health expenditures. (Sec. 7, RA 11223)
1. The DOH and PhilHealth, in consultation with the Insurance Commission, private
health insurance and HMOs, shall issue guidelines and monitoring schemes in
order to rationalize financing schemes and to ensure that there is complementation
in the financing coverage of individual-based health services in accordance with
Sections 18 and 28.23 of these Rules. (Sec. 7.3, IRR RA 11223)
2. PhilHealth shall:
i. Continue to finance individual-based health services utilizing current
payment mechanisms such as capitation and case rate payments.
ii. Develop differential payment schemes that give due consideration to
service quality, efficiency, equity, and public health outcomes; and
iii. Institute strong surveillance and audit mechanisms to ensure networks'
compliance to contractual obligations. (Sec. 18.9, IRR RA 11223)
3. PhilHealth shall adopt any or a combination of closed-end, prospective provider
payment mechanisms, such as capitation, global budget, case-based payment, per
diem or daily charges, and other appropriate mechanisms;
4. All individual-based health services, including those transitioned from
population-based health services, shall be covered by PhilHealth; Provided, That
all current benefit packages of PhilHealth shall continue to be covered as
individual-based services unless reclassified by the DOH as population-based
services.
5. Services that meet both population-based and individual based health services
criteria, or neither of the criteria, shall retain its current financing mechanism;

c. Province-wide and city-wide health systems, as described in Section 19 of these Rules,

shall ensure funding for effective health operations and conduct of activities such as but
not limited to capacity building, research, and health promotion consistent with national
guidelines and with support from the DOH. (Sec. 7.4, IRR RA 11223)

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 Health Benefit Packages under PhilHealth

What are the benefits of the National Health Insurance Program?

a. Every member shall be granted immediate eligibility for health benefit packages under
the Program. The current PhilHealth package for members shall not be reduced. (Sec. 9,
RA 11223)
1. Essential Health Benefit Package refers to a set of individual-based entitlements
covered by the NHIP which includes primary care; medicines, diagnostics, and
laboratory; and preventive, curative, and rehabilitative services (Sec. 4(i), RA
11223)
b. The DOH and PhilHealth shall define specific health service packages for
population-based and individual-based health services in accordance with the provisions
in Sections 17 and 18 of these Rules, respectively. (Sec. 6.2, IRR RA 11223)
c. Comprehensive Outpatient Benefits
1. Within 2 years from the effectivity of these Rules, PhilHealth shall implement a
comprehensive outpatient benefit including outpatient drug benefit and
emergency medical services in accordance with the recommendation of the Health
Technology Assessment Council (HTAC). (Sec. 6, RA 11223)
2. The benefits shall include, but are not limited to: services of health care
professionals; diagnostic, laboratory, dental and other medical services; personal
preventive services; prescription drugs and biologicals, subject to the limitations
of the Act; and other services deemed appropriate. (Sec. 6.6, IRR RA 11223)
d. Additional Benefits
1. PhilHealth shall provide additional Program benefits for direct contributors,
where applicable. (Sec. 9, RA 11223)
2. PhilHealth shall issue the necessary guidelines on the additional Program benefits
for direct contributors, where applicable. (Sec. 9.14, IRR RA 11223)

What is the role of private sector financing agents in financing health services under the
UHC Act?
Under the Section 7(b), in relation to Section 28(e) of the Act, private sector financing agents
such as Health Management Organizations (HMOs) and private health insurance firms will offer
either of these benefit packages to patients:
a. Complementary - benefits that cover services or diagnostic-groups that PhilHealth is
unable to; or
b. Supplementary - benefits that pay for shares of the hospital bill that PhilHealth is unable
to

How are the health benefit packages determined?

a. Goods and services to be included shall be determined through a fair and transparent
Health Technology Assessment (HTA) process. (Sec. 6, RA 11223) As provided under
Sec. 34, RA 11223, the HTA process shall be institutionalized as a fair and transparent
priority setting mechanism that shall be recommendatory to the DOH and PhilHealth for
the development of policies and programs, regulation, and the determination of a range of
entitlements such as drugs, medicines, pharmaceutical products. Investments on any

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 health technology or development of any benefit package by the DOH and PhilHealth
shall be based on the positive recommendations of the HTA.

The following criteria must be observed in the conduct of the HTA:

1. Responsiveness to Magnitude, Severity, and Equity: The health interventions
must address the top medical conditions that place the heaviest burden on the
population, including dimensions of magnitude or the number of people affected
by a health problem, and severity or health loss by an individual as a result of
disease, such as death, handicap, disability or pain, and conditions of the poorest
and most vulnerable population;
2. Safety and Effectiveness: Each intervention must have undergone Phase IV
clinical trial, and systematic review and meta-analysis must be readily available.
The interventions must also not pose any harm to the users and health care
providers;
3. Household Financial Impact: The interventions must reduce out-of-pocket
expenses. Interventions must have economic studies and cost-of-illness studies to
satisfy this criterion
4. Cost-effectiveness: The interventions must provide overall health gain to the
health system and outweigh the opportunity costs of funding drug and technology;
and
5. Affordability and Viability: The interventions must be affordable and the cost
thereof must be viable to the financing agents. (Sec. 34, RA 11223)

b. The HTA process shall adhere to the principles of ethical soundness, inclusiveness and
preferential regard for the underserved, evidence-based and scientific defensibility,
transparency and accountability, efficiency, enforceability and availability of remedies,
and due process. (Sec. 34, IRR RA 11223)

What is the Health Technology Assessment Council (HTAC)?

The HTAC conducts the HTA in accordance with the principles, criteria and procedures of the
UHC and shall ensure that its process is transparent, conducted with reasonable promptness, and
the result of its deliberations is made public.

The HTAC shall be composed of health experts, and shall be created within the DOH and
supported by a Secretariat and a Technical Unit for Policy, Planning and Evaluation with
evidence generation and validation capacity. The HTAC shall:
a. Facilitate provision of financing and/or coverage recommendations on health
technologies to be financed by DOH and PhilHealth;
b. Oversee and coordinate the HTA process within DOH and PhilHealth; and
c. Review and assess existing DOH and PhilHealth benefit packages.

