THE NATIONAL HEALTH

INSURANCE ACT OF 1995

REPUBLIC ACT NO. 7875

[as amended by Republic Act No. 9241]

RATIONALE BEHIND THE

NATIONAL HEALTH INSURANCE
ACT

ToassistFilipinosingainingaccesstoqualityhealthcare,the
PhilippinegovernmentinstitutedtheNHIPtoprovideuniversal
healthcoverageforthePhilippinepopulation.ThePhilippine
HealthInsuranceCorporation(PhilHealth),agovernmentowned
andcontrolledcorporation,ismandatedtoadministertheNHIP
andtoensurethatFilipinoshavefinancialaccesstohealthservices.
NHIPwasenactedtoimplementSection11,ArticleXIIIofthe
1987Constiturion

COVERAGE OF NHIP
All Citizens of the
Philippines
Coverage is COMPULSORY. All Citizens
of the Philippines are required to enroll
in the NHIP

EVOLUTION OF SOCIAL INSURANCE COVERAGE IN THE PHILIPPIN

2014 The Expanded Senior Citizen Act (Republic Act No.
9994)
2012*-2013 National Government assumed
payment of full premium for the indigents
2013 RA No. 7875 amendment (Republic Act No. 10606)
2005 Assumed coverage of Overseas Filipino Workers
from the Overseas Workers Welfare Administration
(OWWA)
2004 RA No. 7875 amendment (Republic Act No. 9241)
1999 Implemented coverage of the self-employed
1998 Implemented coverage of indigent families with
the local government units
1998 Assumed coverage of private employees from the
Social Security System (SSS)
1997 Assumed coverage of government employees
from the Government Service Insurance System
(GSIS)
1995.National Health Insurance Act of 1995 (Republic Act
No. 7875)
1969.Philippine Medical Care Act of 1969 (Republic Act
No. 6111)

THE NATIONAL HEALTH INSURANCE PROGRAM

PROVIDES ALL CITIZENS WITH THE
MECHANISM TO GAIN FINANCIAL ACCESS TO
HEALTH SERVICES
RA 7875 (1995) AS AMENDED BY RA 9241(2004) & RA 10606 (2013)

17

REGIONAL
OFFICES

106

LOCAL

OFFICES

6,400

OFFICERS
STAFF

FILIPINOS

~100,000,000

ENROLMENT OF BENEFICIARIES
BENEFICIARIES
1. Persons currently eligible for benefits under
Medicare Program, Including SSS and GSIS
Members, retirees, pensioners and their
dependents

REQUIREMENT
Automatically Enrolled

2. Persons eligible for the benefits as members of Automatically Enrolled

Local health Insurance plans established by the
PHIC
3. Persons eligible for benefits under health
insurance plans by local government as part of
the program of Medicare

Should be enrolled

4. Persons eligible for benefits as members of other government

initiated health insurance programs

Should be enrolled

ENROLMENT REQUIREMENTS
A. Birth Certificate
B. Baptismal Certificate
C. GSIS/SSS Members ID
D. Passport
E. Any other valid ID

NOTE: MEMBERSHIP IN THE NHIP SHALL TAKE EFFECT UPON

PAYMENT OF THE REQUIRED PREMIUM CONTRIBUTION

PERSONS NOT OBLIGED TO PAY

PREMIUM CONTRIBUTIONS
RETIREES AND PENSIONERS OF SSS AND GSIS PRIOR TO THE
EFFECTIVITY OF NNHIP
MEMBERS WHO REACH THE AGE OF RETIREMENT AS PROVIDED
BY LAW AND HAVE PAID AT LEAST 120 MONTHLY CONTRIBUTIONS
ENROLLED INDIGENTS.

CHARACTERISTICS OF THE NATIONAL HEALTH INSURANCE

PROGRAM
Coverage

Compulsory coverage for all citizens; Family-based membership where primary

member and qualified dependents have almost the same benefit coverage

Administration

Single-payer system

Financing

For employed: Payroll-based premium with employer and employee

contributions (2.5% of basic salary)
For Self-employed: Two-tiered annual premium
PhP2,400 (US$54) with less than P25,000 (US$563.5) monthly
income)
PhP3,600 (US$81) for those earning P25,000 or higher monthly
income
Government subsidy for the poor and senior citizen (PhP2,400 annual
premium)

Benefits

Uniform in-patient package (paid as case rate) including catastrophic

benefit packages
Primary care benefit for the indigents and other sponsored members (will
also be rolled out to all members)

CHARACTERISTICS OF THE NATIONAL HEALTH

INSURANCE PROGRAM
Providers

Accreditation of both government and private-owned health facilities,

voluntary basis
Contract-based for hospitals engaged to deliver catastrophic benefit
packages (in addition to accreditation)

Payment

Case rate for in-patient benefits

Special Case Rate for Z packages
Per Family Payment Rate (PFPR) for Primary Care Benefit

Privileges

Automatic coverage of the poor assessed by the National Household

Targeting System for Poverty Reduction (NHTS-PR) of the Department of
Social Welfare and Development (DSWD)
No Balance Billing for indigents and sponsored members when admitted in
government hospitals
Automatic availment of benefits by pregnant women and those enrolled as
sponsored member at point-of-care
Lifetime entitlement to senior citizens (60 years old and above)

