NATIONAL HEALTH
INSURANCE
ACT OF 1995
[REPUBLIC
ACT
NO. 7875]
AN ACT
INSTITUTING
A NATIONAL HEALTH INSURANCE PROGRAM
FOR ALL FILIPINOS AND ESTABLISHING
THE PHILIPPINE HEALTH INSURANCE CORPORATION FOR THE PURPOSE.
SECTION
1. Short Title. - This Act shall be known as the "National
Health Insurance Act of 1995."
ARTICLE
IGUIDING
PRINCIPLES
SECTION
2.chanrobles virtual law libraryDeclaration
of Principles and Policies. - Section 11, Article XIII of the 1987
Constitution of the Republic of the Philippines declares that the State
shall adopt an integrated and comprehensive approach to health
development
which shall endeavor to make essential goods, health and other social
services
available to all the people at affordable cost. Priority for the needs
of the underprivileged, sick, elderly, disabled, women, and children
shall
be recognized. Likewise, it shall be the policy of the State to provide
free medical care to paupers.cralaw:red
In the
pursuit of a National Health Insurance Program, this Act shall adopt
the
following guiding principles:
a) Allocation
of National Resources for Health - The Program shall underscore
the
importance for government to give priority to health as a strategy for
bringing about faster economic development and improving quality of
life;
b) Universality
- The Program shall provide all citizens with the mechanism to gain
financial access to health services, in combination with other
government
health programs. The National Health Insurance Program shall give the
highest
priority to achieving coverage of the entire population with at least a
basic minimum package of health insurance benefits;
c) Equity
- The Program shall provide for uniform basic benefits. Access to care
must be a function of a person’s health needs rather than his ability
to
pay;
d) Responsiveness
- The Program shall adequately meet the needs for personal health
services
at various stages of a member’s life;
e) Social
Solidarity - The Program shall be guided by community spirit. It
must
enhance risk-sharing among income groups, age groups, and persons of
differing
health status, and residing in different geographic areas;
f) Effectiveness
- The Program shall balance economical use of resources with
quality
of care;
g) Innovation
- The Program shall adopt to changes in medical technology, health
service organizations, health care provider payments systems, scopes of
professional practice, and other trends in the health sector. It must
be
cognizant of the appropriate roles and respective strengths of the
public
and private sectors in health care, including people’s organizations
and
community-based health care organizations;
h) Devolution
- The Program shall be implemented in consultation with the local
government
units (LGUs), subject to the over-all policy directions set by the
National
Government;
i) Fiduciary
Responsibility - The Program shall provide effective stewardship,
funds
management, and maintenance of reserves;
j) Informed
Choice - The Program shall encourage members to choose from among
accredited
health care providers. The Corporation’s local offices shall
objectively
apprise its members of the full range of providers involved in the
Program
and of the services and privileges to which they are entitled as
members.
This explanation, which the member may use as a guide in selecting the
appropriate and most suitable provider, shall be given in clear and
simple
Filipino and in the local language that is comprehensible to the
members;
k) Maximum
Community Participation - The Program shall build on existing
community
initiatives for its organization and human resource requirements.cralaw:red
l) Compulsory
Coverage - All citizens of the Philippines shall be required to
enroll
in the National Health Insurance Program in order to avoid adverse
selection
and social inequity;
m) Cost
Sharing - The Program shall continuously evaluate its cost-sharing
schedule to ensure that the costs borne by the members are fair and
equitable
and that the charges by health care providers are reasonable;
n) Professional
Responsibility of Health Care Providers - The Program shall assure
that all participating health care providers are responsible and
accountable
in all their dealings with the Corporation and its members;
o) Public
Health Services - The Government shall be responsible for providing
public health services for all groups such as women, children,
indigenous
people, displaced communities in environmentally endangered areas,
while
the Program shall focus on the provision of personal health services.
Preventive
and promotive public health services are essential for reducing the
need
and spending for personal health services;
p) Quality
of Services - The Program shall promote the improvement in the
quality
of health services provided through the institutionalization of
programs
of quality assurance at all levels of the health service delivery
system.
The satisfaction of the community, as well as individual beneficiaries,
shall be a determinant of the quality of service delivery;
q) Cost
Containment - The Program shall incorporate features of cost
containment
in its design and operations and provide a viable means of helping the
people pay for health care services; and
r) Care
for the Indigent - The government shall be responsible for
providing
a basic package of needed personal health services to indigents through
premium subsidy, or through direct service provision until such time
that
the program is fully implemented.cralaw:red
SECTION
3. General Objectives. - This Act seeks to:
a) provide
all citizens of the Philippines with the mechanism to gain financial
access
to health services;
b) create
the National Health Insurance Program, hereinafter referred to as the
Program,
to serve as the means to help the people pay for health care services;
c) prioritize
and accelerate the provisions of health services to all Filipinos,
especially
that segment of the population who cannot afford such services; and
d) establish
the Philippine Health Insurance Corporation, hereinafter referred to as
the Corporation, that will administer the Program at central and local
levels.