What are some of the Health Benefit Packages offered by PhilHealth?

a. Inpatient benefits: any kind of diagnostic or therapeutic procedure where the patient
needs to stay longer or be confined in a hospital. This covers the hospital charges (such as
the ER, patient room, lab, medicines) and professional fees of the attending physician

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b. Outpatient benefits: any hospital visits or medical assistance that are less than 24 hours,
and cases that do not need confinement
1. Blood Transfusion: one-day transfusion of blood or blood products with the
maximum covered amount of P3,640.
2. Day Surgeries: refer to ambulatory, non-emergency, and outpatient surgeries
3. Hemodialysis: the maximum covered amount is P2,600 for both inpatient and
outpatient dialysis procedures.
4. Radiotherapy: the maximum covered amount for a cobalt session is P2,000 and
a linear accelerator session is P3,000.
5. Primary Care Benefit: inclusive of preventive services, diagnostic exams,
drugs/medicines for indigent individuals, land-based OFWs, sponsored
members, and organized groups.
6. Expanded Primary Care Benefit: inclusive of initial and/or follow up
consultation, diagnostic exams, medicines, and other essential services for
medical conditions limited to asthma, acute gastroenteritis, pneumonia, upper
respiratory tract infection, and UTI.

c. Z Benefits: Financially and medically catastrophic illnesses, and provides coverage to

conditions needing longer and/or expensive treatments, including, but not limited to:
1. Cancer (prostate, breast, cervical, leukemia)
2. Kidney Failure, heart bypass surgery, congenital heart defects, Z morph- risk
level and criteria apply
3. Expanded Z-Morph: Select orthopedic implants, “PD First” End-Stage Renal
Disease Requiring Peritoneal Dialysis, Colon and Rectum Cancer,
Premature/Preterm and Small Newborn, Children with Developmental
Disabilities/Mobility Impairment/Visual Disabilities/Hearing Impairment

d. Sustainable Development Goals (SDG) benefits: Packages created as part of the

agency’s mandate to set objectives in line with the United Nations SDG
1. Outpatient malaria
2. Outpatient HIV-Aids
3. Anti-TB through DOTS course
4. Voluntary surgical contraception
5. Animal bite treatment

e. Maternity Benefits: provides 4 packages to women who are about give birth
1. Antenatal care package
2. Normal spontaneous delivery package
3. Other methods of delivery
4. Newborn care package

f. Senior Citizen Benefits

i. Senior citizens (and retirees/pensioners) are automatic and lifetime members of
PhilHealth granted that they meet the eligibility requirements. They can also be
listed as dependents of principal members. Their benefits include inpatient,

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 outpatient, Z health services and TsekAp diagnostic exams that are appropriate to
their conditions

g. OFW Benefits
i. OFWs and their dependents can avail of the same health care benefits in the
Philippines. If they are confined outside the country, the expenses can be
reimbursed by filing at any PhilHealth office. OFWs are also eligible to become
lifetime members like that of retirees and pensioners.

h. Covid-19 Benefit Package

i. Testing: Those who needs to be tested for Covid-19 are granted up to P2,800 for
Plate-based RT-PCR Test, and up to P2,450 for Cartridge-based PCR
ii. Home Isolation: For patients who are asymptomatic or has mild symptoms and
passes certain social criteria are covered up to P5,197
iii. Community Isolation: For patients who needs to be isolated in community
isolation units according to DOH regulations, they are covered up to P22,449
iv. Inpatient Care: For patients who have confirmed cases of Covid-19 who have to
stay in the hospital. Coverage depends on the severity of their case
v. Vaccine Injury Compensation: For members who were hospitalized, permanently
disabled or died due to the serious effect on them by the Covid-19 vaccine

Is there a limit to the number of benefits a member may avail of?

NO, the law does not provide a limit to the number of benefit packages that a member may avail
of (i.e in-patient/out-patient benefits, Z benefits, etc.). However, there may be a limit to what
PhilHealth may financially cover for the health services that the member may avail of. This is
because the Universal Health Care Act aims to “provide all Filipinos access to a comprehensive
set of quality and cost-effective, promotive, preventive, curative, rehabilitative and palliative
health services without causing financial hardship, and prioritize the needs of the population who
cannot afford such services.” (Section 2, RA 11223)

PhilHealth Identification Card and Number

Who has the duty to issue Philhealth Identification Cards?

The Philippine Health Insurance Corporation through its local office shall issue a Health
Insurance Identification Card with a corresponding ID number for each of its members. (Sec. 8,
RA 10606)

According to the Philhealth website, the registration procedure of the identification card are as
follows:
1. Fill out 2 copies of the PhilHealth Member Registration Form (PMRF)
2. Submit PMRF to the LHIO or PhilHealth Express
3. Await Member Data Record (MDR) and PhilHealth ID Card
4. Pay the necessary premium contribution using the PhilHealth ID number

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What is the purpose of the Identification Card?
It shall be used for purposes of identification, eligibility verification and utilization recording.
The issuance shall be accompanied by a clear explanation to the enrollee of his rights, privileges
and obligations as a member. A list of healthcare providers accredited by the Local Health
Insurance office shall likewise be provided to the member together with the ID card.

The Identification Card with its corresponding ID number shall be recognized as a valid
government identification and shall be presented and honored in transactions requiring the
verification of a person’s identity. Pursuant to Bangko Sentral ng Pilipinas Memorandum No.
M-2012-021, the Philhealth Insurance card is a duly recognized valid government-issued
identification card which shall be honored in all transactions requiring the identification of a
person’s identity.

NOTE: Under the Universal Health Care Act, the presentment of the PhilHealth Identification
Card shall not be required in the availability of any health service.

