R.A. No.

11223 – Universal Health Care Act

 Long title: An act instituting Universal Health Care for all Filipinos, prescribing reforms in the
health care system, and appropriating fund therefor.

 Coverage: Every Filipino citizen shall be automatically included into the National Health
Insurance Program (NHIP) (Sec. 5)
o Immediate eligibility (Sec. 6)
o 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 (Sec. 6)
 Population-based health services refer to interventions such as health
promotion, disease surveillance, and vector control (e.g., mosquito control),
which have population groups as recipients (Par. (q), Sec. 4).
 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.
(Par. (a), Sec. 7)
 Individual-based health services refer to services which can be accessed within a
health facility or remotely that can be definitely traced back to one (1) recipient,
has limited effect at the population level and does not alter the underlying
cause of illness such as ambulatory and inpatient care, medicines, laboratory
tests and procedures, among others (Par. (p), Sec. 4)
 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 (Par. (b), Sec. 7)
o The goods and services to be included shall be determined through a fair and
transparent Health Technology Assessment (HTA) process (Sec. 6)
 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 (Par. (n), Sec. 4)
 The HTA process shall be the priority setting mechanism which is
recommendatory to the DOH and PhilHealth for the development of policies
and programs, regulation, and the determination of a range of entitlements
such as drugs, medicines, pharmaceutical products, and other devices,
procedures and services as provided under this Act (Sec. 34)
 2 types of membership in the NHIP: direct contributors and indirect contributors (Sec. 8)
o 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 (Par. (f), Sec. 4)
o 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 (Par. (o), Sec.
4)

 Every member shall be granted immediate eligibility for health benefit package under the NHIP
(Par. 1, Sec. 9)
o PhilHealth ID shall not be required in the availment of any health service
o No co-payment shall be charged for services rendered in basic or ward accommodation
o Co-payments and co-insurance for amenities in public hospitals shall be regulated by the
DOH and PhilHealth
 Co-payment refers to a flat fee or predetermined rate paid at point of service
(Par. (e), Sec. 4)
 Co-insurance refers to a percentage of a medical charge that is paid by the
insured, with the rest paid by the health insurance plan (Par. (d), Sec. 4)
o The current PhilHealth package for members shall not be reduced.

 PhilHealth shall provide additional NHIP benefits for direct contributors, where applicable (Par.
2, Sec. 9)
o Failure to pay premiums shall not prevent the enjoyment of any NHIP benefits
o Employers and self-employed direct contributors shall be required to pay all missed
contributions with an interest, compounded monthly, of at least 3% for employers and
not exceeding 1.5% for self-earning, professional practitioners, and migrant workers.

 Schedule of premium rates for direct contributors (Par. 1, Sec. 10)

Year Premium Rate Income Floor Income Ceiling

2019 2.75% P10,000.00 P50,000.00
2020 3.00% P10,000.00 P60,000.00
2021 3.50% P10,000.00 P70,000.00
2022 4.00% P10,000.00 P80,000.00
2023 4.50% P10,000.00 P90,000.00
2024 5.00% P10,000.00 P100,000.00
2025 5.00% P10,000.00 P100,000.00
 o For every increase in the rate of contribution of direct contributors and premium subsidy of
indirect contributors, PhilHealth shall provide for a corresponding increase in benefits. (Par.
2, Sec. 10)

 Health services

Service Agency Responsible Notes

Comprehensive outpatient benefit, PhilHealth  in accordance with the
including outpatient drug benefit and recommendation of the Health
emergency medical services (Par. (b), Technology Assessment Council
Sec. 6) (HTAC)
 to be established within two (2)
years from the effectivity of this
Act
Health care delivery system – that will DOH and local  Except in emergency or serious
afford every Filipino a primary care government units cases and when proximity is a
provider that would act as the navigator, (LGUs) concern, access to higher levels
coordinator, and initial and continuing of care shall be coordinated by
point of contact in the health care the primary care provider
delivery system (Par. (c), Sec. 6)