ARTICLE
IIDEFINITION
OF TERMS
SECTION
4. Definition of Terms. - For the purpose of this Act,
the
following terms shall be defined as follows:
a) Beneficiary
- Any person entitled to health care benefits under this Act.cralaw:red
b) Benefit
Package - Services that the Program offers to its members.cralaw:red
c) Capitation
- A payment mechanism where a fixed rate, whether per person, family,
household,
or group, is negotiated with the health care provider who shall be
responsible
for delivering or arranging for the delivery of health services
required
by the covered person under the conditions of a health provider
contract.cralaw:red
d) Contribution
- The amount paid by or in behalf of a member to the Program for
coverage,
based on salaries or wages in the case of formal sector employees, and
on household earnings and assets, in the case of the self-employed, or
on other criteria as may be defined by the Corporation in accordance
with
the guiding principles set forth in Article I of this Act.cralaw:red
e) Coverage
- The entitlement of an individual, as a member or as a dependent, to
the
benefits of the Program.cralaw:red
f) Dependent
- The legal dependents of a member are: 1) the legitimate spouse who is
not a member; 2) the unmarried and unemployed legitimate, legitimated,
illegitimate, acknowledged children as appearing in the birth
certificate;
legally adopted or stepchildren below twenty-one (21) years of age; 3)
children who are twenty-one (21) years old or above but suffering from
congenital disability, either physical or mental, or any disability
acquired
that renders them totally dependent on the member for support; 4) the
parents
who are sixty (60) years old or above whose monthly income is below an
amount to be determined by the Corporation in accordance with the
guiding
principles set forth in Article I of this Act.cralaw:red
g) Diagnostic
Procedure - Any procedure to identify a disease or condition
through
analysis and examination.cralaw:red
h) Emergency
- An unforeseen combination of circumstances which calls for immediate
action to preserve the life of a person or to preserve the sight of one
or both eyes; the hearing of one or both ears; or one or two limbs at
or
above the ankle or wrist.cralaw:red
i) Employee
- Any person who performs services for an employer in which either or
both
mental and physical efforts are used and who receives compensation for
such services, where there is an employer-employee relationship.cralaw:red
j) Employer
- A natural or juridical person who employs the services of an employee.cralaw:red
k) Enrollment
- The process to be determined by the Corporation in order to enlist
individuals
as members or dependents covered by the Program.cralaw:red
l) Fee
for Service - A reasonable and equitable health care payment system
under which physicians and other health care providers receive a
payment
that does not exceed their billed charge for each unit of service
provided.cralaw:red
m) Global
Budget - An approach to the purchase of medical services by which
health
care provider negotiation concerning the costs of providing a specific
package of medical benefits is based solely on a predetermined and
fixed
budget.cralaw:red
n) Government
Service Insurance System - The Government Service Insurance System
created under Commonwealth Act No. 186, as amended.cralaw:red
o) Health
Care Provider - Refers to:
1)
a
health care institution, which is duly licensed and accredited and
devoted
primarily to the maintenance and operation of facilities for health
promotion,
prevention, diagnosis, treatment, and care of individuals suffering
from
illness, disease, injury, disability or deformity, or in need of
obstretical
or other medical and nursing care. It shall also be construed as any
institution,
building, or place where there are installed beds, cribs, or bassinets
for twenty-four hour use or longer by patients in the treatment of
diseases,
injuries, deformities, or abnormal physical and mental states,
maternity
cases or sanitarial care; or infirmaries, nurseries, dispensaries, and
such other similar names by which they may be designated; or
2) a
health
care professional, who is any doctor of medicine, nurse, midwife,
dentist,
or other health care professional or practitioner duly licensed to
practice
in the Philippines and accredited by the Corporation; or
3) a
health
maintenance organization, which is an entity that provides, offers, or
arranges for coverage of designated health services needed by plan
members
for a fixed prepaid premium; or
4) a
community-based
health care organization, which is an association of indigenous members
of the community organized for the purpose of improving the health
status
of that community through preventive, promotive and curative health
services. p) Health
Insurance Identification (ID) Card - The document issued by the
Corporation
to members and dependents upon their enrollment to serve as the
instrument
for proper identification, eligibility verification, and utilization
recording.
q) Indigent
- A person who has no visible means of income, or whose income is
insufficient
for the subsistence of his family, as identified by the Local Health
Insurance
Office and based on specific criteria set by the Corporation in
accordance
with the guiding principles set forth in Article I of this Act.cralaw:red
r) Inpatient
Education Package - A set of informational services made available
to an individual who is confined in a hospital to afford him with
knowledge
about his illness and its treatment, and of the means available,
particularly
lifestyle changes, to prevent the recurrence or aggravation of such
illness
and to promote his health in general.cralaw:red
s) Member
- Any person whose premiums have been regularly paid to the National
Health
Insurance Program. He may be a paying member, an indigent member, or a
pensioner/retiree member.cralaw:red
t) Means
Test - A protocol administered at the barangay level to determine
the
ability of individuals or households to pay varying levels of
contributions
to the Program, ranging from the indigent in the community whose
contributions
should be totally subsidized by government, to those who can afford to
subsidize part but not all of the required contributions for the
Program.cralaw:red
u) Medicare
- The health insurance program currently being implemented by the
Philippine
Medical Care Commission. It consists of:
1) Program
I, which covers members of the SSS and GSIS, including their legal
dependents; and
2)
Program
II, which is intended for those not covered under Program I.
v) National
Health Insurance Program - The compulsory health insurance program
of the government as established in this Act, which shall provide
universal
health insurance coverage and ensure affordable, acceptable, available
and accessible health care services for all citizens of the Philippines.
w) Pensioner
- An SSS or GSIS member who receives pensions therefrom.cralaw:red
x) Personal
Health Services - Health services in which benefits accrue to the
individual
person. These are categorized into in-patient and out-patient services.cralaw:red
y) Philippine
Medical Care Commission - The Philippine Medical Care Commission
created
under Republic Act No. 6111, as amended.cralaw:red
z) Philippine
National Drug Formulary - The essential drugs list for the
Philippines
which is prepared by the National Drug Committee of the Department of
Health
in consultations with experts and specialists from organized
professional
medical societies, medical academe and pharmaceutical industry, and
which
is updated every year.cralaw:red
aa) Portability
- The enablement of a member to avail of Program benefits in an
area
outside the jurisdiction of his Local Health Insurance Office.cralaw:red
bb) Prescription
Drug - A drug which has been approved by the Bureau of Food and
Drugs
and which can be dispensed only pursuant to a prescription order from a
physician who is duly licensed to do so.cralaw:red
cc) Public
Health Services - Services that strengthen preventive and promotive
health care through improving conditions in partnership with the
community
at large. These include control of communicable and non-communicable
diseases,
health promotion, public information and education, water and
sanitation,
environmental protection, and health related data collection,
surveillance,
and outcome monitoring.cralaw:red
dd) Quality
Assurance - A formal set of activities to review and ensure the
quality
of services provided. Quality assurance includes quality assessment and
corrective actions to remedy any beneficiaries identified in the
quality
of direct patient, administrative, and support services.cralaw:red
ee) Residence
- The place where the member actually lives.cralaw:red
ff) Retiree
- A member of the Program who has reached the age of retirement or who
has retired on account of disability.cralaw:red
gg) Self-employed
- a person who works for himself and is, therefore, both employee and
employer
at the same time.cralaw:red
hh) Social
Security System - The Social Security System created under
Republic
Act No. 1161, as amended.cralaw:red
ii) Treatment
Procedure - Any method used to remove the symptoms and cause of a
disease.cralaw:red
jj) Utilization
Review - A formal review of patient utilization or of the
appropriateness
of health care services, on a prospective, concurrent or retrospective
basis.
ARTICLE
IIITHE
NATIONAL HEALTH INSURANCE PROGRAM
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
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 of 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 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.cralaw:red
SEC.
6. Coverage. - All citizens of the Philippines shall be
covered by the National Health Insurance Program. In accordance with
the
principles of universality and compulsory coverage enunciated in
Section
2 (b) and 2 (1) hereof, implementation of the Program shall,
furthermore,
be gradual and phased in over a period of not more than fifteen (15)
years:
Provided, That the Program shall not be made compulsory in
certain
provinces and cities until the Corporation shall be able to ensure that
members in such localities shall have reasonable access to adequate and
acceptable health care services.cralaw:red
SEC.
7. Enrollment. - The Program shall enroll beneficiaries
in order for them to be placed under coverage that entitles them to
avail
of benefits with the assistance of the financial arrangements provided
by the Program. The process of enrollment shall include the
identification
of beneficiaries, issuance of appropriate documentation specifying
eligibility
to benefits, and indicating how membership was obtained or is being
maintained.