Sample Identification Card With Its Corresponding ID Number

Figure 1. Identification Card with ID Number

Obligations and Premium Contributions

What are the obligations of employers under the National Health Insurance Act?
Under the IRR of the National Health Insurance Act, the obligations of employers under the
National Health Insurance Act are as follows:
a. To register their employees and their qualified dependents
b. To report its newly-hired employees within 30 calendar days from assumption to office
c. To report an employee’s separation within 30 calendar days from separation
d. To pay and remit the premium contributions

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What are the rates for the Premium Contributions?
For Direct Contributors, the Universal Health Care act provided for the premium contributions
rate in accordance with the following schedule and monthly income floor and ceiling:

YEAR PREMIUM RATE FLOOR INCOME CEILING INCOME

2022 4.00% Php 10,000.00 Php 80,000.00

2023 4.50% Php 10,000.00 Php 90,000.00

2024 5.00% Php 10,000.00 Php 100,000.00

2025 5.00% Php 10,000.00 Php 100,000.00

Table 1. Premium Contributions Rate Schedule and Income Floor and Ceiling

In the event that the direct contributors earn below the income floor, they shall pay their
premium contributions based on the income floor. On the other hand, if above the income
ceiling, shall pay a premium contribution based on the income ceiling. For any income from
income floor to the income ceiling, premium contributions shall be computed based on the basic
monthly income.

Illustration: X is a middle class citizen who is earning a basic monthly salary of P50,000. How
much is his premium contribution for the year 2022?
4.00% x 50,000 = Php 2,000.00

What are the Special Provisions on Premium Contributions?

a. Self-earning individuals and practicing professionals: The premium contribution shall
be computed based on the individual’s monthly income as shown in documents
prescribed by PHilHealth. Non-submission of acceptable proof of actual income shall
result in the charging of the rate based on the income ceiling.
b. Kasambahays: The premium payments shall be shouldered by the employer if the
kasambahay is receiving a monthly salary of below P 5,000. If his/her monthly salary is
P5,000 and above, the Kasambahay shall pay the proportionate share in the premium
contributions.
c. Overseas Filipino Workers: The premium contribution shall be salary based as
prescribed by the Universal Health Care Act and shall require submission of acceptable
proof of actual income. Non-submission shall result in the charging of the rate based on
the income ceiling.
d. Persons with Disability: The premium payments of formally employed persons with
disability shall be shared equally by their employers and the national government.

Are all Philhealth members required to pay premium contributions in availing program
benefits?
A member who is a direct contributor shall have paid for at least three months of premium
contributions within 6 months prior to the first day of availing the program benefits.

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However under the National Health Insurance Act, the following are exempted from payment of
monthly contribution to be entitled to the program’s benefits
a. Retirees and pensioners of the SSS and GSIS prior to the effectivity of National Health
Insurance; and
b. Lifetime Members of the National Health Insurance Act

What happens if members fail to pay their contributions?

Failure to pay the required premium contributions shall not prevent the member from enjoyment
of any benefit provided for in the program. However, the employers and the direct contributors
are required to pay all missed contributions with an interest, compounded monthly, of
a. At least three percent (3%) for employers of private and government sector, sea-based
migrant workers and kasambahays; and
b. Not exceeding one and one-half percent (1.5%) for self-earning, professional
practitioners, and migrant workers, Filipinos living abroad and Filipinos with dual
citizenship.

Who are entitled to the benefits provided by the program?

Every member shall be granted immediate eligibility for health benefit packages as provided
under the Program. The PhilHealth Identification Card shall not be required in the availability of
any health services. Failure to present the Philhealth Identification card shall not preclude the
necessity to present any valid Identification Card for purposes of proving the identity of the
member. (Sec. 9.1, IRR RA 7875)

Are there extra charges or hidden fees under the program?

NO, a member shall not be charged extra fees or expenses, including professional fees for
services rendered in a basic or ward accommodation. In absence of available beds and transfer to
another facility is not feasible, members who opt for basic or ward accommodation but admitted
in non-basic accommodation shall be entitled to no co-payment for services, professional fees
and amenities. However, members who opt for admissions in non-basic or non-ward
accommodations may be charged co-payments/co-insurance for services, professional fees, and
amenities.

What are the rules of confinement for less than 24 hours?

Confinement of less than 24 hours shall be compensable under the following instances:
a. If the patient is transferred to another health care institution
b. In emergency cases as defined by the Philhealth
c. If the patient has expired; and
d. In other cases as may be determined by Philhealth

PhilHealth Claims

Where can a member avail of PhilHealth Benefits?

A member has the freedom to choose where to avail such treatment from their chosen health
facility, medical or dental practitioner. The law provides that “Beneficiaries requiring treatment
or confinement shall be free to choose from accredited health care providers. Such choice shall,
however, be subject to limitations based on the area of jurisdiction of the concerned Office and

15
on the appropriateness of treatment in the facility chosen or by the desired provider.” (Sec. 30,
RA 7875 as amended)

However, a member can avail of the PhilHealth benefits only from accredited health care
providers. It is the PhilHealth Corporation that has the authority to grant such accreditation to
health care providers, which confers the privilege of participating in the Program (Section 31, RA
7875 as amended)

What are the conditions in availing the PhilHealth Benefits?

To be eligible to avail of the benefits when hospitalized, the following conditions must be met:
a. Payment of at least 3 months’ worth of premiums within the immediate 6 months of
confinement.
b. Confinement in an accredited hospital for 24 hours due to illness or disease requiring
hospitalization. Attending physician(s) must also be PhilHealth accredited.
c. The claim is within the 45 days allowance for room and board.

Is PhilHealth a Health Management Organization?

No. PhilHealth and Health Management Organization(s) may look similar, but are not of the
same category. According to the Department of Health, PhilHealth is a social health insurance
agency. On one hand, RA 7875 defines Health Management Organizations (HMOs) as “private
entities that provide offers, or arranges for coverage of designated health services needed by plan
members for a fixed prepaid premium.”

In addition, “HMOs are not engaged in the insurance business because its health care programs
are designed to prevent or minimize the possibility of any assumption of risk on its part. THus,
its undertaking under its agreements is not to indemnify its members against any loss or damage
arising from a medical condition, but on the contrary, to provide the health and medical services
needed to prevent such loss or damage” (PHCP v. CIR, G.R. No. 167330, September 18, 2009).

Who are considered as Health Care Providers?

