Transcription
Implementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 2013
Implementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 2013
The Revised Implementing Rules andRegulations of the National HealthInsurance Act of 2013(RA 7875 as amended by RA 9241 and 10606)2013 EditionImplementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 2013
MESSAGEfrom the Secretary of Healthand Chairperson of the BoardThe Aquino government has consistently demonstrated its commitment to Universal HealthCare or Kalusugan Pangkalahatan (KP). This priority reform is supported by increasing budgetfor health as well as the passage of the Sin Tax Reform Law, which will ensure the sustainability ofresources for health. Under KP, all Filipinos must be accorded financial risk protection, especiallythe poor and marginalized. Thus, effective implementation of the National Health InsuranceProgram is imperative to make universal care a reality in our country.The timely amendment of the National Health Insurance Act of 1995 (RA 7875) with theNational Health Insurance Act of 2013 (RA 10606), and its Implementing Rules and Regulationsensures that the aspirations of Kalusugan Pangkalahatan will become a reality.The new implementing rules streamlines the PhilHealth membership experience, fromassurance of full premium payment for the poor families identified by the Department of SocialWelfare and Development to simplify the requirements when availing their benefits. Moreover,the new rules also established simpler procedures in accrediting health care providers to promotegreater access to health services across the country without sacrificing the quality of care. ThisIRR also highlights the new role of the Local Government Units in implementing the National HealthInsurance Program as well as the enhanced powers of PhilHealth in implementing the Program.The new IRR will serve as a guidepost in ensuring viability, adequacy and continuedresponsiveness of PhilHealth towards the achievement of Universal Health Coverage and enhancingthe country’s performance in achieving the targets for health-related Millennium DevelopmentGoals.Through the support of all partners in the health sector, both in government and privatesectors, the vision of “Bawat Pilipino, Miyembro. Bawat Miyembro, Protektado. Kalusugan NatinSegurado.” will soon become a reality.ENRIQUE T. ONAImplementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 2013
MESSAGEfrom the President and CEOOnly recently, President Benigno S. Aquino III, approved and signed intolaw, Republic Act No. 10606, otherwise referred to as the “National HealthInsurance Act of 2013”, and thus marked an unprecedented milestone in theannals of the nation’s social health insurance program. The new PhilHealthlaw is the embodiment of government’s unwavering commitment to the attainment of UniversalHealth Care or “Kalusugan Pangkalahatan”.Some of the law’s salient features includes the dramatic shift from premium sharing betweenthe national and local governments to that of full national subsidy of the indigent sector as definedand listed by the DSWD’s ‘Listahanan’. Having enrolled over 14.7 million families or more than halfof the population in 2014, the government has exhibited its steadfast commitment to the poorest ofthe poor who shall now be able to avail of quality health care at no or very little cost. Coupled withprimary care benefit packages initially intended for them as well, PhilHealth is now investing in thefuture by providing for preventive health care services so as to lessen the costs of more expensivecurative treatments.Priority is also given to the health care needs of the underprivileged, the elderly, persons withdisability, abandoned and neglected children including those who are not regularly employed in theinformal sector. Coverage being made compulsory, social health protection is now extended to theproject based or contractual employees who were previously not considered part of the workforce.Documentary requirements have been reduced to a minimum thus facilitating membership as wellas benefit availment procedures.PhilHealth has likewise been periodically upgrading and expanding its benefits to includecatastrophic benefit packages. With the ‘all case rate’ regime and the ‘no balance billing’, we notonly increase the Corporation’s support value to its members but hopefully ascertain that indeedthe benefits are impacting on