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7875) was ratified into a law by President Fidel V. Ramos on February 14, 1995. Historically, the roots of the law can be traced back in the 1960s. The Philippine Medical Association back then had formed the MARIA project to help poor communities needing medical services. This became the precursor of the Medicare Program. This was instituted years later through R.A. 6111 or the Philippine Medical Care Act of 1969 signed by President Ferdinand E. Marcos. The National Insurance Act is created in accordance to a provision of the Constitution of the Philippines mandating the government to institute a system for affordable health care delivery. Among the guiding principles of the Act are the following: a. Allocation of National Resources for Health b. Universality, which refers to greatest possible coverage with the basic minimum package c. Equity, or uniformity of services based on the need d. Responsiveness e. Social Solidarity, or risk sharing within the community f. Innovation g. Effectiveness h. Devolution, or cooperation with LGU’s i. j. l. Fiduciary Responsibility Informed Choice Compulsory Coverage
k. Maximum Community Participation, or building on existing mechanisms m. Cost Sharing n. Professional Responsibility of Health Care o. Public Health Services p. Quality of Services q. Cost Containment r. Care for the Indigent Aside from health care delivery, the law is also aimed at the creation of a program that will finance the payment for health care services. To administer and facilitate
out-patient psychotherapy and counselling for mental disorders. They are as follows: a. SSS and GSIS and their dependents. c. Inpatient hospital care: 1. 2. Outpatient care: 1. It is aimed at ensuring adequate financial access to quality health care services. 5. inpatient education packages. 6. It envisions adequate and affordable social health insurance coverage for all citizens. subject to the limitations described in Section 37 of this Act. use of surgical or medical equipment and facilities. There are healthcare-related services that are specifically excluded by the program. diagnostic. b. cosmetic surgery. 3. room and board. c. and other medical examination services. personal preventive services. and other medical examinations services. d. 2. . Persons eligible for Program I include qualified beneficiaries under Medicare.the program. prescription drugs and biologicals. prescription drugs and biologicals. however they are required to be enrolled to program subsequently. 3. The law talks of creation of a National Health Insurance Program. Indigents who are not enrolled in the system can also avail of services. services of health care professionals. laboratory. laboratory. Other appropriate healthcare services determined by the corporation. diagnostic. Program II encompasses all others who do not qualify under Program I. drug and alcohol abuse or dependency treatment. non-prescription drugs and devices. The program initially consists of Programs I and II for membership. The benefit package under the whole program covers the following: a. and 4. b. subject to the limitations stated in Section 37 of this Act. Emergency and transfer services. the law provides for the establishment of the Philippine Health Insurance Corporation. 4. d. services of health care professionals.
The Philippine Health Insurance Corporation created under the law is given a taxexempt status and will be attached to the Department of Health. retired members who have pave at least 120 monthly contributions. normal obstetrical delivery. It can summon parties and witnesses and request the production of documents pertaining to a case under investigation. f. In so doing.e. To be entitled to the benefits of the program. Although originally excluded. A suspension of accreditation shall not exceed 24 months while a suspension of a member’s rights shall not exceed 6 months. The Secretary of Labor and Employment or his representative. This body shall be composed of the following 11 members: a. set standards. The corporation is also not required to follow the technical rules of evidence in the exercise of its quasi-judicial powers. It is given a juridical personality that may acquire property. home and rehabilitation services. The Secretary of Health. These include SSS and GSIS retirees prior to the effectivity of the law. sue and be sued. g. and enrolled indigents. inspect and act on matters related to the enforcement of the National Health Insurance plan. It may investigate and conduct hearings on matters and controversies brought upon it. Certain members are not required to pay any premium to avail of the services. it is notable to point out that certain optometric practices like phacosurgery and cataract removal are already incorporated into the program coverage at present. member is required to have paid at least 3 months premium contribution within the first six months of the availment of the service. Its main function is to administer the National Health Insurance plan. it is empowered to create rules. It can also suspend. The PhilHealth Corporation is also granted quasi-judicial powers. cost-ineffective procedures which shall be defined by the Corporation. optometric services. . The Board of Directors shall be appointed by the President of the Philippines. h. enter into contracts. supervise. b. revoke or restore the accreditation of a health care provider and the benefits of a member.
The law mandates the specific creation of two departments in the corporation. The members of the board shall serve a term of four years. Local Health Offices are to be established in every province or chartered city. The President of the corporation has a non-renewable term of six years. A representative of the Self-employed Sector. . and A representative of health care providers representative. The President of the Corporation. The president shall act as the Chief Executive Officer of the corporation and shall be responsible for its general management. as necessary. to bring the services closer to the members. recruit and register members. d. The Secretary of the Interior and Local Government of his The Secretary of Social Welfare and Development or his representative. renewable for maximum of two years with the exception of members whose terms are co-terminus with their positions in the government. The second is the Actuary of the Corporation which conducts the actuarial studies. g. h. The President must be a Filipino citizen and must possess adequate and appropriate training and at least five years experience in the field of health care financing and corporate management. The GSIS General Manager or his representative. He is to be appointed by the President of the Philippines upon the recommendation by the Board of Directors. i. He is required to be uninvolved with any health care institution as owner or board member to avoid conflict of interest. collect premium and contributions. A representative of the labor sector. The SSS Administrator or his representative. which is tasked with development of a master plan and conduct of program review. j.c. The local offices shall have powers among others like work with local government units. e. k. The first is the Health Finance Policy Research. f. A representative of employers. and grant or deny accreditation of health care providers.
The Basic Benefit Fund – shall finance the availment of basic minimum package b.” All members of the Program shall contribute to the fund to be determined by the corporation. remaining Health Insurance balances from SSS and GSIS. Payment for indigent members shall be subsidized partially by the local government where the member resides. The minimum requirements are as follows: . The components of the National Health Insurance Fund shall be: a. The administrative costs for the Program may be charged from the Fund but the annual total of these shall not exceed 12% of the total contributions. be subject to limitations based on the area of jurisdiction of the concerned Office and on the appropriateness of treatment in the facility chosen or by the desired provider. The Corporation shall set aside a portion of its accumulated revenues not needed to meet the cost of the current year’s expenditures as reserved funds. Such portions of the reserve fund as are not needed to meet the current expenditure obligations shall be invested in short-term investments to earn an average annual income at prevailing rates of interest and shall be known as the “Investment Reserve Fund. Financial management shall be governed by the resolution of the Board of Directors subject to certain limitations such as the rules and regulations for public funds. however.The National Health Insurance Fund shall consist of the contribution from members. Beneficiaries requiring treatment or confinement shall be free to choose from accredited health care providers. Health care providers operating for at least three years or more may apply for accreditation. appropriations from national and local governments. Supplementary Benefit Funds – for supplementary coverage to various groups of the population enjoying the basic benefit coverage. donations and grant aids and subsequent/additional appropriations. Such choice shall.
d) adoption of referral protocols and health resources sharing arrangements. c) A combination of both. and . The following mechanisms for public and private providers shall be allowed in the Program: a) Fee-for-service based on mechanisms established by the Corporation. e) recognition of the rights of patients. dependents or health care providers who believe they have been aggrieved by any decision of the Program implementors may seek redress of grievance through a system of grievance and appeal. or networks of the same including HMOs. and d) Any or all of the above. and f) acceptance of information system requirements and regular transfer of information. c) unjustifiable delay in actions or claims. utilization review and technology assessment. the Corporation may deny or reduce payment. Members. Monitoring mechanism is to be set-up to provide safeguards against over-utilization and under-utilization of services. c) acceptance of the payment mechanisms specified in the following section. subject to a global budget. b) a willful neglect of duties of Program implementors that results in the loss or non-enjoyment of benefits by members or their dependents. and other legally formed health service groups. as determined by the Department of Health. b) acceptance of formal program of quality assurance and utilization review. The valid grounds for grievance are as follows: a) any violation of the rights of patients. Health care providers are to take part in quality assurance programs. d) delay in the processing of claims that extends beyond the period agreed upon. medical cooperatives. equipment and physical structure in conformity with the standards of the relevant facility. When claims are attended by false or incorrect information. b) Capitation of health care professionals and facilities.a) human resource.