Health Care Providers refer to any of the following:
a. A duly licensed health care institution;
b. A health care professional duly licensed to practice in the Philippines;
c. A health maintenance organization; or
d. A community-based health care organization

What are the requirements for an eligible health care provider to be accredited?
Eligible health care providers operating for at least three (3) years may apply for accreditation. If
a health care provider has not operated for at least three (3) years, it may likewise apply and
qualify for accreditation if they comply with other requirements and meet and of the following
conditions:
a. Its managing health care professional has had a working experience in another accredited
health care institution for at least three (3) years;
b. It operates as a tertiary facility or its equivalent;
c. It operates in a LGU where the accredited health care provider cannot adequately or fully
service its population; and

16
 d. Other conditions as may be determined by the Corporation (Sec. 32, RA 7875 as
amended)

What is the period of claims?

Section 46 of the IRR of RA 7875 as amended provides for the reimbursement and period to file
claims. The law provides that “All claims for reimbursement or payment for services rendered
shall be filed within a period of sixty (60) calendar days from the date of discharge of the
patient from the health care provider. The period to file the claim may be extended for such
reasonable causes as may be determined by the Corporation.”

The Grievance System under RA 7875, as amended

What is the Grievance System?

Under Section 39 of RA 7875 as amended, “a grievance system is established wherein members,
dependents, or health care providers of the Program who believe they have been aggrieved by
any decision of the implementors of the Program, may seek redress of the grievance”. This is the
manifestation of one of the quasi-judicial powers of the Corporation in conducting investigations
of unresolved grievances that has been brought to its attention and render a decision, order or
resolution thereon (Section 17a, RA 7875 as Amended)

Grievances filed by an accredited health care provider or by a PhilHealth member against a

program implementer (including protests administrative actions involving payment of charges,
fees or claims), may be brought to the grievance system under the law.

What are considered as valid grievances under RA 7875?

Section 191, Rule II, Title XI of the IRR of RA 7875 as amended provides for the grounds for
grievances. The law provides that: “The following acts shall constitute valid grounds for
grievance action:
a. Any violation of the rights of patients;
b. A willful neglect of duties of Program implementers that results in the loss or
non-enjoyment of benefits by members or their dependents;
c. Unjustifiable delay in actions or claims;
d. Delay in the processing of claims that extends beyond the period agreed upon; and
e. Any other act or neglect that tends to undermine or defeat the purposes of this Act.”

What are not considered as valid grievances?

Section 190, Rule I of the IRR of RA 7875 as amended provides grievances and protests that are
not covered within the grievance system. The law provides that “Any action of a program
implementer which can be the basis of an administrative or criminal complaint or charge
under the jurisdiction of the Office of the Ombudsman, Sandiganbayan, Civil Service
Commission, or the regular courts of justice is neither a grievance nor a protest.”

Who has jurisdiction in processing the grievances?

Section 189 of the IRR of RA 7875 as amended provides that “the Corporation provides
jurisdiction to the Grievance and Appeals Review Committee (GARC) to hear and decide all
grievances filed by any accredited health care provider or by any member against any program

17
implementer.” The complaint for grievance should be filed with the PhilHealth Office where the
aggrieved health care provider is located or where the member resides. Thereafter, the grievance
complaint will be referred to the GARC, pursuant to Section 41 of the RA 7875, and Sections 190
and 195 of the IRR of RA 7875 as Amended.

The decisions of the GARC and the PhilHealth Board is appealable to the Board of Directors
within 15 calendar days from the receipt of the decision.

The Philippine Health Insurance Corporation

Who is the Philippine Health Insurance Corporation?

It is a tax-exempt government corporation attached to the Department of Health for policy
coordination and guidance (Sec. 14, RA No. 7875)

What are the powers and functions of PhilHealth?

a. Administer the National Health Insurance Program;
b. Formulate and promulgate policies for the sound administration of the Program;
c. Supervise the provision of health benefits and to set standards, rules, and regulations
necessary;*
d. 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. Establish branch offices as mandated;
f. Receive and manage grants, donations, and other forms of assistance;
g. Sue and be sued in court;
h. Acquire property which may be necessary or expedient for the attainment of the purposes
of the law;
i. Collect, deposit, invest, administer, and disburse the National Health Insurance Fund;
j. Negotiate and enter into contracts with health care institutions, professionals, and other
persons, regarding the pricing, payment mechanisms, design and implementation of
administrative and operating systems and procedures, financing, and delivery of health
services in behalf of its members;*
k. Authorize Local Health Insurance Offices to negotiate and enter into contracts in the
name and on behalf of the Corporation with any accredited government or private sector
health provider organization for the providing at least the minimum package of personal
health services prescribed;
l. Determine requirements and issue guidelines for the accreditation of health care
providers for the Program;
m. Visit, enter and inspect facilities of health care providers and employers, and where
applicable, secure copies of their medical, financial, and other records and data pertinent
to the claims, accreditation, premium contribution, and that of their patients or
employees, who are members of the Program;*
n. Submit to the President of the Philippines and to both Houses of Congress its Annual
Report and publish a synopsis of such report in two (2) newspapers of general circulation;
o. Keep records of the operations of the Corporation and investments of the National Health
Insurance Fund;*

18
 p. Establish and maintain an electronic database of all its members and ensure its security to
facilitate efficient and effective services;*
q. Invest in the acceleration of the Corporation’s information technology systems;*
r. Conduct an information campaign on the principles of the NHIP to the public and to
accredited health care providers;*
s. Conduct post-audit on the quality of services rendered by health care providers;*
t. Establish an office, or where it is not feasible, designate a focal person in every
Philippine Consular Office in all countries where there are Filipino citizens*
u. Impose interest and/or surcharges of not exceeding three percent (3%) per month in case
of any delay in the remittance of contributions which are due within the prescribed period
by an employer*
v. Endeavor to support the use of technology in the delivery of health care services
especially in far flung areas;*
w. Monitor compliance by the regulatory agencies and carry out necessary actions to enforce
compliance;*
x. Mandate the national agencies and LGUs to require proof of PhilHealth membership
before doing business with a private individual or group;*
y. Accredit independent pharmacies and retail drug outlets;*
z. Perform such other acts as it may deem appropriate for the attainment and proper
enforcement of the objectives of the Corporation and the law;*
aa. Fix the reasonable compensation, allowances and other benefits of all positions, subject
to the approval of the President of the Philippines;**
bb. Establish the organizational structure and staffing pattern of PhilHealth’s central and
regional offices to cover as many provinces, cities and legislative districts, including
foreign countries, subject to the approval by the Board;**
cc. Maintain a Provident Fund which consists of contributions made by both PhilHealth and
its officials and employees and earnings for the payment of benefits to such officials and
employees or their dependents or heirs; and**
dd. Adopt or approve the annual and supplemental budget of receipts and expenditures and
authorize such capital and operating expenditures and disbursements as may be necessary
and proper for the effective management and operation of PhilHealth.**
NOTE: RA 7875; *amendments under RA 10606; **amendments under RA 11223

