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H. Universal Health Care

1. Policy

a. Declaration of Principles and Policies

It is the policy of the State to protect and promote the right to health of all Filipinos and instill health consciousness among them. (Section 2, R.A. 11223, Universal Health Care Act)

Towards this end, the State shall adopt:

1) An integrated and comprehensive approach to ensure that all Filipinos are health literate, provided with healthy living conditions, and protected from hazards and risks that could affect their health; (Section 2[a], Ibid.)

2) A health care model that provides all Filipinos access to a comprehensive set of quality and cost-effective, promotive, preventive, curative, rehabilitative and palliative health services without causing financial hardship,, and prioritizes the needs of the population who cannot afford such services; (Section 2[b], Ibid.)

3) A framework that fosters a whole-of-system, whole-of-government, and whole-of-society approach in the development, implementation, monitoring, and evaluation of health policies, programs and plans; (Section 2[c], Ibid.)

4) A people-oriented approach for the delivery of health services that is centered on people’s needs and well-being, and cognizant of the differences in culture, values, and beliefs. (Section 2[d], Ibid.)

b. General Objectives

The Universal Health Care Law seeks to:

1) Progressively realize universal health care in the country through a systemic approach and clear delineation of roles of key agencies and stakeholders towards better performance in the health system; (Section 3[a], Ibid.)

2) Ensure that all Filipinos are guaranteed equitable access to quality and affordable health care goods and services, and protected against financial risk. (Section 3[b], Ibid.)

c. Concepts

Direct contributors – refer to those who have the capacity to pay premiums, are gainfully employed and are bound by an employer-employee relationship, or are self-earning, professional practitioners, migrant workers, including their qualified dependents, and lifetime members. (Section 4[f], Ibid.)

Entitlement – refers to any singular or package of health services provided to Filipinos for the purpose of improving health. (Section 4[h], Ibid.)

Essential health benefit package – refers to a set of individual-based entitlements covered by the National Health Insurance Program (NHIP) which includes primary care; medicines, diagnostics and laboratory; and preventive, curative, and rehabilitative services. (Section 4[i], Ibid.)

Health care provider – refers to any of the following:

1) A health facility which may be public or private, devoted primarily to the provision of services for health promotion, prevention, diagnosis, treatment, rehabilitation and palliation of individuals suffering from illness, disease, injury, disability, or deformity, or in need of obstetrical or other medical and nursing care;

2) A health care professional who may be a doctor of medicine, nurse, midwife, dentist, or other allied professional or practitioner duly licensed to practice in the Philippines;

3) A community-based health care organization, which is an association of members of the community organized for the purpose of improving the health status of that community; or

4) Pharmacies or drug outlets, laboratories and diagnostic clinics. (Section 4[k], Ibid.)

Health care provider – network refers to a group of primary to tertiary care providers, whether public or private, offering people-centered and comprehensive care in an integrated and coordinated manner with the primary care provider acting as the navigator and coordinator of health care within the network; (Section 4[l], Ibid.)

Health Maintenance Organization (HMO) –  refers to an entity that provides, offers, or covers designated health services for its plan holders or members for a fixed prepaid premium; (Section 4[m], Ibid.)

Health Technology Assessment (HTA) –  refers to the systematic evaluation of properties, effects, or impact of health-related technologies, devices, medicines, vaccines, procedures and all other health-related systems developed to solve a health problem and improve quality of lives and health outcomes, utilizing a multidisciplinary process to evaluate the social, economic, organizational, and ethical issues of a health intervention or health technology; (Section 4[n], Ibid.)

Indirect contributors – refer to all others not included as direct contributors, as well as their qualified dependents, whose premium shall be subsidized by the national government including those who are subsidized as a result of special laws; (Section 4[o], Ibid.)

Individual-based health services – refer to services which can be accessed within a health facility or remotely that can be definitively traced back to one (1) recipient, has limited effect at a population level and does not alter the underlying cause of illness such as ambulatory and inpatient care, medicines, laboratory tests and procedures, among others; (Section 4[p], Ibid.)

Population-based health services – refer to interventions such as health promotion, disease surveillance, and vector control, which have population groups as recipients; (Section 4[q], Ibid.)

Primary care – refers to initial-contact, accessible, continuous, comprehensive and coordinated care that is accessible at the time of need including a range of services for all presenting conditions, and the ability to coordinate referrals to other health care providers in the health care delivery system, when necessary; (Section 4[r], Ibid.)