The enrollment shall proceed in accordance with these specific policies:
a) all
persons currently eligible fro benefits under Medicare Program I,
including
SSS and GSIS members, retirees, pensioners and their dependents, shall
immediately and automatically be made members of the National Health
Insurance
Program;
b) all
persons eligible for benefits through health insurance plans
established
by local governments as part of Program II of Medicare or in accordance
with the provisions of this Act, including indigent members, shall also
be enrolled in the Program;
c) all
persons eligible for benefits as members of local health insurance
plans
established by the Corporation in accordance with the implementing
rules
and regulations of this Act shall also be deemed to have enrolled in
the
Program. Enrollment of persons who have no current health insurance
coverage
shall be given priority by the Corporation; and
d) all
persons eligible for benefits as members of other government-initiated
health insurance programs, community-based health care organizations,
cooperatives,
or private non-profit health insurance plans shall be enrolled in the
Program
upon accreditation by the Corporation which shall devise and provide
incentives
to ensure that such accredited organizations will benefit from their
participation
in the program.cralaw:red
All indigents
not enrolled in the Program shall have priority in the use and
availment
of the services and facilities of government hospitals, health care
personnel,
and other health organizations: Provided, however, That such
government
health care providers shall ensure that said indigents shall
subsequently
be enrolled in the Program.cralaw:red
SEC.
8. Health Insurance ID Card - In conjunction with the
enrollment
provided above, the Corporation through its local office shall issue a
health insurance ID which shall be used for purposes of identification,
eligibility verification, and utilization recording. The issuance of
this
ID card shall be accompanied by a clear explanation to the enrollee of
his rights, privileges and obligations as a member. A list of health
care
providers accredited by the Local Health Insurance Office shall
likewise
be attached thereto.cralaw:red
SEC.
9. Change of Residence. - A citizen can be under only
one
Local Health Insurance Office which shall be located in the province or
city of his place of residence. A person who changes residence, becomes
temporarily employed, or for other justifiable reasons, is transferred
to another locality, should inform said Office of such transfer and
subsequently
transfer his Program membership.cralaw:red
SEC.
10. Benefit Package. - Subject to the limitations
specified
in this Act and as may be determined by the Corporation, the following
categories of personal health services granted to the member or his
dependents
as medically necessary or appropriate, shall include:
a) Inpatient
hospital care:
1)
room
and board;
2)
services
of health care professionals;
3)
diagnostic,
laboratory, and other medical examination services;
4)
use
of surgical or medical equipment and facilities;
5)
prescription
drugs and biologicals; subject to the limitations stated in Section 37
of this Act;
6)
inpatient
education packages; b) Outpatient
care:
1)
services
of health care professionals;
2)
diagnostic,
laboratory, and other medical examination services;
3)
personal
preventive services; and
4)
prescription
drugs and biologicals, subject to the limitations described in Section
37 of this Act; c) Emergency
and transfer services; and
d) Such
other health care services that the Corporation shall determine to be
appropriate
and cost-effective: Provided, That the Program, during its
initial
phase of implementation, which shall not be more than five (5) years,
shall
provide a basic minimum package of benefits which shall be defined
according
to the following guidelines:
1) the
cost of providing said packages is such that the available national and
local government subsidies for premium payments of indigents are
sufficient
to extend coverage to the widest possible population.cralaw:red
2) the
initial set of services shall not be less than half of those provided
under
the current Medicare Program I in terms of overall average cost of
claims
paid per beneficiary household per year.cralaw:red
3) the
services included are prioritized, first, according to its
cost-effectiveness
and, second, according to its potential of providing maximum
relief
from the financial burden on the beneficiary: Provided, That,
in
addition to the basic minimum package, the Program shall provide
supplemental
health benefit coverage to beneficiaries of contributory funds, taking
into consideration the availability of funds for the purpose from said
contributory funds: Provided, further, That the Program
progressively
expand the basic minimum benefit package as the proportion of the
population
covered reaches targeted milestone so that the same benefits are
extended
to all members of the Program within five (5) years after the
implementation
of this Act. Such expansion will provide for the gradual incorporation
of supplementary health benefits previously extended only to some
beneficiaries
into the basic minimum package extended to all beneficiaries: and Provided,
finally, That in the phased implementation of this Act, there
should
be no reduction or interruption in the benefits currently enjoyed by
present
members of Medicare.cralaw:red
SEC.
11. Excluded Personal Health Service. - The benefits
granted
under this Act shall not cover expenses for the services enumerated
hereunder
except when the Corporation, after actuarial studies, recommend their
inclusion
subject to the approval of the Board:
a)
non-prescription
drugs and devices;
b)
out-patient
psychotherapy and counseling for mental disorders;
c)
drug
and alcohol abuse or dependency treatment;
d)
cosmetic
surgery;
e)
home
and rehabilitation services;
f)
optometric
services;
g)
normal
obstetrical delivery; and
h)
cost
ineffective procedures which shall be defined by the Corporation. SEC.
12. Entitlement to Benefits. - A member whose premium
contributions
for at least three (3) months have been paid within six (6) months
prior
to the first day of his or his availment, shall be entitled to the
benefits
of the Program: Provided, That such member can show that he
contributes
thereto with sufficient regularity, as evidenced in his health
insurance
ID card: and Provided, further, That he is not currently
subject
to legal penalties as provided for in Section 44 of this Act.
The following
need not pay the monthly contributions to be entitled to the Program’s
benefits:
a) Retirees
and pensioners of the SSS and GSIS prior to the effectivity of this Act;
b)
Members
who reach the age of retirement as provided for by law and have paid at
least one hundred twenty (120) contributions; andc)
Enrolled
indigents.
SEC.
13. Portability of Benefits. - The Corporation shall
develop
and enforce mechanisms and procedures to assure that benefits are
portable
across Offices.
ARTICLE
IVTHE
PHILIPPINE HEALTH INSURANCE CORPORATION
SEC.
14. Creation and Nature of the Corporation. - There is
hereby
created a Philippine Health Insurance Corporation, which shall have the
status of a tax-exempt government corporation attached to the
Department
of Health for policy coordination and guidance.cralaw:red
SEC.
15. Exemptions from Taxes and Duties. - The
Corporation
shall be exempt from the payment of taxes on all contributions thereto
and all accruals on its income or investment earnings.cralaw:red
Any donation,
contribution, bequest, subsidy or financial aid which may be made to
the
Corporation shall constitute as allowable deduction from the income of
the donor for income tax purposes and shall be exempt from donor’s tax,
subject to such conditions as provided in the National Internal Revenue
Code, as amended.cralaw:red
SEC.