Distribution of health insurance is

becoming more pro-poor over time
80%
60%
40%
20%
0%

Q1

Q2

Q3

Q4

2008
Data source: NDHS 2008, NFHS 2011, NDHS 2013

Q5

2011

Utilization of health services by

the poor went up over time.
22,500.00

18,000.00

13,500.00

9,000.00

4,500.00

2010

2011

2012

Source: PhilHealth Stats and Charts, 2010-2013, Analysis of claims Jan-Oct 2014

2013

Oct, 2014

Sustainability of coverage of the poor is assured by

the Sin Tax Law (RA 10351)

85% of incremental revenues from Sin

Taxes intended for the Universal Health
Coverage
80% to cover the poor under NHIP
20% to upgrade government health facilities

60

44.7

45

30

47.6

???
51.9

33.7

30.5

15

0
2013

2014

2015

Collection for health from Sin Taxes, in billion pesos.

Source: DOH

THE NATIONAL HEALTH

INSURANCE ACT OF 1995
REPUBLIC ACT NO. 7875
[as amended by Republic Act No. 9241]

BENEFITS UNDER THE NATIONAL

HEALTH INSURANCE PROGRAM
In-patient hospital care
Out-patient care
Emergency and Transfer Services; and
Such other health care services that the Philippine Health Insurance
Corporation shall determine to be appropriate and cost-effective.
Sec. 10, R.A. No. 7871
PHIC also provides outpatient services to its members such as chemotherapy,
radiation therapy, dialysis, cataract extraction, and minor surgical procedures
performed in an operating room complex of an accredited facility

HEALTH SERVICES
NOT COVERED
a) Non-prescription drugs and devices;
b) Alcohol abuse or dependency treatment;
c) Cosmetic Surgery;
d) Optometric Services;
e) Obstetrical deliveries*;
f) Cost-ineffective procedures;
g) Outpatient psychotherapy and counseling for mental disorders;
h) Home and rehabilitation services.

CONDITIONS FOR ENTITLEMENT

TO THE BENEFITS
Member/Dependent should meet the following conditions:
1. Suffer illness or injury
which requires treatment as in-patient or out-patient in an accredited health care
institution;

2. Paid Premium Contributions

For at least 3 months within the 6-month period prior to the first day of his or his
dependents availment

3. Contributes with sufficient regularity

As shown in their health Insurance ID card

4. Not currently subject to the penal sanctions under the law

CONDITIONS FOR ENTITLEMENT

TO THE BENEFITS CONT.
Members/Dependents outside the country
Can they avail benefits? YES.

HOW?
1.
2.

They meet the conditions earlier stated

Following requirements are submitted
a)
b)

Official receipt of payment or statement of account from the health care

institution where the member/dependent was confined; and
Certification of the attending physician as to the final diagnosis, period of
confinement, and services rendered.

HEALTH CARE
PROVIDERS
Duly licensed Health Care Institution
Health Care Professional
Health Maintenance Organization
Community-based Health Care Organization of Indigenous members of the
community
NOTE: Health Care Providers should be accredited
To qualify for accreditation, the health care provider must have operated for
at least three years
If less than three years, it may still apply and qualify for accreditation.

PAYMENT OF
CLAIMS
Payment of the health care provider shall be made through any of the
following mechanisms:
a) Fee for service;
b) Capitation of health care professionals, institutions, or networks of the same;
c) Such other mechanisms as may hereafter be determined by the PHIC.

Is Direct Payment allowed? General Rule: No

Exceptions:
Member/Dependent confined abroad;
If drugs, medicines, and other medical supplies were bought and used by the member
within the confinement period with supporting official receipts;
If member advanced the payment because of failure to submit the required documents;
If the member paid professional fees directly.

GROUNDS FOR DENIAL OR

REDUCTION OF CLAIMS
a)
b)
c)
d)
e)

Over-utilization and under-utilization of services;

Unnecessary diagnostic and therapeutic procedures and intervention;
Irrational medication and prescriptions;
Fraud;
Gross, unjustified deviations from currently accepted standards of practice
and/or treatment protocols;
f) Inappropriate referral practices;
g) Use of fake, adulterated, or misbranded pharmaceuticals, or unregistered
drugs; or
h) Use of drugs other than those recognized in the latest PNDF and those for
which exemptions were granted by the Board.

COMPENSABILITY OF
CONFINEMENT
As a rule, hospital confinement for less than 24 hours are not compensable,
except in the following instances:
Patient died;
Patient transferred to another health care institution;
In emergency cases.

WHAT IS THE PHILIPPINE HEALTH

INSURANCE CORPORATION?
Tax-exempt government corporation attached to the Department of Health
for policy coordination and guidance;
Administers the National Health Insurance Program;
Vested not only with administrative powers but also quasi-judicial powers
Decisions of the PHIC are immediately be executory, even pending appeal,
when the public interest so requires.

WHAT IS THE PHILIPPINE HEALTH

INSURANCE CORPORATION?
Vision
"Bawat Pilipino, Miyembro,
Bawat Miyembro, Protektado,
Kalusugan Natin, Segurado"

Mission
"Sulit na Benepisyo sa Bawat Miyembro,
Dekalidad na Serbisyo para sa Lahat

Core Values
Inobasyon, Serbisyong Dekalidad, Lubos na Integridad, Angkop na Benepisyo,
Panlipunang Pagkakabuklod, at Ganap na Pagkalinga