Primary care provider – refers to a health care worker, with defined competencies, who has received certification in primary care as determined by the Department of Health (DOH) or any health institution that is licensed and certified by the DOH; (Section 4[s], Ibid.)

Private health insurance – refers to coverage of a defined set of health services financed through private payments in the form of a premium to the insurer; (Section 4[t], Ibid.)

2. Coverage

a. Population Coverage

Every Filipino citizen shall be automatically included into the NHIP, hereinafter referred to as the Program. (Section 5, Ibid.)

b. Service Coverage

1) Every Filipino

Every Filipino shall be granted immediate eligibility and access to preventive, promotive, curative, rehabilitative, and palliative care for medical, dental, mental and emergency health services, delivered either as population-based or individual-based health services: Provided, That the goods and services to be included shall be determined through a fair and transparent HTA process. (Section 6[a], Ibid.)

2) Comprehensive outpatient service

Within two (2) years from the effectivity of this Act, PhilHealth shall implement a comprehensive outpatient benefit, including outpatient drug benefit and emergency medical services in accordance with the recommendations of the Health Technology Assessment Council (HTAC). (Section 6[b], Ibid.)

3) Health Care Delivery System

The DOH and the local government units (LGUs) shall endeavor to provide a health care delivery system that will afford every Filipino a primary care provider that would act as the navigator, coordinator, and initial and continuing point of contact in the health care delivery system: Provided, That except in emergency or serious cases and when proximity is a concern, access to higher levels of care shall be coordinated by the primary care provider; (Section 6[c], Ibid.)

4) Mandatory registration with primary care provider of choice

Every Filipino shall register with a public or private primary care provider of choice. The DOH shall promulgate the guidelines on the licensing of primary care providers and the registration of every Filipino to a primary care provider. (Section 6[d], Ibid.)

c. Financial Coverage

1) Population-based health services

Population-based health services shall be financed by the National Government through the DOH and provided free of charge at point of service for all Filipinos. (Section 7[a], Ibid.)

2) Individual-based health services

Individual-based health services shall be financed primarily through prepayment mechanisms such as social health insurance, private health insurance, and HMO plans to ensure predictability of health expenditures. (Section 7[b], Ibid.)

3. National Health Insurance Program

a. Program Membership

Membership into the Program shall be simplified into two (2) types:

1) Direct contributors; and

2) Indirect contributors.  (Section 8, Ibid.)

b. Entitlement to Benefits

Every member shall be granted immediate eligibility for health benefit package under the Program:

1) Provided, That PhilHealth Identification Card shall not be required in the availment of any health service:

2) Provided, further, That no co-payment shall be charged for services rendered in basic or ward accommodation:

3) Provided, furthermore, That co-payments and co-insurance for amenities in public hospitals shall be regulated by the DOH and PhilHealth:

4) Provided, finally, That the current PhilHealth package for members shall not be reduced. (Section 9, Ibid.)

1) Additional program benefits for direct contributors

PhilHealth shall provide additional Program benefits for direct contributors, where applicable:

1) Provided, That failure to pay premiums shall not prevent the enjoyment of any Program benefits:

2) Provided, further, That employers and self-employed direct contributors shall be required to pay all missed contributions with an interest, compounded monthly, of at least three percent (3%) for employers and not exceeding one and one-half percent (1.5%) for self-earning, professional practitioners, and migrant workers. (Paragraph 2, Section 9, Ibid.)

c. Health Services

1) Population-based Health Services

The DOH shall endeavor to contract province-wide and city-wide health systems for the delivery of population-based health services. Province-wide and city-wide health systems shall have the following minimum components:

1) Primary care provider network with patient records accessible throughout the health system;

2) Accurate, sensitive, and timely epidemiologic surveillance systems; and

3) Proactive and effective health promotion programs or campaigns. (Section 17, Ibid.)

b. Individual-based Health Services

1) Public, private, or mixed health care provider networks

PhilHealth shall endeavor to contract public, private, or mixed health care provider networks for the delivery of individual-based health services:

1) Provided, That member access to services shall not be compromised:

2) Provided, further, That these networks agree to service quality, co-payment/co-insurance, and data submission standards:

3) Provided, furthermore, That during the transition, PhilHealth and DOH shall incentivize health care providers that form networks:

4) Provided, finally, That apex or end-referral hospitals, as determined by the DOH, may be contracted as stand-alone health care providers by PhilHealth. (Section 18[a], Ibid.)

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