16. Powers and Functions. - The Corporation shall have
the
following powers and functions:
a)
to
administer the National Health Insurance Program;
b)
to
formulate and promulgate policies for the sound administration of the
Program;
c)
to
set standards, rules and regulations necessary to ensure quality of
care,
appropriate utilization of services, fund viability, member
satisfaction,
and over-all accomplishment of Program objectives;
d)
to
formulate and implement guidelines on contributions and benefits;
portability
of benefits, cost containment and quality assurance; and health care
provider
arrangements, payment methods, and referral systems;
e)
to
establish branch offices as mandated in Article V of this Act;
f)
to
receive and manage grants, donations, and other forms of assistance;
g)
to
sue and be sued in court;
h)
to
acquire property, real and personal, which may be necessary or
expedient
for the attainment of the purposes of this Act;
i)
to
collect, deposit, invest, administer, and disburse the National Health
Insurance Fund in accordance with the provisions of this Act;
j)
to
negotiate and enter into contracts with health care institutions,
professionals,
and other persons, juridical or natural, regarding pricing, payment
mechanisms,
design and implementation of administrative and operating systems and
procedures,
financing, and delivery of health services;
k)
to
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 maintenance organizations, cooperatives and
medical
foundations, for the provision of at least the minimum package of
personal
health services prescribed by the Corporation;
l)
to
determine requirements and issue guidelines for the accreditation of
health
care providers for the Program in accordance with this Act.;
m)
to
supervise the provision of health benefits with the power to inspect
medical
and financial records of health care providers and patients who are
participants
in or members of the Program, the power to enter and inspect accredited
health care institutions, subject to the rules and regulations to be
promulgated
by the Corporation;
n)
to
organize its office, fix the compensation of and appoint personnel as
may
be deemed necessary and upon the recommendation of the president of the
Corporation;
o)
to
submit to the President of the Philippines and to both Houses of
Congress
its Annual Report which shall contain the status of the National Health
Insurance Fund, its total disbursements, reserves, average costings to
beneficiaries, any request for additional appropriation, and other data
pertinent to the implementation of the Program and publish a synopsis
of
such report in two (2) newspapers of general circulation;
p)
to
keep records of the operation of the Corporation and investments of the
National Health Insurance Fund; and
q)
to
perform such other acts as it may deem appropriate for the attainment
of
the objectives of the Corporation and for the proper enforcement of the
provisions of this Act. SEC.
17. Quasi-Judicial Powers.- The Corporation, to carry
out
its tasks more effectively, shall be vested with the following powers:
a) to
conduct investigations for the determination of a question,
controversy,
complaint, or unresolved grievance brought to its attention, and render
decisions, orders, or resolutions thereon. It shall proceed to hear and
determine the case even in the absence of any party who has been
properly
served with notice to appear. It shall conduct its proceedings or any
part
thereof in public or in executive session; adjourn its hearings to any
time and place; refer technical matters or accounts to an expert and to
accept his reports as evidence; direct parties to be joined in or
excluded
from the proceedings; and give all such directions as it may deem
necessary
or expedient in the determination of the dispute before it;
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;
c) to
suspend temporarily, revoke permanently, or restore the accreditation
of
a health care provider or the right to benefits of a member and/or
impose
fines after due notice and hearing. The decision shall immediately be
executory,
even pending appeal, when the public interest so requires and as may be
provided for in the implementing rules and regulations. Suspension of
accreditation
shall not exceed twenty-four (24) months. Suspension of the rights of
the
members shall not exceed six (6) months.cralaw:red
The revocation
of a health care provider’s accreditation shall operate to disqualify
him
from obtaining another accreditation in his own name, under a different
name, or through another person, whether natural or juridical.cralaw:red
The Corporation
shall not be bound by the technical rules of evidence.cralaw:red
SEC.
18. The Board of Directors. - (a) Composition -
The
Corporation shall be governed by a Board of Directors hereinafter
referred
to as the Board, composed of eleven members as follows:
The Secretary
of Health;
The Secretary
of Labor and Employment or his representative;
The Secretary
of Interior and Local Government or his representative;
The Secretary
of Social Welfare and Development or his representative;
The President
of the Corporation;
A representative
of the labor sector;
A representative
of employers;
The SSS
Administrator or his representative;
The GSIS
General Manager or his representative;
A representative
of the self-employed sector; and
A representative
of health care providers.cralaw:red
The Secretary
of Health shall be the ex-officio Chairperson while the
President
of the Corporation shall be the Vice-Chairperson of the Board.cralaw:red
(b) Appointment
and Tenure - The President of the Philippines shall appoint the
Members
of the Board upon the recommendation of the Chairman of the Board and
in
consultation with the sectors concerned. Members of the Board shall
have
a term of four (4) years each, renewable for a maximum of two (2)
years,
except for members whose terms shall be co-terminous with their
respective
positions in government. Any vacancy in the Board shall be filled in
the
manner in which the original appointment was made and the appointee
shall
serve only the unexpired term of his predecessor.cralaw:red
(c) Meetings
and Quorum - The Board shall hold regular meetings at least once a
month. Special meetings may be convened at the call of the Chairperson
or by a majority of the members of the Board. The presence of six (6)
voting
members shall constitute a quorum. In the absence of the Chairperson
and
Vice-Chairperson, a temporary presiding officer shall be designated by
the majority of the quorum.cralaw:red
(d) Allowance
and Per Diems - The members of the Board shall receive a per
diem
for every meeting actually attended subject to the pertinent budgetary
laws, rules and regulations on compensation, honoraria and allowances.cralaw:red
SEC.
19. The President of the Corporation. - (a) Appointment
and Tenure - The President of the Philippines shall appoint for
non-renewable
term of six (6) years, the President of the Corporation, hereinafter
referred
to as the President, upon the recommendation of the Board. The
President
shall not be removed from office except in accordance with existing
laws.cralaw:red
(b) Duties
and Functions - The President shall have the duty of advising the
Board
and carrying into effect its policies and decisions. His functions are
as follows:
1)
to
act as the chief executive officer of the Corporation; and
2)
to
be responsible for the general conduct of the operations and management
functions of the Corporation and for other duties assigned to him by
the
Board. (c) Qualifications
- The President must be a Filipino citizen and must possess adequate
and
appropriate training and at least five (5) years experience in the
field
of health care financing and corporate management.
(d) Salary
- The President shall receive a salary to be fixed by the Board, with
the
approval of the President of the Philippines, payable from the funds of
the Corporation.cralaw:red
(e) Prohibition
- To avoid conflict of interest, the President must not be involved in
any health care institution as owner or member of its board.cralaw:red
SEC.
20. Health Finance Policy Research. - Among the staff
departments
that will be established by the Corporation shall be the Health Finance
Policy Research Department, which shall have the following duties and
functions:
a) development
of broad conceptual framework for implementation of the Program through
a national health finance master plan to ensure sustained investments
in
health care, and to provide guidance for additional appropriations from
the National Government;
b)
conduct
of researches and studies toward the development of policies necessary
to ensure the viability, adequacy and responsiveness of the Program;
c)
review,
evaluation, and assessment of the Program’s impact on the access to, as
well as the quality and cost of, health care in the country;
d)
periodic
review of fees, charges, compensation rates, capitation rates, medical
standards, health outcomes and satisfaction of members, benefits, and
other
matters pertinent to the operations of the Program;
e)
comparison
in the delivery, quality, use, and cost of health care services of the
different Offices;
f)
submission
for consideration of program of quality assurance, utilization review,
and technology assessment; and
g)
submission
of recommendations on policy and operational issues that will help the
Corporation meet the objectives of this Act. SEC.
21. Actuary of the Corporation. - An Office of Actuary
shall
be created within the Corporation to conduct the necessary actuarial
studies
and present recommendations on insurance premium, investments and other
related matters.
ARTICLE
VLOCAL
HEALTH INSURANCE OFFICE
SEC.
22. Establishment. - The Corporation shall establish a
Local
Health Insurance Office, hereinafter referred to as the Office, in
every
province or chartered city, or wherever it is deemed practicable, to
bring
its services closer to members of the Program. However, one office may
serve the needs of more than one province or city when the merged
operations
will result in lower administrative cost and greater cross-subsidy
between
rich and poor localities.cralaw:red
Provinces
and cities where prospective members are organized shall receive
priority
in the establishment of local health insurance offices.cralaw:red
SEC.
23. Functions. - Each Office shall have the following
powers
and functions:
a)
to
consult and coordinate, as needed, with the local government units
within
its jurisdiction in the implementation of the Program;
b)
to
recruit and register members of the Program from all areas within its
jurisdiction;
c)
to
collect and receive premiums and other payment contributions to the
Program;
d)
to
maintain and update the membership eligibility list at community levels;
e)
to
supervise the conduct of means testing which shall be based on the
criteria
set by the Corporation and undertaken by the Barangay Captain in
coordination
with the social welfare officer and community-based health care
organizations
to determine the economic status of all households and individuals,
including
those who are indigent;
f)
to
issue health insurance ID cards to persons whose premiums have been
paid
according to the requirements of the Office and the guidelines issued
by
the Board;
g)
to
recommend to the Board premium schedules that provide for lower rates
to
be paid by the members whose dependents include those with reduced
probability
of utilization, as in fully immunized children;
h)
to
recommend to the Board a contribution schedule which specifies
contribution
levels by the individuals and households, and a corresponding uniform
package
of personal health service benefits which is at least equal to the
minimum
package of such benefits prescribed by the Board as applying to the
nation;
i)
to
grant and deny accreditation to health care providers in their area of
jurisdiction, subject to the rules and regulations to be issued by the
Board;
j)
to
process, review and pay the claims of providers, within a period not
exceeding
sixty (60) days, whenever applicable in accordance with the rules and
guidelines
of the Corporation;
k)
to
pay fees, as necessary, for claims review and processing when such are
conducted by the central office of the Corporation or by any of its
contractors;
l)
to
establish referral systems and network arrangements with other Offices,
as may be necessary, and following the guidelines set by the
Corporation;
m)
to
establish mechanisms by which private and public sector health
facilities
and human resources may be shared in the interest of optimizing the use
of health resources;
n)
to
support the management information system requirements of the
Corporation;
o)
to
serve as the first level for appeals and grievance cases;
p)
to
tap community-based volunteer health workers and barangay officials, if
necessary, for member recruitment, premium collection and similar
activities,
and to grant such workers incentives according to the guidelines set by
the Corporation and in accordance with the applicable laws. However,
the
incentives for the barangay officials shall accrue to the barangay and
not to the said officials;
q)
to
participate in information and education activities that are consistent
with the government’s priority programs on disease prevention and
health
promotion; and
r)
to
prepare an annual report according to the guidelines set by the Board
and
to submit the same to the central office of the Corporation.
ARTICLE
VITHE
NATIONAL HEALTH INSURANCE FUND
SEC.
24. Creation of the National Health Insurance Fund. -
There
is hereby created a National Health Insurance Fund, hereinafter
referred
to as the Fund, that shall consist of:
a)
contributions
from Program members;
b)
current
balances of the Health Insurance Fund of the SSS and 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;
c)
other
appropriations earmarked by the national and local governments
purposely
for the implementation of the Program;
d)
subsequent
appropriations provided for under Sections 46 and 47 of this Act;
e)
donations
and grants-in-aid; and
f)
all
accruals thereof. SEC.
25. Components of the National Health Insurance Fund. -
The National Health Insurance Fund shall have the following components:
a) The
Basic Benefit Fund. - This Fund shall finance the availment of the
basic minimum benefit package by eligible beneficiaries. All
liabilities
associated with the extension of entitlement to the basic minimum
benefit
package to the enrolled population shall be borne by the basic benefit
fund. It shall be constituted and maintained through the following
process:
1)
upon
the determination of the amount of government subsidies and donations
available
for paying fully or partially the premium of indigent beneficiaries, a
basic minimum package affordable for enrolling as many of the indigent
beneficiaries as possible shall be defined. The government subsidies
will
then be constituted as premium payments for enrolled indigents and
contributed
into the basic benefit fund.
2)
for
extending coverage of this same minimum benefit package to
non-indigents
who are not members of Medicare, premium prices for specific population
shall be actuarially determined based on variations in risk, capacity
to
pay, and projected costs of services utilized. The amounts
corresponding
to the premium required, including costs of direct benefit payments,
all
costs of administration, and provision of adequate reserves, for
extending
the coverage of the basic minimum benefit package for such population
groups
shall be contributed into the basic benefit fund.
3)
for
the population enrolled through Medicare Program I under SSS, the
corresponding
premium for the basic minimum benefit package, including costs of
direct
benefit payments, all costs of administration, and provision of
adequate
reserves, shall be charged to the health insurance fund of the SSS and
paid into the basic benefit fund.
4)
for
the population enrolled through Medicare Program I under GSIS, the
corresponding
premium for the basic minimum benefit package, including costs of
direct
benefit payments, all costs of administration, and provision of
adequate
reserves, shall be charged to the health insurance fund of the GSIS and
paid into the basic benefit fund.
5)
for
groups enrolled through any of the existing or future health insurance
schemes and plans, including those created under Medicare Program II
and
those organized by local government units, national agencies,
cooperatives,
and other similar organizations, the corresponding premium, including
costs
of direct benefit payments, all costs of administration, and provision
of adequate reserves, for extending the basic minimum benefit package
to
their respective enrollees will be charged to their respective funds
and
paid into the basic benefit fund. b) Supplementary
Benefit Funds. These are separate and distinct supplementary
benefit
funds created by the Corporation as eligible for use to provide
supplementary
coverage to various groups of the population enjoying the basic benefit
coverage as are affordable by their respective funding sources. Each
supplementary
benefit fund shall finance the extension and availment of additional
benefits
not included in the basic minimum benefit package but approved by the
Board.
Such supplementary benefits shall be financed by whatever amounts are
available
after deducting the costs of providing the basic minimum benefit
package,
including costs of direct benefit payments, all costs of
administration,
and provision of adequate reserves. All liabilities associated with the
extension of supplementary benefits to the defined group of enrollees
shall
be borne exclusively by the respective supplementary benefit funds.
Upon
the implementation of this Act, the following supplementary benefit
funds
shall be established:
1)
supplementary
benefit fund for SSS-Medicare members and beneficiaries. After
deducting
the amount corresponding to the premium of the basic minimum benefit
package,
the balance of the SSS-Health Insurance Fund (HIF) shall be constituted
into a supplementary benefit fund to finance the extension of benefits
in addition to the minimum basic package to SSS members and
beneficiaries;
and
2)
supplementary
benefit fund for GSIS-Medicare members and beneficiaries. After
deducting
the amount corresponding to the premium for the basic minimum benefit
package,
the balance of the GSIS-HIF plus the arrearages of the Government of
the
Philippines with the GSIS for the said HIF shall be constituted into a
supplementary benefit fund to finance the extension of benefits in
addition
to the minimum basic package to GSIS members and beneficiaries. In
accordance
with the principles of equity and social solidarity, as enunciated in
Section
2 of this Act, the above supplementary benefit funds shall be
maintained
for not more than five (5) years, after which, such funds shall be
merged
into the basic benefit fund.
