RA 11223

Population-based health services

Target population groups

indirect contributors

That for _______, premium subsidy shall be gradually adjusted and included annually in the General Appropriations Act (GAA)

An Act Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the Health Care System, and Appropriating Funds Therefore

Republic Act No. 11223: ________

fraudulent act

Results in undue benefit or advantage for the doer

health facilities

Serve individuals suffering from illness, disease, injury, disability, or deformity

Essential health benefit package

Set of individual-based entitlements covered by the National Health Insurance Program (NHIP)

Health Technology Assessment (HTA)

Systematic evaluation of health-related technologies, devices, medicines, vaccines, and procedures

Individual-based health services

Traced back to a specific recipient

Ambulatory and inpatient care, medicines, laboratory tests, and procedures

examples of Individual-based health services

○ Overbilling ○ Upcasing (inflating medical diagnoses or procedures) ○ Harboring ghost patients (fictitious beneficiaries) ○ Recruitment practices violating ethical standards. ○ Any act contrary to the Code of Ethics of responsible professionals. ○ Similar acts that undermine the integrity and effective implementation of the NHIP

examples of unethical act:

Co-insurance

Portion paid by the insured

Health care provider network

Primary care providers act as the navigator and coordinator within the network.

health facilities

Provide services for health promotion, prevention, diagnosis, treatment, rehabilitation, and palliation

Basic or Ward Accommodation

Provision of regular meal, bed in shared room, fan ventilation, and shared toilet and bath

Unethical act

Refers to actions against the National Health Insurance Program (NHIP).

Abuse of authority

Refers to an act exceeding authorized duties

fund manager

The ______ shall submit an annual report on investment performance to PhilHealth

● ₱50,000.00 fine for each count or ● suspension from availment of the benefits of the Program for 3 to 6 months *or both, at the discretion of PhilHealth

A Member a) who commits any violation of this Act, including the filing of a fraudulent claim for benefits or entitlement under this Act, shall be punished by:

Health care provider network

A group of primary to tertiary care providers (public or private)

● pay a fine of ₱50,000.00 for every violation per affected employee, or ● imprisonment of 6 months to 1 year

Any Employer a) Non-registration of employees, deduction from the employee's compensation or failure to accurately and timely remit or submit the report of the same to PhilHealth shall:

Emergency

Immediate danger based on prudent medical officer's findings

shall be presumed to have misappropriated the contributions and is immediately obligated to return or remit the amount.

ANY EMPLOYER Or any officer authorised to collect contributions failing or refusing to accurately and timely remit the contributions to PhilHealth within thirty (30) days from due date

Health Technology Assessment (HTA)

Aims to solve health problems and improve lives and health outcomes

indirect contributors

Also includes those subsidized due to special laws

Health Maintenance Organization (HMO)

An entity providing, offering, or covering designated health services

fine equivalent to triple the amount misappropriated per count and suspension for 3 months without pay

Any director, officer, or employee of PhilHealth who a) Misappropriate Funds by: 1) wrongfully receiving or keeping funds or property payable or deliverable to the PhilHealth 2) appropriates and applies such for personal use 3) willingly or negligently consents to the misappropriation of funds or property without objecting to the same and promptly reporting the matter to proper authority ● shall be punished with a fine

Community-based health care organizations

Associations improving community health status

Primary care

Available when needed

Individual-based health services

Can be accessed within a health facility or remotely

Primary care provider

Certified in primary care by the Department of Health (DOH) or certified health institutions

Amenities

Comfort features in health services

● fine of ₱200,000 ● 3 month suspension without pay

Commits an unethical act, abuse of authority, or performs a fraudulent act

Private health insurance

Covers a defined set of health services

punishable by imprisonment for 6 months and 1 day up to 6 years

Criminal Violation

● a fine of ₱5,000.00 multiplied by the total number of affected employees or ● imprisonment of 6 months to 1 year

Deduction from the compensation of the covered employees shall be punished by:

○ Loss of life or permanent disability ○ Permanent injury or loss of unborn child (for pregnant women) ○ Non-institutional delivery

Delay in treatment may cause:

Abuse of authority

Detrimental to the public

fraudulent act

Deviates from normal procedure

healthcare professionals

Doctors of medicine, nurses, midwives, dentists, and allied practitioners

Private accommodation, air conditioning, telephone, television, meal choices

EXAMPLES OF AMENITIES

○ Primary care ○ Medicines, diagnostics, and laboratory services ○ Preventive, curative, and rehabilitative services

Essential health benefit package include:

Primary care

Facilitates referrals to other health care providers

Private health insurance

Financed through private payments (premiums) to insurers

co-payment

Flat fee or predetermined rate paid at the point of service.

direct contributors

For ________, premium rates shall be in accordance with the following schedule, and monthly income floor and ceiling.

Health Maintenance Organization (HMO)

For its plan holders or members for a fixed prepaid premium

Primary care provider

Health care worker with defined competencies

co-insurance

Health insurance plan covers the rest of the medical charge

entitlement

Health services provided to Filipinos for health improvement.

Population-based health services

Include health promotion, disease surveillance, and vector control

Primary care

Includes services for all presenting conditions

indirect contributors

Includes those not classified as direct contributors

● fine of ₱200,000.00 for each count or ● Up to 3 months of contract suspension or the remaining period of its contract

Individual-based services who commits an unethical act, abuses the authority, or performs a fraudulent act shall be punished by:

Primary care

Initial-contact, accessible, continuous, comprehensive, and coordinated care

fraudulent act

Involves misrepresentation or deception

Individual-based health services

Limited impact at a population level

fraudulent act

May cause damage and prejudice with pecuniary estimation

Health Technology Assessment (HTA)

Multidisciplinary process evaluating social, economic, organizational, and ethical aspects of health interventions or technologies

direct contributors and indirect contributors

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

health facilities

Offer obstetrical and other medical and nursing care.

Health care provider network

Offers people-centered and comprehensive care

₱5,000.00 to 20,000.00

Other violations of the provisions of this Act or of the rules and regulations fine of

1) five (5) ex officio members, namely: the Secretary of Health, Secretary of Social Welfare and Development, Secretary of Budget and Management, Secretary of Finance, Secretary of Labor and Employment; (2) three (3) expert panel members with expertise in public health, management, finance, and health economics; and (3) five (5) sectoral panel members, representing the direct contributors, indirect contributors, employers group, health care providers

PHILHEALTH BOARD OF DIRECTOR MEMBERS

direct contributors; employers and self-employed direct contributors; interest

PhilHealth shall provide additional Program benefits for ______, where applicable: Provided, That failure to pay premiums shall not prevent the enjoyment of any Program benefits: Provided, further, That __________ shall be required to pay all missed contributions with an ________, 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

maximum of thirteen (13) members

The PhilHealth Board of Directors is hereby reconstituted to have a __________

● 6 months and 1 day up to 1 year imprisonment *both such fine and imprisonment, at the discretion of the court.

The same shall also constitute a criminal violation punishable by:

indirect contributors

Their premiums are subsidized by the national government

direct contributors; ○ Gainfully employed (employer-employee relationship) ○ Self-earning professionals ○ Migrant workers and their qualified dependents ○ Lifetime members

Those with capacity to pay premiums: enumerate and its dot

ABUSE OF AUTORITY; Republic Act No. 7875 (National Health Insurance Act of 1995)

______Violates this Act or ____________ and their implementing rules

No more than seven and one-half percent (7.5%)

___________ of the actual total premium collected from direct and indirect contributory members

health facilities health care professionals community-based health care organizations pharmacies, drug outlets, laboratories, and diagnostic clinics

under health care provider: