RT205 The Universal healthcare law (Philippines) part 1

REPUBLIC ACT No. 11223

An Act Instituting Universal Health Care for All Filipinos,

Prescribing Reforms in the Health Care System, and

Appropriating Funds Therefor

Section 1

Short Title. - This Act shall be known as the "Universal

Health Care Act".

Universal Health Care Act

Section 1. Short Title. - This Act shall be known as the?

Section 2. 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. Towards this end,

the State shall adopt:

• (a) 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;

• (b) 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;

• (c) 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; and

• (d) 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 3. General Objectives.

- This Act seeks to:

(a) 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; and

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

• Abuse of Authority

• Amenities

• Basic or ward accommodation

• Co-insurance

• Co-payment

• Direct contributors

• Emergency

• Entitlement

• Essential health

• Fraudulent act

• Health care provider

• Health care provider network

• Health Maintenance Organization (HMO)

• Health Technology Assessment (HTA)

• Indirect contributors

• Individual-based health services

• Population-based health services

• Primary Care

• Primary care provider

• Private health insurance

• Unethical act

Section 4. Definition of Terms. - As used in this Act:

Abuse of authority

refers to an act of a person performing a duty or function that goes beyond what is authorized by this Act and Republic Act No. 7875, otherwise known as the "National Health Insurance Act of 1995", as amended, or their implementing rules and regulations (IRR), and is inimical to the public;

"National Health Insurance Act of 1995"

refers to an act of a person performing a duty or function that goes beyond what is authorized by this Act and Republic Act No. 7875, otherwise known as the ________________________________, as amended, or their implementing rules and regulations (IRR), and is inimical to the public;

Amenities

refer to features of the health service that provide comfort or convenience, such as private accommodation, air conditioning, telephone, television, and choice of meals, among others; plan;

Basic or ward accommodation

refers to the provision of regular meal, bed in shared room, fan ventilation, and shared toilet and bath;

Co-insurance

refers to a percentage of a medical charge that is paid by the insured, with the rest paid by the health insurance

Co-payment

refers to a flat fee or predetermined rate paid at point of service;

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;

Emergency

refers to a condition or state of a patient wherein based on the objective findings of a prudent medical officer on duty, there is immediate danger and where delay in initial support and treatment may cause loss of life or permanent disability to the patient, or in the case of a pregnant woman, permanent injury or loss of her unborn child, or a non-institutional delivery;

Entitlement

refers to any singular or package of health services provided to Filipinos for the purpose of improving health;

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;

Fraudulent act

refers to any act of misrepresentation or deception resulting in undue benefit or advantage on the part of the doer or any means that deviate from normal procedure and is undertaken for personal gam, resulting thereafter to damage and prejudice which may be capable of pecuniary estimation;

• Health facility

• Health care professional

• Community-based health care organization

• Pharmacies or drug outlets

Health care provider refers to any of the following:

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;

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;

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

Pharmacies or drug outlets

laboratories and diagnostic clinics.

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;

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;

Health Maintenance Organization

HMO

Health Technology Assessment

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;

Health Technology Assessment

HTA

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;

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;

Population-based health services

refer to interventions such as health promotion, disease surveillance, and vector control, which have population groups as recipients;

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;

Private health insurance

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;

Unethical act

refers to any action, scheme or ploy against the NHIP, such as overbilling, upcasing, harboring ghost patients or recruitment practice, or any act contrary to the Code of Ethics of the responsible persons profession or practice, or other similar, analogous acts that put or tend to put in disrepute the integrity and effective implementation of the NHIP.

• Section 5. Population Coverage

• Section 6. Service Coverage

• Section 7. Financial Coverage

CHAPTER II UNIVERSAL HEALTH CARE (UHC)

Section 5. Population Coverage.

Every Filipino citizen shall be automatically included into the NHIP, hereinafter referred to as the Program.

Section 6. Service Coverage.

(a) 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;

(b) 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) created under Section 34 hereof;

(c) 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;

(d) 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.

• Population-based health services

• Individual-based health services

Section 7. Financial Coverage.

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.

The National Government

shall support LGUs in the financing of capital investments and provision of population-based interventions.

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 8. Program Membership.

• Section 9. Entitlement to Benefits.

• Section 10. Premium Contributions.

CHAPTER III NATIONAL HEALTH INSURANCE PROGRAM

Section 8. Program Membership.

Membership into the Program shall be simplified into two (2) types, direct contributors and indirect contributors, as defined in Section 4 of this Act.

Section 9. Entitlement to Benefits.

Every member shall be granted immediate eligibility for health benefit package under the Program: Provided, That PhilHealth Identification Card shall not be required in the availment of any health service: Provided, further, That no co-payment shall be charged for services rendered in basic or ward accommodation: Provided, furthermore, That co-payments and co-insurance for amenities in public hospitals shall be regulated by the DOH and PhilHealth: Provided, finally, That the current PhilHealth package for members shall not be reduced.

PhilHealth shall provide additional Program benefits for direct contributors, where applicable: Provided, That failure to pay premiums shall not prevent the enjoyment of any Program benefits: 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.

Section 10. Premium Contributions.

For direct contributors, premium rates shall be in accordance with the following schedule, and monthly income floor and ceiling: