A collection of Philippine laws, statutes and codes not included or cited in the main indices of the Chan Robles Virtual Law Library.
Republic Acts :
|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."
Sec. 2. Declaration 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.
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 adapt to changes in medical technology, health service organizations, health care provider payment 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 local government units (LGUs), subject to the overall 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 members 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 languages that is comprehensible to the member;
k) Maximum Community Participation — The Program shall build on existing community initiatives for its organization and human resource requirements;
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 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 and 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.
Sec. 3. General Objectives. — This Act seeks to:
DEFINITIONS OF TERMS
Sec. 4. Definitions 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.
b) Benefit Package — Services that the Program offers to its members.
c) Capitation — A payment mechanism where a fixed rate, whether per person, family, household, or group, is negotiated with a 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 care provider contract.
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.
e) Coverage — The entitlement of an individual, as a member or as a dependent, to the benefits of the Program.
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.
g) Diagnostic Procedure — Any procedure to identify a disease or condition through analysis and examination.
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.
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.
j) Employer — A natural or juridical person who employs the services of an employee.
k) Enrollment — The process to be determined by the Corporation in order to enlist individuals as members or dependents covered by the Program.
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.
m) Global Budget — An approach to the purchase of medical services by which health care provider negotiations concerning the costs of providing a specific package of medical benefits is based solely on a predetermined and fixed budget.
n) Government Service Insurance System — The Government Service Insurance System created under Commonwealth Act No. 186, as amended.
o) Health Care Provider — Refers to:
1) a health care institution, which is duly licensed and accredited 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 obstetrical 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 1 of this Act;
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.
s) Member — Any person whose premiums have been regularly paid to the National Health Program. He may be a paying member, an indigent member, or a pensioner/retiree member.
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 the required contributions for the Program.
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.
x) Personal Health Services — Health services in which benefits accrue to the individual person. These are categorized into inpatient and outpatient services.
y) Philippine Medical Care Commission — The Philippine Medical Care Commission created under Republic Act No. 6111, as amended.
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 consultation with experts and specialists from organized professional medical societies, medical academe and the pharmaceutical industry, and which is updated every year.
aa) Portability — The enablement of a member to avail of Program benefits in an area outside the jurisdiction of his Local Health Insurance Office.
bb) Prescription Drug — A drug which has been approved by the Bureau of Food and Drug and which can be dispensed only pursuant to a prescription order from a physician who is duly licensed to do so.
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.
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 deficiencies identified in the quality of direct patient, administrative, and support services.
ee) Residence — The place where the member actually lives.
ff) Retiree — A member of the Program who has reached the age of retirement or who was retired on account of disability.
gg) Self-employed — A person who works for himself and is thereforee both employee and employer at the same time.
hh) Social Security System — The Social Security System created under Republic Act No. 1161, as amended.
ii) Treatment Procedure — Any method used to remove the symptoms and cause of a disease.
jj) Utilization Review — A formal review of patient utilization or of the appropriateness of health care services, on a prospective, concurrent or retrospective basis.
THE NATIONAL HEALTH INSURANCE PROGRAM
Sec. 5. Establishment and Purposes. — There is hereby created the National Health Insurance Program which shall provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines, in accordance with the policies and specific provisions of this Act. This social insurance program shall serve as the means for the healthy to help pay for the care of the sick and for those who can afford medical care to subsidize those who cannot. It shall initially consist of programs I and II 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 other supplementary packages of health insurance benefits by a progressively expanding proportion of the population. The Program shall be limited to paying for the utilization of health services by covered beneficiaries or to purchasing health services in behalf of such beneficiaries. It shall be prohibited from providing health care directly, from buying and dispensing drugs and pharmaceuticals, from employing physicians and other professionals for the purpose of directly rendering care, and from owning or investing in health care facilities.
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 Sec. 2 (b) and 2 (l) 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.
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:
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.
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
THE PHILIPPINE HEALTH INSURANCE CORPORATION
SECTION 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.
SECTION 15. Exemption 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.
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.
SECTION 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 overall accomplishment of Program objectives;
d) to formulate and implement guidelines on contributions and 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 the 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 provider organization, including but not limited to 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, and 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 operations 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.
SECTION 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 members shall not exceed six (6) months.
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.
The Corporation shall not be bound by the technical rules of evidence.
SECTION 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 the 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.
The Secretary of Health shall be the ex officio Chairperson while the President of the Corporation shall be the Vice Chairperson of the Board.
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-terminus 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.
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.
d) Allowances 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.
SECTION 19. The President of the Corporation. —
a) Appointment and Tenure — The President of the Philippines shall appoint for a 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.
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 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.
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.
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:
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.
LOCAL 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.
Provinces and cities where prospective members are organized shall receive priority in the establishment of local health insurance offices.
Sec. 23. Functions. — Each Office shall have the
following powers and functions:
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:
Sec. 25. Components of the National Health
Insurance Fund. — The National Health Insurance Fund shall have the
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
Sec. 27. Reserve Fund. — 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
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 (3%) 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
LGUs, 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 LGUs shall be progressively increased
until such time that its share becomes equal to that of the National
HEALTH 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.
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.
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.
Sec. 33. Minimum Requirements for Accreditation. —
The minimum accreditation requirements for health care providers are as
Sec. 34. Provider Payment Mechanisms. — The
following mechanisms for public and private providers shall be allowed
in the Program:
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 reviewed every three (3) years. Fees paid for professional services rendered by salaried public providers shall be allowed to be retained by the health facility in which services are rendered 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.
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.
Sec. 37. Quality Assurance. — Under the guidelines
approved 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
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:
GRIEVANCE 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.
Sec. 40. Grounds for Grievances. — The following
acts shall constitute valid grounds for grievance action:
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
Sec. 42. Grievance and Appeal Review Committee. — The Board shall create a Grievance and 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 other 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.
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 (3) months to the whole term of 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.
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).
Any employer or any officer authorized to collect contributions under this Act who, after collecting or deducting the monthly contributions from his employees' 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.
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.
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.
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 (P10,000.00) 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.
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.
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 regulations necessary for the implementation of this Act. In addition, initial funding shall come from any unappropriated but available fund of the Government.
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.
Sec. 47. Additional Appropriations. — The
Corporation may request Congress to appropriate supplemental funding to
meet targeted milestones of the Program in accordance with Section 10(d) of this Act.
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.
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.
Sec. 50. Promulgation. — Within one (1) 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.
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.
Sec. 52. Transfer of 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 .
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 systems, 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
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 Committees of the Senate and the House of Representatives which have legislative jurisdiction over the Program.
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.
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.
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 also hereby amended, modified, or repealed accordingly.
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
newspapers of general circulation.
February 14, 1995