the members themselves, now the focus of our attention.PhilHealth believes that every Filipino should have the opportunity to access quality healthcare because health is a matter of entitlement and right and not merely a privilege bestowed uponor removed at the whim of others.Thus, with the timely publication and dissemination of the law’s Implementing Rules andRegulations (IRR), one that was forged through years of experience and upon valued consultationsfrom concerned stakeholders, the circle is now complete for the full attainment of the promise ofUniversal Health Care.As PhilHealth moves steadily forward with Kalusugan Pangkalahatan, we are again remindedof our mission statement which succinctly describes what financial risk protection is all about;Bawa’t PILIPINO, MIYEMBRO;Bawa’t MIYEMBRO, PROTEKTADO;KALUSUGAN Natin, SEGURADO.Mabuhay po ang PhilHealth, Mabuhay po ang bansang Pilipinas.ALEXANDER A. PADILLAImplementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 2013
HISTORYThe National Health Insurance Program (NHIP) administered by the Philippine HealthInsurance Corporation (PhilHealth) was established in 1995 with the passage of Republic Act(RA) 7875. PhilHealth took over the Medicare functions previously administered by the PhilippineMedical Care Commission (PMCC) since 1972.PhilHealth’s mandate is to provide health insurance coverage to all Filipinos. In 1997, itassumed Medicare functions for government workers from the Government Service InsuranceSystem (GSIS) and a year later, for the private sector workers, which was previously administeredby the Social Security System (SSS). In the same year, PhilHealth started the Indigent Program.In partnership with Local Government Units (LGUs), PhilHealth has enrolled millions of familieswho otherwise have no access to health services. Since then, this program has been at the heart ofPhilHealth’s program and now forms the bulk of membership. To date, all families in the DSWD’sNational Household Targeting System for Poverty Reduction (NHTS-PR) are covered by PhilHealth.For 2014, 14.7 million families are being enrolled through full National Government subsidy. Theprovision of full National Government subsidy was made possible by an amendment introduced inRA 10606 enacted into law in 2013.In 1999, PhilHealth started covering self-employed and the informal sector and in 2005,PhilHealth assumed Medicare functions from the Overseas Workers Welfare Administration(OWWA) for Overseas Filipino Workers.Now on its 19th year, PhilHealth has improved the way health services are delivered, financedand regulated. It has introduced a primary and catastrophic benefit package as it had shifted toan all case rates system from the previous inflationary and ineffective fee for service which hasbeen in place since Medicare. PhilHealth endeavors to cover the financing of every Filipino’s healthneeds, from preventive primary to hospital care including catastrophic conditions.With Kalusugan Pangkalahatan as the overall sectoral agenda, PhilHealth is committed to ensure a coordinated and intensified effort towards its end goal of “Bawat Pilipino, Miyembro, BawatMiyembro, Protektado, Kalusugan Natin Segurado”.Implementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 2013
TABLE OF CONTENTSImplementing Rules and Regulations of Republic Act 7875 as AmendedOtherwise Known as the National Health Insurance Act of 2013TITLE ISection 1Section 2TITLE IISection 3TITLE IIIRule ISection 4Section 5Section 6Rule IISection 7Section 8Section 9Section 10Section 11Section 12Rule IIISection 13Section 14Section 15Section 16Section 17Section 18Section 19Section 20Rule IVSection 21Section 22Rule VSection 23Section 24Section 25Section 26Rule VISection 27Section 28Section 29Section 30Rule VIISection 31Rule VIIIGUIDING PRINCIPLES AND OBJECTIVESDeclaration of Principles General Objectives .DEFINITION OF TERMSDefinition of Terms . .MEMBERSHIP AND CONTRIBUTIONSCoverageObjective .Nature and Scope .Functions .General Provisions Concerning All MembersPhilHealth Identification Number and Health Insurance ID Card .Replacement of Health Insurance ID Card . .Requirements for Registration of Members and Dependents Emancipated Individual of Single Parent . Remittance of Premium Contribution .Effectivity . . . . .Specific Provisions Concerning Members in the Formal EconomyRegistration of Employers .Employer Data Amendment and Revision .Obligations of the Employer Rates of Premium Contributions .Mandatory Appropriation of Premium Contribution for Government Agencies .Payment of Premium Contributions .Remittance of Premiums for Employees with Income Gaps .Premium Contribution of the Government and Private Sectors with MultipleEmployment .Specific Provisions Concerning the KasambahaysObligations of the Employer of Household Help or Kasambahay .Premium Payment of Household Help .Specific Provisions Concerning Members in the Informal EconomyPayment of Premium Contributions .Cessation from Formal Employment or Coverage as Indigent, Sponsored Memberor as Migrant Worker .Retroactive Payment of Premium Contribution Enrollment of Citizens of Other Countries Working in the Philippines .Specific Provisions Concerning IndigentsIdentification and Enrollment of Indigents .Payment of Premium Contributions .Women as Primary Members .Data Sharing on the List of Indigents and their Dependents .Specific Provisions Concerning Sponsored MembersPayment for Sponsored Members’ Contributions .Specific Provisions Concerning Lifetime MembersImplementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 1616161616161617
Section 32Section 33Rule IXSection 34TITLE IVRule ISection 35Section 36Section 37Section 38Section 39Section 40Section 41Rule IISection 42Section 43Section 44Section 45Section 46Section 47Section 48Section 49TITLE VRule ISection 50Section 51Section 52Rule IISection 53Section 54Section 55Section 56Section 57Section 58Section 59Section 60Section 61Section 62Section 63Rule IIISection 64Rule IVSection 65Rule VSection 66Rule VIRequired Number of Monthly Contributions to Qualify as Lifetime Member .Lifetime Member with Current Source of Income .Provision on Making PhilHealth a Requisite for Issuance/Renewal of License/PermitsRequisite for Issuance or Renewal of License/Permits .BENEFIT ENTITLEMENTSBenefitsObjective .Functions .Benefit Package .Excluded Personal Health Services Entitlement to Benefits .Continuation of Entitlement of Benefits in Case of Death of Member .Benefits of Members and their Dependents Confined Abroad .Payment of ClaimsProvider Payment Mechanisms .No Balance Billing for Indigent and Sponsored Members in the GovernmentHealth Care Institutions .Payment for Health Care Professionals in the Health Care Institutions .Income Retention by Government Health Care Institutions .Reimbursement and Period to File Claims .Guidelines on Claims Payment .Capitation Arrangement . .Disposition of Capitation Payments .QUALITY ASSURANCE AND ACCREDITATIONQuality AssuranceObjective . .Functions .Health Finance Policy Research .AccreditationTypes of Accreditation .Participation to the Program Health Care Providers .Accreditation Requirements and Conditions for Health Care Institutions .Exemptions from the Three-Year Operation Requirement .Accreditation Requirements for Group Health Care Institutions, HealthSystem Providers, Pharmacies and Retail Drug Outlets, Health MaintenanceOrganizations, and Community-Based Health Care Organizations .Guidelines of Accreditation of Health Care Institution .Third Party Accreditation through Hospital Accreditation Commission .Accreditation Requirements for Physicians Dentists, Nurses, Midwives,Pharmacists and other Licensed Health Care Professionals .Process of Accreditation for Health Care Professionals .Grounds for Denial/Non-Reinstatement of Accreditation .Performance Monitoring of Health Care ProvidersPerformance Monitoring System for Health Care Providers .Outcomes AssessmentSystem of Outcomes Assessment .Mechanism For FeedbackMechanism for Feedback .Health Technology AssessmentImplementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 262727282829292930303131
Section 67Rule VIISection 68Section 69Section 70TITLE VIRule ISection 71Section 72Rule IISection 73Section 74TITLE VIIRule ISection 75Rule IISection 76Section 77Rule IIISection 78Section 79TITLE VIIIRule ISection 80Section 81Section 82Section 83Rule IISection 84Section 85Rule IIISection 86Section 87Section 88Section 89Section 90Rule IVSection 91Section 92Rule VSection 93Section 94Section 95Section 96Section 97Section 98Section 99Section 100Section 101Health Technology Assessment .Policy Formulation and ReviewPolicy Formulation . .Policy Review .Remedial Measures .CREATION OF NATIONAL HEALTH INSURANCE FUNDNational Health Insurance FundCreation of the National Health Insurance Fund Financial Management Reserve FundsReserve Funds .Funds for Lifetime Members and Supplemental Benefits .QUASI-JUDICIAL POWERS OF THE CORPORATIONQuasi-Judicial PowersQuasi-Judicial Powers .The Board as a Quasi-Judicial BodyThe Board as Quasi-Judicial Body .Quorum and Votes Required .The Prosecutors, Arbiters and Investigating Officers of the CorporationJurisdiction and Qualifications of the Prosecutors and Arbiters of the Corporation.Authority of the Investigating Officers RULES OF PROCEDURE ON ADMINISTRATIVE CASES AGAINST HEALTHCARE PROVIDERS AND MEMBERSComplaints, Grounds, Venue and PartiesWho May File .Grounds for a Complaint Against a Health Care Provider .Grounds for a Complaint Against a Member .Where To File .Fact-Finding InvestigationComplaints Filed Before the Fact-Finding Investigation and EnforcementDepartment .Complaints Filed Before the Legal Office of the PRO .Preliminary Investigation Before the Prosecution DepartmentDuty of the Prosecutor .Directive to Answer .Finding of a Prima Facie Case .Period for Approval of the Senior Vice-President for Legal Sector .Finality of Resolutions .Contents of the Formal ComplaintCaption and Title Contents of Formal Complaint .Procedure Before the Arbitration OfficeDocket Number . .Service of Summons Proof of Service .Verified Answer .Default .Pre-Hearing and Final Hearing .Affidavits and Position Papers .Rendition of Judgment .Procedure of Trial .Implementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 394040404141414141424242
Section 102Section 103Section 104Section 105Section 106Section 107Section 108Rule VISection 109Section 110Section 111Section 112Section 113Section 114Section 115Section 116Section 117Rule VIISection 118Section 119Section 120Section 121Section 122Section 123Rule VIIISection 124Section 125Section 126Rule IXSection 127Section 128Section 129Section 130Section 131Section 132Rule XSection 133Section 134Rule XISection 135Rule XIISection 136Section 137Section 138Section 139Section 140Rule XIIISection 141Section 142Section 143Role of Arbiter in Proceedings .Powers of the Arbiter .Non-Appearance of Parties at Hearings . .Postponement of Hearing Records of Proceedings Contents of Decisions .Motion for Reconsideration Appeal to the BoardGrounds . Filling of Appeal (Notice of Memorandum of Appeal) .Who May File an Appeal Appeal Fee and Appeal Bond .Period of Appeal .No Extension of Appeal Period .Perfection of Appeal .Memorandum of Appeal of Appellant . .Transmittal of the Records of the Case on Appeal .Review of Appealed Administrative CasesJurisdiction .Delegation of Review . .Composition of CAAC .Review and Recommendation by CAAC . .Decision En Banc .Inhibition .Procedure Before the Board on Appealed CasesFunctions of the Clerk of the Board .Comment, Answer or Reply of Appellee . Rejoinder . .Decision ProcessReply/Deliberation of Appealed Case . .Substantial Evidence .Assignment of the Appealed Case .Decision or Resolution on Appeal .Form of Decision or Resolution .Promulgation of Decisions and Resolutions . .Entry of JudgmentEntry of Judgment and Final Resolution . .Form .Execution of a DecisionExecution of a Decision .Writ of Execution on Institutional Health Care InstitutionsWrit of Execution on Institutional Health Care Institutions .Directive to Execute Writ .Notice of Suspension/Revocation .Report .Deduction of Fines from Benefit Claims .Writ of Execution on Health Care ProfessionalsWrit of Execution on Health Care Professionals .Directive to Execute Writ .Claims Filed with Suspended Professionals . .Implementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 47474747474848484848494949505051515152
Section 144Section 145Rule XIVSection 146Section 147Section 148Rule XVSection 149TITLE IXRule ISection 150Section 151Section 152Section 153Section 154Section 155Section 156Section 157Section 158Section 159Section 160Section 161Rule IISection 162Section 163Section 164Section 165Rule IIISection 166Section 167Rule IVSection 168Section 169Section 170Section 171Rule VSection 172Section 173Section 174TITLE XRule ISection 175Section 176Section 177Rule IISection 178Section 179Section 180Section 181Report .Deductions of Fines from Benefit Claims . .Writ of Execution on MembersWrit of Execution on Members .Claims Filed by Suspended Members .Report Appeal to the Court of AppealsAppeal to the Court of Appeals of Board Decisions .DEFINITION OF ADMINITRATIVE OFFENSES AND PENALTIESOffenses of Health Care InstitutionsPadding of Claims . .Claims for Non-Admitted or Non-Treated Patients .Extending Period of Confinement .Post-Dating of Claims .Misrepresentation by Furnishing False or Incorrect Information .Filing of Multiple Claims .Unjustified Admission Beyond Accredited Bed Capacity .Unauthorized Operations Beyond Service Capability . .Fabrication or Possession of Fabricated Forms and Supporting Documents .Other Fraudulent Acts .Breach of the Warranties of Accreditation/Performance Commitment .Criminal Liability .Offenses of Health Care ProfessionalsMisrepresentation by False or Incorrect Information .Breach of the Warranties of Accreditation/Performance Commitment .Other Violations .Criminal Liability .Offenses of MembersFraudulent Acts . .Criminal Liability .Classification of Administrative OffensesNon-Fraudulent Offenses . .Fraudulent Offenses Scale of Administrative Penalties .Cumulative Application of Penalties/Recidivists .General ProvisionsMitigating and Aggravating Circumstances .Application of Circumstances in the Imposition of Penalties .Application of Suspension and Revocation of Accreditation PENAL OFFENSES AND PENALTIESOffenses of Officers and Employees of the CorporationInfidelity in the Custody of Property .Other Violations Involving Funds .Connivance . .Offenses of EmployersFailure or Refusal to Register / Deduct Contributions .Failure/Refusal to Remit Contributions .Unlawful Deductions .Institution as Offender .Implementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 575757585859595960606060616161
Section 182Section 183Section 184Rule IIISection 185Section 186Section 187Section 188TITLE XIRule ISection 189Section 190Rule IISection 191Section 192Section 193Section 194Section 195Rule IIISection 196Section 197Section 198Section 199Section 200Section 201Section 202Section 203Section 204Section 205Section 206Rule IVSection 207Section 208Section 209Section 210Rule VSection 211Section 212Section 213Section 214Section 215Section 216Rule VISection 217Section 218Section 219Section 220TITLE XIISection 221TITLE XIIIReports on Violations by Employers . .Affidavit-Complaint and Complainant in Actions .Preparation and Filling of Affidavit-Complaint .Final ProvisionsProsecution of Offenses Filing of Complaint .Execution of Penalty .Applicability of this Rules .ADMINISTRATIVE REMEDIES OF HEALTH CARE PROVIDERS AND MEMBERSCommon ProvisionsJurisdiction .Grievance and Protests Not Covered .Grievance Against Program ImplementorsGrounds for Grievances Who May File .Venue Contents of Grievance .Referral of Grievance Complaint to the GARC .The Grievance and Appeals Review CommitteeGrievance and Appeals Review Committee (GARC) .Quorum and Votes Required .Preliminary Determination .Judgment by Default Position Papers .Clarificatory Hearing .Contents of the Decision .Finality of Judgment .Administrative Sanctions . .Construction and Suppletory Application of the Rules of Court .Powers of the GARC .Review of GARC DecisionAppellate Jurisdiction of the Board Over Grievance Cases . .Period to File Petition for Review . .Who May File Petition for Review .Decision of the Board .Administrative ProtestsOriginal Jurisdiction of the PhilHealth Regional Office . .Claims Subject to Protest .Form and Period to File . Procedure Before the PhilHealth Regional Office .Action on Protests Appeal Before the Protest and Appeals Review Department (PARD) Construction and ApplicationTitle of this Rules . .Application of this Rules .Construction .Suppletory Application of the Rules of Court and Jurisprudence .VISITORIAL POWERS OF THE CORPORATIONVisitorial Powers . . .TRANSITORY PROVISIONSImplementing Rules and Regulations of Republic Act 7875 As Amended Otherwise Known As the National Health Insurance Act of 6666666666666767676767676868686868
Section 222Section 223TITLE XIVSection 224Section 225Section 226Section 227Section 228PhilHealth Identification Card .Excluded Benefits . .MISCELLANEOUS PROVISIONSNine (9) Months Contribution Within The Twelve (12) Months .Validation Studies .Repealing Clause Separability Clause .Promulgation and Effectivity .6969Section 1ARTICLE ISection 2Section 3ARTICLE IISection 4ARTICLE IIISection 5Se
The Aquino government has consistently demonstrated its commitment to Universal Health Care or Kalusugan Pangkalahatan (KP). This priority reform is supported by increasing budget for health as well as the passage of the Sin Tax Reform Law, which will ensure the sustainability of resources for health.