the imposition of fines. b) Appeals from Office decisions must be filed with the Board within thirty (30) days from receipt of notice of dismissal or disallowance by the Office. d) All decisions by the Board as to entitlement to benefits of members or to payments of health care providers shall be considered final and executory. the Committee and the Board may administer oaths. or any other valid ground for dismissal of the complaint. Respondents are require to file a verified answer within five (5) days from service of summons. The Grievance and Appeal Review Committee may dismiss the case outright due to lack of verification. The committee may render judgment if the defendant fails to answer the complaint within the reglamentary five-day period. The appellees are also given fifteen days from notice of appeal to file an answer. The committee may render judgment within ten days from submission of position statements of the parties or may hold a hearing to clarify matters before rendering judgment. In the exercise of quasi-judicial powers. The decision shall be executory fifteen days after notice. or the imposition of charges on members or their dependents in case of revocation of their entitlement. Created by the Board. c) The Offices shall have no jurisdiction over any issue involving the suspension or revocation of accreditation. the Committee shall require all parties to submit affidavits of witnesses and other evidence within ten days of the order. certify official acts and issue subpoena to compel witnesses and production of . Hearing will be terminated within 15 days and decision upon the case shall be rendered fifteen days thereafter. failure to state the cause of action. The procedure for grievance and appeal are as follows: a) A complaint for grievance must be filed with the Office which shall rule on the complaint within ninety (90) calendar days from receipt thereof.e) any other act or neglect that tends to undermine or defeat the purposes of this Act. however the same shall be appealable by filing a memorandum of appeal within the same period. the Grievance and Appeal Review Committee shall have three to five members which shall receive and recommend appropriate action on complaints. The Board shall decide within 30 days upon submission of the aforementioned pleadings. Once an answer is filed.
fails to remit the said contributions to the Corporation within thirty (30) days from the date they become due shall be presumed to have misappropriated such contribution and shall suffer the penalties provided for in Article 315 of the Revised Penal Code. Any employer who shall deduct directly or indirectly from the compensation of the covered employees . Where the violations consist of failure or refusal to deduct contributions from the employee’s compensation or to remit the same to the Corporation.000).000) multiplied by the total number of employees employed by the firm and imprisonment of not less than six (6) months but not more than one (1) year: Provided.000) in case the violation is committed by the hospital management or provider.documents. the penalty shall be a fine of not less than Five hundred pesos (P500) but not more than One thousand pesos (P1. Violations of the provisions of the code shall have the following penalties: A fine of not less than Ten thousand pesos (P 10.000) nor more than Fifty thousand pesos (P50. further. That in the case of self-employed members. Any employer or any officer authorized to collect contributions under this Act who. That recidivists may not anymore be accredited as a participant of the Program. after collecting or deducting the monthly contributions from his employee’s compensation. Technical rules of evidence shall no bind the committee and the Board in all of its proceedings but the Rules of Court shall have suppletory effect. A fine of not less than Five hundred pesos (P500) nor more than Five thousand pesos (P5. They may prescribe administrative sanctions. however. in accordance to the Revised Administrative Code and the Rules of Court. In addition. its accreditation shall be suspended or revoked from three (3) months to the whole term of accreditation: Provided. failure to remit one’s own contribution shall be penalized with a fine of not less than five hundred pesos (P500) but not more than One thousand pesos (P1.000) and imprisonment of not less than six (6) months nor more than one (1) year in case the violation is committed by the member.
