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: