National Health Insurance

Act of 2013
REPUBLIC ACT NO. 7875
[As Amended by Republic Act Nos. 9241 and 10606]
Rationale
• Adopt an integrated and comprehensive approach to health
development
• Make essential goods, health and other social services available to all
people at affordable cost, with priority to:

(1)Underprivileged (2)Sick (4)Elderly (6)Disabled

(3)Children (5)Women
 The National Health Insurance Program

National Philippine
Health Health
is administered by
Insurance Insurance
Program Corporation
Who are covered by the NHIP?

ALL the citizens of the

Philippines
Enrollment
• Identification of beneficiaries

• Issuance of appropriate documentation

specifying eligibility to benefits

• Indication on how the beneficiaries’

membership was maintained or is being
maintained
Requirements
• Properly accomplished
prescribed Membership
Registration Form, including the
list of declared qualified legal
dependents
Member Categories
1. Members in the FORMAL ECONOMY
• Government employees
• Private employees
• All other workers in government or private offices, such as:
• Job order contractors
• Project-based contractors
• Owners of micro-enterprises
• Owners of small, medium, and large enterprises
• Domestic workers
• Family drivers
Member Categories
2. Members in the INFORMAL ECONOMY
• Migrant workers
• Persons in the informal sector which includes:
• Street hawkers
• Market vendors
• Pedicab drivers
• Tricycle drivers
• Small construction workers
• Home-based industries and services
• Self-earning individuals
• Filipinos with dual citizenship
• Naturalized Filipino citizens
• Citizens of other countries working or residing in the Philippines
Member Categories
3. INDIGENTS
• No visible means of income
• Income is insufficient for subsistence of family

4. SPONSORED MEMBERS
• Contribution is being paid by another individual,
government agency, or private entity

5. LIFETIME MEMBERS
• Member who have reached the retirement age
• Have paid at least 120 monthly contributions
Effectivity

Membership shall take effect upon enrollment and payment of

required premium contributions
Entitlement of Benefits

Payment of at least 3 months

First day of availment
within 6 months prior to
Local Health Insurance Office

Province Chartered City

Scope of the National Health Insurance Program

Allowed Prohibited
Paying for the utilization Buying and
of health services by Directly providing
dispensing drugs and
covered beneficiaries health care
pharmaceuticals

Employing physicians
Owning or investing
Purchasing of health and other
in health care
services in behalf of professionals to
covered beneficiaries facilities
render care
Identification Card and Number

• Identification

• Eligibility verification

• Utilization recording

This is a VALID government ID

Dependents
• Legitimate spouse
• Unmarried and unemployed legitimate, legitimated, acknowledged,
illegitimate children and legally adopted or stepchildren below 21 years old
• Children who are 21 years old and above but suffering from congenital
physical or disability
• Foster child as defined in the Foster Care Act of 2012
• Parents who are 60 years old and above, whose monthly income is below
the amount determined by PhilHealth
• Parents with permanent disability who are totally dependent on the
member for support
Obligations of the Employer
• To register their employees and qualified dependents
• To report to PhilHealth its newly hired employees within 30 calendar
days
• To notify PhilHealth of an employee’s separation within 30 calendar
days
• To contribute to the member’s monthly premium contribution
Premium Contributions
• Members in the formal economy
• Maximum of 5% of the basic monthly salary to be shared equally by the employer
and employee
• Members in the informal economy
• Based on household earnings and assets
• Sponsored members
• DSWD sponsored (orphans, abandoned and abused minors, out-of-school youth,
street children, persons with disability, senior citizens and battered women)
• LGU sponsored (barangay health workers, nutrition scholars and other barangay
workers and volunteers)
• Househelpers’ annual contributions shall be fully paid by their employers in
accordance to the Domestic Workers Act
Premium Contributions
• Indigents
• Fully subsidized by the National Government

• Unenrolled women about to give birth

• Borne by the National Government, LGU or legislative sponsor
Is a member who is separated from formal employment or whose
coverage as a sponsored member or as an Indigent or as a migrant
worker required to pay his premium?

YES, as a self-earning individual

Is an employee with no income for particular months still required to
pay premium contributions?

YES, to ensure continuous entitlement to benefits

Can a member avail of benefits if the employer failed to deduct or
remit premium contributions?

YES, failure of the employer to do so is not a ground for denial of a

properly claimed benefit. The employer will reimburse to PhilHealth
the payment for the benefit
Benefits
In-patient hospital care:
• Room and board
• Services of health care
professionals
• Diagnostic, laboratory, and other
medical examination services
• Use of surgical or medical
equipment and facilities
• Prescription drugs and biologicals
Benefits
Out-patient care Emergency and transfer services
• Services of health care
professionals Such other health care services
• Diagnostic, laboratory, and other that PhilHealth and DOH shall
medical examination services determine to be appropriate and
• Personal preventive services cost-effective
• Prescription drugs and other
biologicals
Period of Claim

Claims shall be filed within a period of 60 calendar days from the date
of discharge of the patient
Health Care Providers
1. Health Care Institution
2. Health Care Professional
3. Health Maintenance Organization
4. Community-based Health Care Organization
5. Any other Institution, Building, or Place
Grievances may be filed by
an accredited health care provider
a member
a dependent
against a program implementor

with the PhilHealth Office where the healthcare provider is located or

where the member resides

The complaint will be referred to the Grievance and Appeal Review

Committee