SEC.
26. Financial Management. - The use, disposition,
investment,
disbursement, administration and management of the National Health
Insurance
Fund, including any subsidy, grant or donation received for program
operations
shall be governed by resolution of the Board of Directors of the
Corporation,
subject to the following limitations:
a) All
funds under the management and control of the Corporation shall be
subject
to all rules and regulations applicable to public funds.cralaw:red
b) The
Corporation is authorized to charge the various funds under its control
for the costs of administering the Program. Such costs may include
administration,
monitoring, marketing and promotion, research and development, audit
and
evaluation, information services, and other necessary activities for
the
effective management of the Program. The total annual costs for these
shall
not exceed twelve percent (12%) of the total contributions, including
government
contributions to the Program and not more than three percent (3%) of
the
investment earnings collected during the immediately preceding year.cralaw:red
SEC.
27.chanrobles virtual law libraryReserve
Funds. - The Corporation shall set aside a portion of its
accumulated
revenues not needed to meet the cost of the current year’s expenditures
as reserve funds: Provided, That the total amount of reserves
shall
not exceed a ceiling equivalent to the amount actuarially estimated for
two years’ projected Program expenditures: Provided, further, That
whenever actual reserves exceed the required ceiling at the end of the
Corporation’s fiscal year, the Program’s benefits shall be increased or
member-contributions decreased prospectively in order to adjust
expenditures
or revenues to meet the required ceiling for reserve 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" which shall be invested in any or all of the
following:
a)
In
interest-bearing bonds, securities or other evidences of indebtedness
of
the Government of the Philippines, or in bonds, securities, promissory
notes and other evidences of indebtedness to which full faith and
credit
and unconditional guarantee of the Republic of the Philippines is
pledged;
b)
In
interest-bearing deposits and loans to or securities in any domestic
bank
doing business in the Philippines: Provided, That in the case
of
such deposits, this shall not exceed at any time the unimpaired capital
and surplus or total private deposits of the depository bank, whichever
is smaller: Provided, further, That said bank shall first have
been
designated as a depository for this purpose by the Monetary Board of
the
Bangko Sentral ng Pilipinas; and
c)
In
preferred stocks of any solvent corporation or institution created or
existing
under the laws of the Philippines: Provided, That the issuing,
assuming,
or guaranteeing entity or its predecessor has paid regular dividends
upon
its preferred or guaranteed stocks for a period of at least three (3)
years
immediately preceding the date of investment in such preferred
guaranteed
stocks: Provided, further, That if the corporation or
institution
has not paid dividends upon its preferred stocks, the corporation or
institution
has sufficient retained earnings to declare dividends for at least two
(2) years on such preferred stocks and in common stocks option or
warrants
to common stocks of any solvent corporation or institution created or
existing
under the laws of the Philippines in the stock exchange with proven
track
record of profitability and payment of dividends over the last three
(3)
years or in common stocks of a newly organized corporation about to be
listed in the stock exchange: Provided, finally, That such duly
organized corporations shall have been rated "A", double "A’s"
or triple "A’s" by authorized accredited domestic rating
agencies
or by the Corporation or in mutual funds including allied investments.
ARTICLE
VIIFINANCING
SEC.
28. Contributions. - All members of the Program shall
contribute
to the Fund, in accordance with a reasonable, equitable and progressive
contribution schedule to be determined by the Corporation on the basis
of applicable actuarial studies and in accordance with the following
guidelines:
a)
Formal
sector employees and current Medicare members and their employers shall
continue paying the same monthly contributions as provided for by law
until
such time that the Corporation shall have determined the contribution
schedule
mentioned herein: Provided, That their monthly contribution
shall
not exceed three percent of their respective monthly salaries.
b)
Contributions
from self-employed members shall be based primarily on household
earnings
and assets; their total contributions for one year shall not, however,
exceed three percent (3%) of their estimated actual net income for the
preceding year.
c)
Contributions
made in behalf of indigent members shall not exceed the minimum
contributions
set for employed members. SEC.
29. Payment for Indigent Contributions. - Contributions
for indigent members shall be subsidized partially by the local
government
unit where the member resides. The Corporation shall provide
counterpart
financing equal to the LGU’s subsidy for indigents: Provided, That
in the case of fourth, fifth and sixth class LGU’s, the National
Government
shall provide up to ninety percent (90%) of the subsidy for indigents
for
a period not exceeding five (5) years. The share of the LGU’s shall be
progressively increased until such time that its share becomes equal to
that of the National Government.
ARTICLE
VIIIHEALTH
CARE PROVIDERS
SEC.
30. Free Choice of Health Facility, Medical or Dental
Practitioner.
- 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 on the appropriateness of treatment in the facility chosen
or
by the desired provider.cralaw:red
SEC.
31. Authority to Grant Accreditation. - The Corporation
shall have the authority to grant to health care providers
accreditation
which confers the privilege of participating in the Program.cralaw:red
SEC.
32. Accreditation Eligibility. - All health care
providers,
as enumerated in Sec. 4(o) hereof and operating for at least three (3)
years, may apply for accreditation.cralaw:red
SEC.
33. Minimum Requirements for Accreditation. - The
minimum
accreditation requirements for health care providers are as follows:
a)
human
resource, equipment and physical structure in conformity with the
standards
of the relevant facility, as determined by the Department of Health;
b)
acceptance
of formal program of quality assurance and utilization review;
c)
acceptance
of the payment mechanisms specified in the following section;
d)
adoption
of referral protocols and health resources sharing arrangements;
e)
recognition
of the rights of the patients; and
f)
acceptance
of information system requirements and regular transfer of information. SEC.
34. Provider Payment Mechanisms. - 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;
b)
Capitation
of health care professionals and facilities, or network of the same,
including
HMOs, medical cooperatives, and other legally formed health service
groups;
c) A
combination
of both; and
d)
Any
or all of the above, subject to global budget. Each
Office
shall recommend the appropriate payment mechanism within its
jurisdiction
for approval by the Corporation. Special consideration shall be given
to
payment for services rendered by public and private health care
providers
serving remote or medically underserved areas.
SEC.
35. Fee-for-service Payments and Payments in General. -
Fee-for-service payments may be made separately for professional fees
and
hospital charges, or both, based on arrangements with health care
providers.
This fee shall be based on a schedule to be established by the Board
which
shall be reviewed every three (3) years. Fees paid for professional
services
rendered by salaried public providers shall be allowed and be pooled
and
distributed among health personnel. Charges paid to public facilities
shall
be allowed to be retained by the individual facility in which services
were rendered and for which payment was made. Such revenues shall be
used
to defray operating costs other than salaries, to maintain or upgrade
equipment,
plant or facility, and to maintain or improve the quality of service in
the public sector.cralaw:red
SEC.