What are the Quasi-judicial Powers of the PhilHealth?

a. To conduct investigations for the determination of a question, controversy, complaint, or
unresolved grievance brought to its attention, and render decisions, orders and resolutions
on them;
b. To summon the parties to a controversy, issue subpoenas requiring the attendance and
testimony of witnesses or the production of documents and other materials necessary to a
just determination of the case under investigation; and
c. To suspend, revoke, or restore the accreditation of a health care provider or the rights to
benefits of a member and/or impose fines; (Sec. 17, RA 7875)

19
 Penalties

What are the penalties for violating the law?

a. Health care provider of population-based health services who violates any of the
provision in its respective contract: shall be subject to sanctions and penalties under its
respective contracts without prejudice to the right of the government to institute any
criminal or civil action before the proper judicial body

b. Health care provider contracted for the provision of individual-based health services
who commits an unethical act, abuses the authority vested upon the health care provider,
or performs a fraudulent act: shall punished by a fine of two hundred thousand pesos
(Php 200,000.00) 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; or

Note: If the health care provider is a juridical person, its officers and employees or other
representatives who caused the commission of the violation, shall be held liable

c. Member who commits any violation of this Act or knowingly and deliberately
cooperates or agrees to the commission of a violation by a contracted health care provider
or employer: shall be punished by a fine of Fifty thousand pesos (Php 50,000.00) for each
count or suspension from availment of the benefits of the Program for not less than three
(3) months but not more than six (6) months, or both, at the discretion of PhilHealth

d. Employer
1. Deliberately or through inexcusable negligence, fails or refuses to register
employees: shall be punished with a fine of Fifty thousand pesos (₱50,000.00) for
every violation per affected employee, or imprisonment of not less than six (6)
months but not more than one (1) year, or both such fine and imprisonment, at the
discretion of the court

Any employer or any officer authorized to collect contributions who fails or

refuses to accurately and timely remit the contributions to PhilHealth within thirty
(30) days from due date: shall be presumed prima facie to have misappropriated
the same and is obligated to hold the same in trust for and in behalf of the
employees and PhilHealth, and is immediately obligated to return or remit the
amount

Note: If the employer is a juridical person, its officers and employees or other
representatives who caused the commission of the violation, shall be liable.

2. Deducts from the compensation of the covered employees or recover from them
the employer’s own contribution on behalf of such employees: shall be punished
with a fine of Five thousand pesos (Php 5,000.00) multiplied by the total number
of affected employees or imprisonment of not less than six (6) months but not

20
 more than one (1) year, or both such fine and imprisonment, at the discretion of
the court.

Note: If committed by an association, partnership, corporation or any other

institution, its managing directors or partners or president or general manager, or
other persons responsible for the commission of the act shall be liable for the
penalties provided for in this Act. (RA 11223, Section 38)

e. Any director, officer or employee of PhilHealth who:

1. Without prior authority or contrary to the provisions of the Act or its IRR,
wrongfully receives or keeps funds or property payable or deliverable to the
PhilHealth, and who appropriates and applies such fund or property for personal
use, or shall willingly or negligently consents to the misappropriation of funds or
property without objecting to the same and promptly reporting the matter to
proper authority:
i. Shall be liable for misappropriation of funds; and
ii. Shall be punished with a fine equivalent to triple the amount
misappropriated per count and suspension for three (3) months without
pay
2. Commits an unethical act, abuse of authority, or performs a fraudulent act: shall
be punished by a fine of Two hundred thousand pesos (Php 200,000.00) or
suspension for (3) three months without pay, or both, at the discretion of
PhilHealth

f. Other violations of the provisions of the Act or of the rules and regulations
promulgated by PhilHealth: shall be punished with a fine of not less than Five thousand
pesos (Php 5,000.00) but not more than Twenty thousand pesos (Php 20,000.00)

g. All other violations involving funds of PhilHealth: shall be governed by the applicable
provisions of the Revised Penal Code or other laws (Sec. 38, RA 11223)

21
 Jurisprudence on the National Health Insurance Program

1. Philippine Health Insurance Corp. v. Chinese General Hospital & Medical Center,
G.R. No. 163123, [April 15, 2005], 496 PHIL 349-363

“The avowed policy in the creation of a national health program is, as provided in Section 11,
Article XIII of the 1987 Constitution, to adopt an integrated and comprehensive approach to
health development which shall endeavor to make essential goods, health and other social
services available to all people at affordable cost. To assist the state in pursuing this policy,
hospitals and medical institutions such as herein petitioner are accredited to provide health care.
It is true, as aptly stated by the GOCC, that petitioner was not required by the government to take
part in its program, it did so voluntarily. But the fact that the government did not "twist"
petitioner’s arm, so to speak, to participate does not make petitioner’s participation in the
program less commendable, considering that at rate PHILHEALTH is denying claims of health
care givers, it is more risky rather than providential for health care givers to take part in the
government’s health program.

It is Our firmly held view that the policy of the state in creating a national health insurance
program would be better served by granting the instant petition. Thus, it is noteworthy to
mention that health care givers are threatening to "boycott" PHILHEALTH, reasoning that the
claims approved by PHILHEALTH are not commensurate with the services rendered by them to
its members. Thus, how can these accredited health care givers be encouraged to serve an
increasing number of members when they end up on the losing end of this venture. We must
admit that the costs of operating these medical institutions cannot be taken lightly. They must
also earn a modicum amount of profit in order to operate properly.