 All health service providers and insurers shall each maintain a health information system
consisting of enterprise resource planning, human resource information, electronic health
records, and an electronic prescription log consistent with DOH standards, which shall be
electronically uploaded on a regular basis through interoperable systems: Provided, That the
health information system shall be developed and funded by the DOH and PhilHealth: Provided,
further, That patient privacy and confidentiality shall at all times be upheld, in accordance with
the Data Privacy Act of 2012. (Sec. 36)
 The DOH, PhilHealth, HMOs, life and non-life private health insurance (PHIs) shall develop
standard policies and plans that complement the NHIP’s benefit schedule
o A coordination mechanism between PhilHealth, PHIs and HMOs shall be set up to
ensure that no benefits shall be unnecessarily dropped (Par. (e), Sec. 28).

 Special Health Fund

o The province-wide or city-wide health system shall pool and manage, through a special
health fund, all resources intended for health services to finance population-based and
individual-based health services health system operating costs , capital investments, and
remuneration of additional health workers and incentives for all health workers (Sec.
20)
 Implementing agency: DOH, in consultation with DBM and LGUs
 o All income derived from PhilHealth payments hall accrue to the Special Health Fund to
be allocated by the LGUs exclusively for the improvement of the LGU health system
(Sec. 21)
 PhilHealth payments shall be credited to the annual regular income of the LGU.

 Sources of funding: (Sec. 37)

o Sin tax collection provided for in R.A. No. 10351 or Sin Tax Reform Law
o 50% of the National Government share from the income of the PAGCOR as provided in
PD No. 1869
o 40% of the Charity Fund and mandatory contributions of PCSO as provided for in RA No.
1169, as amended
o Premium contributions of members
o Annual appropriations of the DOH included in the GAA
o National Government subsidy to PhilHealth included in the GAA.

 Government and private hospitals (Par. (c), Sec. 29)

o All government hospitals are required to operate not less than 90% of their bed capacity
as basic or ward accommodation
o Specialty hospitals are required to operate not less than 70% of their bed capacity as
basic or ward accommodation
o Private hospitals are required to operate not less than 10% of their bed capacity as basic
or ward accommodation
  Penal provisions – Any violation of the provisions of the Act, after due notice and hearing, shall
suffer the corresponding penalties:

Person Liable Act Punishable Penalty

Member  Commits any violation of this Act; or  Fine of P50,000.00 for each
(Par. (c), Sec.  Knowingly and deliberately cooperates or count;
38) agrees, whether explicitly and implicitly, to the  Suspension from availment
commission of a violation by a contracted of the benefits of the
health care provider or employer as defined in Program for not less than 3
this Section, including the filing of a fraudulent months but not more than 6
claim for benefits or entitlement under this Act months; or
 Both
**at the discretion of PhilHealth
Any employer Deliberately or through inexcusable negligence,  Fine of P50,000.00 for every
(Par. (d)(1), fails or refuses to register employees, regardless of violation per affected
Sec. 38) their employment status, accurately and timely employee;
deduct contributions from the employee’s  Imprisionment of not less
compensation or to accurately and timely remit or than 6 months but not more
submit the report of the same to PhilHealth than 1 year; or
 Both
**at the discretion of court
Any employer Deducts, directly or indirectly, from the  Fine of P5,000.00 multiplied
(Par. (d)(2), compensation of the covered employees or by the total number of
Sec. 38) otherwise recover from them the employer’s own affected employees;
contribution on behalf of such employeess  Imprisonment of not less
than 6 months but not more
than 1 year; or
 Both
**at the discretion of the court

o Note that healthcare providers, and directors and officers of PhilHealth can also be held
liable for certain acts.
 Within three (3) years from the effectivity of this Act, all private insurance companies and
HMOs, togetherwith DOH and PhilHealth, shal have developed a system of co-payment that
complements PhilHealth packages. (Par. (h), Sec. 41)

 Note: The Implementing Rules and Regulations shall be prepared by the DOH and the
PhilHealth, in consultation and coordination with appropriate national government agencies,
civil society organizations, NGOs, private sector representatives, and other stakeholders, not
later than 180 days upon the effectivity of this Act.