36. Capitation Payments. - Capitation payments may be
paid
to public or private providers according to rates of capitation
payments
based on annual capitation rate guidelines to be issued by the
Corporation.cralaw:red
SEC.
37. Quality Assurance. - Under the guidelines provided
by
the Corporation and in collaboration with their respective Offices,
health
care providers shall take part in programs of quality assurance,
utilization
review, and technology assessment that have the following objectives:
a)
to
ensure that the quality of personal health services delivered, measured
in terms of inputs, process, and outcomes, are of reasonable quality in
the context of the Philippines over time;
b)
to
ensure that the health care standards are uniform within the Office’s
jurisdiction
and eventually throughout the nation; and
c)
to
see to it that the acquisition and use of scarce and expensive medical
technologies and equipment are consistent with actual needs and
standards
of medical practice, and that:
1)
the
performance of medical procedures and the administration of drugs are
appropriate,
necessary and unquestionably consistent with accepted standards of
medical
practice and ethics. Drugs for which payments will be made shall be
those
included in the Philippine National Drug Formulary, unless explicit
exception
is granted by the Corporation.
2)
the
performance of medical procedures and the administration of drugs are
appropriate,
consistent with accepted standards of medical practice and ethics, and
respectful of the local culture. SEC.
38. Safeguards Against Over and Under Utilization. - It
is incumbent upon the Corporation to set up a monitoring mechanism to
be
operationalized through a contract with health care providers to ensure
that there are safeguards against:
a)
over-utilization
of services;
b)
unnecessary
diagnostic and therapeutic procedures and intervention;
c)
irrational
medication and prescriptions;
d)
under-utilization
of services; and
e)
inappropriate
referral practices. The
Corporation
may deny or reduce the payment for claims when such claims are attended
by false or incorrect information and when the claimant fails, without
justifiable cause, to comply with the rules and regulations of this Act.
ARTICLE
IXGRIEVANCE
AND APPEAL
SEC.
39. Grievance System. - A system of grievance is hereby
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 in accordance with
the
provisions of this Article.cralaw:red
SEC.
40.chanrobles virtual law libraryGrounds
for Grievances. - The following acts shall constitute valid grounds
for grievance action:
a)
any
violation of the rights of the patients;
b) a
willful
neglect of duties of Program implementors that results in the loss or
non-enjoyment
of benefits of members or their dependents;
c)
unjustifiable
delay in actions on claims;
d)
delay
in 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. SEC.
41. Grievance and Appeal Procedures. - A member, his
dependent,
or a health care provider, may file a complaint for grievance based on
any of the above grounds, in accordance with the following procedures:
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.
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.
c)
The
Offices shall have no jurisdiction over any issue involving the
suspension
or revocation of accreditation, the imposition of fines, or the
imposition
of charges on members or their dependents in case of revocation of
their
entitlement.
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. SEC.
42. Grievance and Appeal Review Committee. - The Board
shall
create a Grievance Appeal Review Committee, composed of three (3) to
five
(5) members, hereinafter referred to as the Committee, which, subject
to
the procedures enumerated above, shall receive and recommend
appropriate
action on complaints from members and health care providers relative to
this Act and its implementing rules and regulations.
SEC.
43. Hearing Procedures of the Committee. - Upon the
filing
of the complaint, the Grievance and Appeal Review Committee, from a
consideration
of the allegations thereof, may dismiss the case outright due to lack
of
verification, failure to state the cause of action, or any valid ground
for the dismissal of the complaint after consultation with the Board;
or
require the respondent to file a verified answer within five (5) days
from
service of summons.cralaw:red
Should
the defendant fail to answer the complaint within the reglementary
5-day
period herein provided, the Committee, motu proprio or upon
motion
of the complainant, shall render judgment as may be warranted by the
facts
alleged in the complaint and limited to what is prayed for therein.cralaw:red
After
an answer is filed and the issues are joined, the Committee shall
require
the parties to submit, within ten (10) days from receipt of the order,
the affidavits of witnesses and other evidence on the factual issues
defined
therein, together with a brief statement of their positions setting
forth
the law and the facts relied upon by them. In the event the Committee
finds,
upon consideration of the pleadings, the affidavits and other evidence,
and position statements submitted by the parties, that a judgment may
be
rendered thereon without need of formal hearing, it may proceed to
render
judgment not later than ten (10) days from the submission of the
position
statements of the parties.cralaw:red
In cases
where the Committee deems it necessary to hold a hearing to clarify
specific
factual matters before rendering judgment, it shall set the case for
hearing
for the purpose. At such hearing, witnesses whose affidavits were
previously
submitted may be asked clarificatory questions by the proponent and by
the Committee and may be cross-examined by the adverse party. The order
setting the case for hearing shall specify the witnesses who will be
called
to testify, and the matters on which their examination will deal. The
hearing
shall be terminated within fifteen (15) days, and the case decided by
the
Committee within fifteen (15) days from such termination.cralaw:red
The decision
of the Committee shall become final and executory fifteen (15) days
after
notice thereof: Provided, however, That it is appealable to the
Board by filing the appellant’s memorandum of appeal within fifteen
(15)
days from receipt of the copy of the judgment appealed from. The
appellee
shall be given fifteen (15) days from notice to file the appellee’s
memorandum
after which the Board shall decide the appeal within thirty (30) days
from
the submittal of the said pleadings.cralaw:red
The decision
of the Board shall also become final and executory fifteen (15) days
after
notice thereof: Provided, however, That it is reviewable by the
Supreme Court on purely questions of law in accordance with the Rules
of
Court.cralaw:red
The Committee
and the Board, in the exercise of their quasi-judicial function, as
specified
in Section 17 hereof, can administer oaths, certify to official acts
and
issue subpoena to compel the attendance and testimony of the
witnesses,
and subpoena duces tecum ad testificandum to enjoin the
production
of books, papers and other records and to testify therein on any
question
arising out of this Act. Any case of contumacy shall be dealt with in
accordance
with the provisions of the Revised Administrative Code and the Rules of
Court. The Board or the Committee, as the case may be, shall prescribe
the necessary administrative sanctions such as fines, warnings,
suspension
or revocation of the right to participate in the Program.cralaw:red
In all
its proceedings, the Committee and the Board shall not be bound by the
technical rules of evidence: Provided, however, That the Rules
of
Court shall apply with suppletory effect.
ARTICLE
XPENALTIES
SEC.