Again, it is trite to emphasize that essentially, the purpose of the national health insurance
program is to provide members immediate medical care with the least amount of cash expended.
Thus, with PHILHEALTH, members/patients need only to present their card to prove their
membership and the accredited health care giver is mandated by law to provide the necessary
medical assistance, said health care giver shouldering the PHILHEALTH part of the bill.
However, it is the members/patients who bear the brunt. Thus, they are made to shoulder the
PHILHEALTH part of the bill, and the refund thereof is subject to whether or not the claims of
the health care providers are approved by PHILHEALTH. This is blatantly contrary to the very
purpose for which the National Health Insurance Program was created.

xxx

There is no need to belabor the fact that the baseless denial of respondent’s claims will be
gravely disturbing to the healthcare industry, specially the providers whose claims will be
unpaid. The unfortunate reality is that there are today some health care providers who admit
numbers for treatment and/or confinement yet require them to pay the portion which ought to be
shouldered by Philhealth. A refund is made only if their claim is first paid, due to the
apprehension of not being reimbursed. Simply stated, a member cannot avail of his benefits
under the NHIP at the time he needs it most.

22
We cannot turn a deaf ear to respondent’s plea for fairness which essentially demands that its
claims for services already rendered be honored as the National Health Insurance Program law
intended.”

2. Funa v. Chairman, Civil Service Commission, G.R. No. 191672, [November 25,
2014], 748 PHIL 169-204

The GSIS, PHILHEALTH, ECC and HDMF are vested by their respective charters with various
powers and functions to carry out the purposes for which they were created. While powers and
functions associated with appointments, compensation and benefits affect the career
development, employment status, rights, privileges, and welfare of government officials and
employees, the GSIS, PHILHEALTH, ECC and HDMF are also tasked to perform other
corporate powers and functions that are not personnel-related. All of these powers and functions,
whether personnel-related or not, are carried out and exercised by the respective Boards of the
GSIS, PHILHEALTH, ECC and HDMF. Hence, when the CSC Chairman sits as a member of the
governing Boards of the GSIS, PHILHEALTH, ECC and HDMF, he may exercise these powers
and functions, which are not anymore derived from his position as CSC Chairman, such as
imposing interest on unpaid or unremitted contributions, issuing guidelines for the accreditation
of health care providers, or approving restructuring proposals in the payment of unpaid loan
amortizations. The Court also notes that Duque’s designation as member of the governing Boards
of the GSIS, PHILHEALTH, ECC and HDMF entitles him to receive per diem, a form of
additional compensation that is disallowed by the concept of an ex officio position by virtue of
its clear contravention of the proscription set by Section 2, Article IX-A of the 1987
Constitution. This situation goes against the principle behind an ex officio position, and must,
therefore, be held unconstitutional.

xxx

As provided in their respective charters, PHILHEALTH and ECC have the status of a
government corporation and are deemed attached to the Department of Health and the
Department of Labor, respectively. On the other hand, the GSIS and HDMF fall under the Office
of the President. The corporate powers of the GSIS, PHILHEALTH, ECC and HDMF are
exercised through their governing Boards, members of which are all appointed by the President
of the Philippines. Undoubtedly, the GSIS, PHILHEALTH, ECC and HDMF and the members of
their respective governing Boards are under the control of the President. As such, the CSC
Chairman cannot be a member of a government entity that is under the control of the President
without impairing the independence vested in the CSC by the 1987 Constitution.”

3. Kilusang Mayo Uno v. Aquino III, G.R. No. 210761, [June 28, 2016]

“Under the NHIA, all citizens of the Philippines are required to enroll in the Program;
membership is mandatory. In other words, the NHIP covers all Filipinos in accordance with the
principles of universality and compulsory coverage. Ultimately, every Filipino is affected by an
increase in the premium rates. Thus, the petitioners have sufficient legal standing to file the
present suit.

23
 xxx

PhilHealth has the mandate of realizing the State's vision of affordable and accessible health
services for all Filipinos, especially the poor. To realize this vision and effectively administer the
Program, PhilHealth is empowered to promulgate its policies, and to formulate a contribution
schedule that can realistically support its programs.

PhilHealth justified the increase in annual premium rates with the enhanced benefits and the
expanded coverage of medical conditions. This reasonable decision to widen the coverage of the
program - which led to increased premium rates - is a business judgment that this Court cannot
interfere with.

This Court does not have administrative supervision over administrative agencies, nor is it an
entity engaged in making business decisions. We cannot interfere in purely administrative
matters nor substitute administrative policies and business decisions with our own. This would
amount to judicial overreach. The courts' only concern is the legality, not the wisdom, of an
agency's actions. Policy matters should be left to policy makers.

xxx

The NHIP is a social insurance program. It is the government's means to allow the healthy to
help pay for the care of the sick, and for those who can afford medical care to provide subsidies
to those who cannot. The premium collected from members is neither a fee nor an expense but an
enforced contribution to the common insurance fund.

From this perspective, the petitioners-in-intervention cannot invoke the non-increase clause
under Section 36 of the Migrant Workers and Overseas Filipinos Act. There is no valid
distinction between migrant workers and the rest of the population that would justify a lower
premium rate for the former. It would unduly burden the other PhilHealth contributors in favor of
Overseas Filipino Workers.

Any distinctions between OFW s and all the other sectors are not germane to the NHIA' s
purpose of ensuring affordable, acceptable, available, and accessible health care services for all
citizens of the Philippines. Therefore, the application of Section 36 of the Migrant Workers and
Overseas Filipinos Act to obstruct the increase of premiums under the NHIP amounts to an
unreasonable classification, in violation of the equal protection clause.”

4. Philippine Health Insurance Corp. v. Commission on Audit, G.R. No. 213453,

[November 29, 2016], 801 PHIL 427-472

“Accordingly, that Section 16(n) of R.A. 7875 granting PHIC's power to fix the compensation of
its personnel does not explicitly provide that the same shall be subject to the approval of the
OBM or the OP as in Section 19(d) thereof does not necessarily mean that the PHIC has
unbridled discretion to issue any and all kinds of allowances, limited only by the provisions of its
charter. As clearly expressed in PCSO v. COA, even if it is assumed that there is an explicit
provision exempting a GOCC from the rules of the then Office of Compensation and Position

24
Classification (OCPC) under the OBM, the power of its Board to fix the salaries and determine
the reasonable allowances, bonuses and other incentives was still subject to the standards laid
down by applicable laws: P.O. No. 985, its 1978 amendment, P.O. No. 1597, the SSL, and at
present, R.A. 10149. To sustain petitioners' claim that it is the PHIC, and PHIC alone, that will
ensure that its compensation system conforms with applicable law will result in an invalid
delegation of legislative power, granting the PHIC unlimited authority to unilaterally fix its
compensation structure. Certainly, such effect could not have been the intent of the legislature”

5. Philippine Health Insurance Corp. Regional Office-Caraga v. Commission on Audit,

G.R. No. 230218, [August 14, 2018]

“Simply put, Philhealth CARAGA is still required to 1) observe the policies and guidelines
issued by the President with respect to position classification, salary rates, levels of allowances,
project and other honoraria, overtime rates, and other forms of compensation and fringe benefits,
and 2) report to the President, through the Budget Commission, on their position classification
and compensation plans, policies, rates and other related details following such specifications as
may be prescribed by the President.

Thus, Philhealth CARAGA's power to fix the compensation of its personnel as granted by its
charter, does not necessarily mean that it has unbridled discretion to issue any and all kinds of
allowances and other forms of benefits or compensation packages, limited only by the provisions
of its charter. The power of GOCCs or its board to fix the salaries, allowances and bonuses must
still conform to compensation and position classification standards laid down by applicable laws,
as discussed above. To sustain Philhealth, CARAGA's claim that it has unbridled authority to
unilaterally fix its compensation package will result in an invalid delegation of legislative power.
Further, Philhealth CARAGA's fiscal autonomy does not automatically preclude the COA's
power to disallow the grant of allowances in cases of irregular, excessive, unnecessary, or
unconscionable expenditures of government funds.

As discussed and quoted above, Philhealth CARAGA's compensation standardization scheme

notwithstanding its exemption from the coverage of the Office of Compensation and Position
Classification requires it to observe the guidelines issued by the President and to submit a report
to DBM. The rationale for the review of the DBM is to provide for the standardized
compensation of all government employees and officials, including those in GOCCs under
Salary Standardization Laws, which are P.D. No. 985, its amendment, P.D. No. 1597, R.A. No.
6758 and R.A. No. 10149, based on the government's national policy of equal pay for work of
equal value and to base differences in pay upon substantive differences in duties and
responsibilities, and qualification requirements of the positions.”

6. Philippine Health Insurance Corp v. Commission on Audit, G.R. No. 222710, [July
24, 2018]

“Here, PhilHealth's mandate is the administrator of the National Health Insurance Program
through which covered employees may ensure affordable, acceptable, accessible health care
services for all citizens of the Philippines. PhilHealth's establishment and purpose was detailed
under RA No. 7875 of Article III, Section 5, to wit:

25
 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 the 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 or 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 other 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. (Emphasis Ours)

Stated otherwise, PhilHealth is 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.

Clearly, the functions of the PhilHealth personnel are not principally related to health services.

xxx

PhilHealth personnel perform functions which pertain to the effective administration of the
National Health Insurance Program or facilitating the availability of funds of health services to
its covered employees, and, among others involve the: determination of requirements and issue
guidelines in relation to insurance program; inspection of health care institutions; inspection of
medical, financial, and other records relevant to the claims, accreditation, premium contribution
of employees covered by the program; and, to keep records of the operations of the Corporation
and investments of the National Health Insurance Fund. These functions are not similar to those
of persons rendering health or health-related services, or those employees working in
health-related establishments, as discussed above. Undoubtedly, the PhilHealth personnel cannot
be considered public health workers under RA No. 7305.

It is Our firm view that PhilHealth functions are not commensurate with the services rendered by
those workers who actually and directly provide health care services. PhilHealth's objective as
the National Health Insurance Program provider, is to help the people pay for health care
services; unlike workers or employees of the government and private hospitals, clinics, health
centers and units, medical service institutions, clinical laboratories, treatment and rehabilitation
centers, health-related establishments of government corporations, and the specific health service

26
section, division, bureau or unit of a government agency, who are actually engaged in health
work services.

It will also be absurd if the same benefits and treatment will be given to the PhilHealth personnel
and to those employees who actually rendered health services. Health workers or employees are
not similarly situated with the PhilHealth employees. Health workers have sets of skills, training,
medical background, work quality and ethical considerations to patients, and risks in
transmission, occupational and hazard exposures, diseases etc., in the performance of their
functions, while in PhilHealth, as National Health Insurance Program provider, its policy is only
to help the people subsidize; or pay, or finance for the health care services.

Although it is the DOH which principally determines who are specifically entitled to benefits
under RA No. 7305, its authority to make such determination must be in accordance with the
definition of terms and standards set in the law and its Implementing Rules. Moreover, there is
nothing in the law which precludes review of the DOHs determinations by other government
agencies such as the DBM and the COA in the performance of their respective functions. In fact,
in accordance with Section 35 of RA 7305, the Secretary of Health collaborated with other
government agencies and health workers organizations in drafting the Implementing Rules which
lay down, among others, the guidelines and procedure for the grant of hazard pay to public health
workers. Also, mindful of the objectives of RA No. 7305, the DBM had earlier requested for a
moratorium on the DOHs approval of requests made by agencies for certifications that their
personnel are covered by RA No. 7305 due to serious lapses in the issuance of such
certifications. (Emphasis supplied)”

7. Philippine Health Insurance Corp. v. Commission on Audit, G.R. No. 222838,

[September 4, 2018]