or shall take or misappropriate or shall consent. or imprisonment not exceeding one (1) year. or both fine and imprisonment.000) nor more than Twenty thousand pesos (P20. it is mandated that the Board shall formulate the Implementing Rules and Regulations 30 days after its members are appointed. shall likewise be liable for misappropriation of funds or property and shall suffer imprisonment of not less than six (6) years and not more than twelve (12) years and a fine of not less than Ten thousand pesos (P10. The Philippine Medical Care Commission shall cease to exist and all its functions and assets shall be merged with the Corporation. Any employee of the Corporation who receives or keeps funds or property belonging. Any shortage of the funds or loss of the property upon audit shall be deemed prima facie evidence of the offense. or other persons responsible for the commission of the said act shall be liable for the penalties provided for in this Act and other laws for the offense. taking into consideration the rules on collection. some of the definitions of the terms in the law were modified. Among others. This law amended some provisions of RA 7875. its managing directors or partners or president or general manager. All other violations involving funds of the Corporation shall be governed by the applicable provisions of the Revised Penal Code or other laws. at the discretion of the Court. RA 9241 was enacted. corporation or any other institution. Initial funding will come from the unexpected portion of the Philippine Medical Care Commission and from any unappropriated but available fund of the Government. remittances.000). . If the act or omission penalized by this Act be committed by an association. or through abandonment or negligence shall permit any other person to take such property or funds wholly or partially. and investment of funds as may be promulgated by the Corporation. and who shall appropriate the same. Among the transitory provisions of the law.000) multiplied by the total number of employees employed by the firm. payable or deliverable to the Corporation. partnership. On February 2004.or otherwise recover from them his own contribution on behalf of such employees shall be punished by a fine not exceeding One thousand pesos (P1.
the Vice chairperson for the basic sector of the National Anti-Poverty Commission or his representative and 2. The 90% National Government subsidy for indigents residing in 4th. a representative of Filipino overseas workers.In the list of excluded services. the NEDA. In case of penalties. In case of oversight. Whereas before the health care provider has to be in operation for at least three years before being qualified for accreditation. and d) Other conditions as may be determined by the Corporation. c) It operates in a local government unit where the accredited health care provider cannot adequately or fully service its population. b) It operates as a tertiary facility or its equivalent. a provider whose existence is less than three years may also be accredited provided it complies with all requisites for accreditation in addition to the following: a) Its managing health care professional has had a working experience in another accredited health care institution for at least three (3) years. . there is no longer a penalty for self-employed members who fail to remit one’s own contribution. with NSO and NIH shall undertake studies to validate the accomplishments of PhilHealth. in addition to regular review by Congress. out-patient psychotherapy and counselling for mental disorders was removed. with the amendment. 5th and 6th class municipalities is no longer limited to five years. There are also 2 members added to the Board of Directors – 1.
This factor is completely beyond provider’s control. The Implementing Rules and Regulations of PhilHealth required the filing of claims within 60 days from the discharge of patients. so the claims were filed instead to the petitioner PhilHealth. it has to comply with several requirements. sought relief from the Court of Appeals which decided in their favor. Chinese General Hospital had a claim of more than eight million pesos.5 million pesos to petitioner. a number of which have to be submitted by patients. 361 claims were denied due to delay in filing. . Of the 373 claims. There will always be delay not attributable to respondent. but the hospital was overtaken by the passage of the PhilHealth Act RA 7875. Respondent. Such Medicare claim was supposed to be filed with SSS and GSIS.Philippine Health Insurance Corp. For the period 1989 to 1992. Subsequently. The appellate body ordered PhilHealth to pay Chinese General Hospital more than fourteen million pesos for the unsettled claims. Chinese General Hospital filed claims for the period 1998 to 1999 amounting to 7. It is unreasonable to expect providers to comply 100% of the time with the prescribed 60-day rule of Philhealth. PhilHealth did not recognize the whole amount asked for by respondent but paid only more 1 million pesos to the latter. after final denial by PhilHealth. Before a health care provider can file a claims for services rendered. There is no assurance of the members’ prompt submission of the required documents. Most patients cannot immediately accomplish such requirements. as most of the claims were 5 to 16½ months late. vs Chinese General Hospital GR 163123 Facts: PHIC denied the claims for services rendered to patients by Chinese General Hospital. Issue: w/n PhilHealth can deny respondent’s claims filed beyond 60 day period provided in the IRR Held: PhilHealth cannot deny the claims due to delays in filing.
RA 7875 itself does not provide does not provide for any specific period within which to file claims. It is safe to presume therefore that the period for filing was not the principal concern of the legislature. . Only the IRR has that provision.
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