44. Penal Provisions. - Any violation of the provisions
of this Act, after due notice and hearing, shall suffer the following
penalties:
A fine
of not less than Ten thousand pesos (P10,000) nor more than Fifty
thousand
pesos (P50,000) in case the violation is committed by the hospital
management
or provider. In addition, its accreditation shall be suspended or
revoked
from three months to the whole term of the accreditation: Provided,
however, That recidivists may not anymore be accredited as a
participant
of the Program;
A fine
of not less than Five hundred pesos (P500) nor more than Five thousand
pesos (P5,000) and imprisonment of not less than six (6) months nor
more
than one (1) year in case the violation is committed by the member.cralaw:red
Where
the violations consist of failure or refusal to deduct contributions
from
the employee’s compensation or to remit the same to the Corporation,
the
penalty shall be a fine of not less than Five hundred pesos (P500) but
not more than One thousand pesos (P1,000) 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, further, That
in the case of self-employed members, 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).cralaw:red
Any employer
or any officer authorized to collect contributions under this Act who,
after collecting or deducting the monthly contributions from his
employee’s
compensation, 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 contributions and shall suffer the
penalties
provided for in Article 315 of the Revised Penal Code.cralaw:red
Any employer
who shall deduct directly or indirectly from the compensation of the
covered
employees or otherwise recover from them his own contribution on behalf
of such employees shall be punished by a fine not exceeding One
thousand
pesos (P1,000) multiplied by the total number of employees employed by
the firm, or imprisonment not exceeding one (1) year, or both fine and
imprisonment, at the discretion of the Court.cralaw:red
If the
act or omission penalized by this Act be 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 said act shall be liable for the penalties provided for in this
Act and other laws for the offense.cralaw:red
Any employee
of the Corporation who receives or keeps funds or property belonging,
payable
or deliverable to the Corporation, and who shall appropriate the same,
or shall take or misappropriate or shall consent, or through
abandonment
or negligence, shall permit any other person to take such property or
funds
wholly or partially, 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 (P10,000) nor more than Twenty thousand pesos (P20,000). Any
shortage
of the funds or loss of the property upon audit shall be deemed prima
facie evidence of the offense.cralaw:red
All other
violations involving funds of the Corporation shall be governed by the
applicable provisions of the Revised Penal Code or other laws, taking
into
consideration the rules on collection, remittances, and investment of
funds
as may be promulgated by the Corporation.
ARTICLE
XIAPPROPRIATIONS
SEC.
45. Initial Appropriation. - The unexpended portion of
the
budget of the Philippine Medical Care Commission (PMCC) for the year
during
which this Act was approved shall be utilized for establishing the
Corporation
and initiating its operations, including the formulation of the rules
and
regulation necessary for the implementation of this Act. In addition,
initial
funding shall come from any unappropriated but available fund of the
Government.cralaw:red
SEC.
46. Subsequent Appropriations. - Starting 1995 and
thereafter,
twenty-five percent (25%) of the increment in total revenue collected
under
Republic Act No. 7654 shall be appropriated in the General
Appropriations
Act solely for the National Health Insurance Fund.cralaw:red
In addition,
starting 1996 and thereafter, twenty-five percent (25%) of the
incremental
revenue from the increase in the documentary stamp taxes under Republic
Act No. 7660 shall likewise be appropriated solely for the said fund.cralaw:red
SEC.
47. Additional Appropriations. - The Corporation may
request
Congress to appropriate supplemental funding to meet targetted
milestones
of the Program in accordance with Section 10(d) of this Act.
ARTICLE
XIITRANSITORY
PROVISIONS
SEC.
48. Appointment of Board Members.- Within thirty (30)
days
from the date of effectivity of this Act, the President of the
Philippines
shall appoint the members of the Board and the President of the
Corporation.cralaw:red
SEC.
49. Implementing Rules and Regulations. - Within
thirty
(30) days from the completion of such appointments, the Board shall
convene
to formulate the rules and regulations necessary for the implementation
of this Act.cralaw:red
SEC.
50. Promulgation. - Within one year from its initial
meeting,
the Board shall promulgate the aforementioned rules and regulations in
at least two (2) national newspapers of general circulation. But until
such time that the Corporation shall have promulgated said rules and
regulations,
the existing rules and regulations of the PMCC shall be followed. The
present
Medicare Program shall continue to be so administered, until the
Corporation’s
Board deems the new system as ready for implementation in accordance
with
the provisions of this Act.cralaw:red
SEC.
51. Merger. - Within sixty (60) days from the
promulgation
of the implementing rules and regulations, all functions and assets of
the Philippine Medical Care Commission shall be merged with those of
the
Corporation without need of conveyance, transfer or assignment. The
PMCC
shall thereafter cease to exist.cralaw:red
The liabilities
of the PMCC shall be treated in accordance with the existing laws and
pertinent
rules and regulations.cralaw:red
To the
greatest extent possible and in accordance with existing laws, all
employees
of the PMCC shall be absorbed by the Corporation.cralaw:red
SEC.
52. Transfer of the Health Insurance Funds of the SSS and
GSIS.
- The Health Insurance Funds being administered by the SSS and GSIS
shall be transferred to the Corporation within sixty (60) days from the
promulgation of the implementing rules and regulations. The SSS and
GSIS
shall, however, continue to perform Medicare functions under contract
with
the Corporation until such time that such functions are assumed by the
Corporation, in accordance with the following Section.cralaw:red
SEC.
53. Transfer of the Medicare Functions of the SSS and GSIS.
- Within five (5) years from the promulgation of the implementing
rules
and regulations, the functions, assets, equipment, records, operating
system,
and liabilities, if any, of the Medicare operations of the SSS and GSIS
shall be transferred to the Corporation: Provided, however, That
the SSS and GSIS shall continue performing its Medicare functions
beyond
the stipulated five-year period if such extension will benefit Program
members, as determined by the Corporation.cralaw:red
Personnel
of the Medicare departments of the SSS and GSIS shall be given priority
in the hiring of the Corporation’s employees.
ARTICLE
XIIIMISCELLANEOUS
PROVISIONS
SEC.
54. Oversight Provision. - Congress shall conduct a
regular
review of the National Health Insurance Program which shall entail a
systematic
evaluation of the Program’s performance, impact or accomplishments with
respect to its objectives or goals. Such review shall be undertaken by
the Committee of the Senate and the House of Representatives which have
legislative jurisdiction over the Program.cralaw:red
SEC.
55. Information Campaign. - There shall be provided a
substantial
period of time to undertake an intensive public information campaign
prior
to the implementation of the rules and regulations of this Act.cralaw:red
SEC.
56. Separability Clause. - In the event any provision
of
this Act or the application of such provision to any person or
circumstances
is declared invalid, the remainder of this Act or the application of
said
provisions to other persons or circumstances shall not be affected by
such
declaration.cralaw:red
SEC.
57. Repealing Clause. - Executive Order 119,
Presidential
Decree 1519 and other laws currently applying to the administration of
Medicare are hereby repealed. All other laws, executive orders,
administrative
rules and regulations or parts thereof which are inconsistent with the
provisions of this Act are also hereby amended, modified, or repealed
accordingly.cralaw:red
SEC.
58. Government Guarantee. - The Government of the
Philippines
guarantees the financial viability of the Program.
SEC.
59. Effectivity. - This Act shall take effect fifteen
(15)
days after its publication in at least three (3) national newspaper of
general circulation.
Approved
: February 14, 1995
(Sgd.)
FIDEL V. RAMOSPresident
of the Philippines |