RA No. 7875 was enacted pursuant to the constitutional policy to create a National Health
Insurance Program (Program) that would grant discounted medical coverage to all citizens, with
priority to the needs of the underprivileged, sick, elderly, disabled, women and children, and free
medical care to paupers. The Program is designed to be compulsory, universal in coverage,
affordable, acceptable, available, and accessible for all citizens of the Philippines. In order to
achieve this noble goal, RA No. 7875 created the National Health Insurance Fund which consists
of contributions from members; current balances of the Health Insurance Funds of the SSS and
Government Service Insurance System (GSIS) collected under the Philippine Medical Care Act
of 1969, as amended, including arrearages of the Government of the Philippines with the GSIS
for the said Fund; other appropriations earmarked by the national and local governments
purposely for the implementation of the Program; subsequent appropriations; donations and
grants-in-aid; and all accruals thereof. The National Health Insurance Fund is managed by
PhilHealth through its BOD, subject to certain limitations. In line with managing the Program,
RA No. 7875 speaks of ensuring fund viability, as well as carrying out a fiduciary responsibility
such that the Program shall provide effective stewardship, funds management, and maintenance
of reserves. In a lot of ways, therefore, it is also imperative for PhilHealth to utilize funds for the
salaries and allowances of its BOD members with as much circumspection and restraint as the
SSS. Like the latter, the funds under PhilHealth's stewardship need to be devoted primarily to
providing universal and affordable health care to all Filipinos.

27
 8. Philippine Health Insurance Corp. v. Commission on Audit, G.R. No. 222710
(Resolution), [September 10, 2019]

One of the objectives of R.A. No. 11223, or the Universal Health Care Act, is to ensure that all
Filipinos are guaranteed equitable access to quality and affordable health care goods and
services, and protected against financial risk.21 In line with this objective, the law declares that
every Filipino citizen shall be automatically included in the National Health Insurance
Program.22

Notably, R.A. No. 11223 provides for a clear and unequivocal declaration regarding the
classification of all PhilHealth personnel, to wit:

SECTION 15. PhilHealth Personnel as Public Health Workers. — All PhilHealth

personnel shall be classified as public health workers in accordance with the
pertinent provisions under Republic Act No. 7305, also known as the Magna
Carta of Public Health Workers (emphasis supplied)

Plainly, the law states that all personnel of PhilHealth are public health workers in accordance
with R.A. No. 7305. This confirms that PhilHealth personnel are covered by the definition of a
public health worker. In other words, R.A. No. 11223 is a curative statute that remedies the
shortcomings of R.A. No. 7305 with respect to the classification of PhilHealth personnel as
public health workers.

xxx

In this case, while the Court initially declared that PhilHealth personnel were not public health
workers in its July 24, 2018 Decision and that ND No. H.O. 12-005 (11) was final and executory,
the subsequent enactment of R.A. No. 11223, which transpired after the promulgation of its
decision, convinces the Court to review its ruling. Thus, R.A. No. 11223 is a curative legislation
that benefits PhilHealth personnel and has retrospective application to pending proceedings.

Indeed, R.A. No. 11223, as a curative law, should be given retrospective application to the
pending proceeding because it neither violates the Constitution nor impairs vested rights. On the
contrary, R.A. No. 11223 further promotes the objective of R.A. No. 7305, which is to promote
and improve the social and economic well-being of health workers, their living and working
conditions and terms of employment.31 As a curative statute, R.A. No. 11223 applies to the
present case and to all pending cases involving the issue of whether PhilHealth personnel are
public health workers under Section 3 of R.A. No. 7305. To reiterate, R.A. No. 11223 settles,
once and for all, the matter that PhilHealth personnel are public health workers in accordance
with the provisions of R.A. No. 7305.

Evidently, R.A. No. 11223 removes any legal impediment to the treatment of PhilHealth
personnel as public health workers and for them to receive all the corresponding benefits
therewith, including longevity pay. Thus, ND H.O. 12-005 (11), disallowing the longevity pay of
PhilHealth personnel, must be reversed and set aside. As PhilHealth personnel are considered
public health workers, it is not necessary anymore to discuss the issue in good faith.

28
 9. Jerzon Manpower and Trading, Inc. v. Nato, G.R. No. 230211, [October 6, 2021]

Under R.A. No. 7875, or the National Health Insurance Act of 1995, as amended by R.A. No.
9241 and R.A. No. 10606, all Filipinos shall be part of a National Health Insurance Program
(NHIP) which aims to provide universal health insurance coverage and affordable, acceptable,
available, and accessible health care services.89 Consequently, the Philippine Health Insurance
Corporation (Phi/health) was established to administer the National Health Insurance Program.90
Sec. 4(a)(ii) of R.A. No. 7875, in relation to Secs. 3(hh) and 30, provides that overseas workers
are compulsory members and categorized as paying members who shall pay the full amount of
their contribution through the Overseas Workers' Welfare Administration (OWWA).
Furthermore, under Sec. 12 of R.A. No. 7875, members who have paid premium contributions
for at least three months are entitled to the benefits of the NHIP.

xxx

To emphasize, the health insurance benefits contractually granted to respondent was not
dependent on his employment or on whether the illness contracted was work-connected, contrary
to petitioners' claim. The payment of the premium contributions itself initiated respondent's
membership in Philhealth and activated the coverage and provisions of R.A. No. 7875, as
amended by R.A. No. 9042. Hence, petitioners could not deny respondent of his rights and
privileges under R.A. No. 7875, and its amendments, to which he had become legally and
contractually entitled.

Consistent with the State's obligation under R.A. No. 8042 to provide adequate and timely social,
economic, and legal services to Filipino migrant workers, petitioners are obligated to comply
with their contractual obligations and to do so in a timely manner, especially to a distressed
migrant worker. More often than not, the responsiveness of the employer and the recruitment
agency to the needs of migrant workers, who have delayed access to legal or social aid in a
foreign country, could mean life or death to the latter.

This is the case for the respondent when petitioners failed to provide him with prompt medical
and financial assistance through the health and labor benefits he was entitled to under his
employment contract. The expenses he allotted for his regular dialysis sessions that were
necessary for the treatment and management of his illness could have been diverted to his other
medical needs and his, and his family's, daily subsistence. Veritably, the receipt by respondent of
the insurance benefits he was entitled to could have brought about a different outcome of the fate
he suffered. Petitioners could not therefore deny their failure to perform their contractual
obligation of providing the respondent his health and labor insurance benefits under the
employment contract.

29