The Philippine Health Insurance Corporation (PhilHealth) was created in 1995 to create a universal

health coverage for the Philippines. It is a tax-exempt government-owned and government-controlled

corporation (!"##) of the Philippines and is attached to the $epartment of %ealth. It states its goal as
insuring a sustaina&le national health insurance program for all.
'1(
In )*1* it claimed to have achieved
+universal+ coverage with ,-. of the population although the )**, /ational $emographic %ealth
0urve1 showed that onl1 2, percent of respondents were aware of at least one household mem&er &eing
enrolled in Phil%ealth.
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/evertheless this social insurance program provides a means for the health1 to
pa1 for the care of the sic3 and for those who can a4ord medical care to su&sidi5e those who cannot.
6oth local
'2(
and national government allocate funds to su&sidi5e the indigent.
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Mandate and Functions
In 2000 and 2005, reform efforts were outlined to make decentralization and health insurance work more effectively,
including an expanded government subsidy for the enrollment of the poor, the creation of local health service
delivery/planning units to reduce fragmentation, and a stronger !" role in regulation#
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&hil"ealth has four categories of enrollees encompassing nearly the entire population# 'he (formal( sector is for workers
employed by companies and other institutions# Indigents have no means of support# )etirees *non+paying members, have
already paid premiums for -20 months of membership and are .0 or older# 'he individual paying program *I&&, is for
those not eligible for the other three categories# /lthough treated separately, the !verseas 0ilipino 1orkers *!01,
program can be considered as part of the I&& category#
2ince -33., the benefits package and delivery system have improved# 0or example, &hil"ealth now has an !utpatient
and iagnostic &ackage limited to indigent enrollees# 'his addition creates nearly comprehensive coverage for indigents#
/ll other beneficiaries have access to nearly comprehensive services, excluding some outpatient care# &hil"ealth
introduced an accreditation program for private hospitals#
2ome key reform indicators to date include4
5stimated coverage is 678 as of 9une 2003
/verage period for payment of providers is estimated at :0 to :5 days# 'he law re;uires &hil"ealth to reimburse
providers and/or members within .0 days# / recent move as of ecember -, 2003, implemented a <simplified
reimbursement scheme= wherein :58 of the claims amount is reimbursed after a rapid assessment of member
and provider eligibility and the remaining 258 follows after detailed review of the claims#
!n average, 30 out of every -00 claims are paid, 7 to > are denied, and . to : are returned to health care providers for
more information# 268 of claims were submitted by public providers and :28 by private providers#
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Funding and Revenues
0unding varies based on the population covered, although the ma?ority of funds flow from general taxation# &remiums
for the formal sector reach up to 78 of monthly income# &remiums for both the poor and the informal sector are -,200
pesos annually *about 25 @2,# "owever, the cost of insurance for the poor is fully subsidized by the central and local
governments# 'he Aational government allocates more than 3 billion pesos annually to meet its target#
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Patient groups
&rogram summary
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Group Premiums Enrollment Payment
0ormal 5mployer and worker each pay half, up to /s of hire date 7 months
2#58 *maximum of 78, of income up to
70,000 pesos
Indigent -,200 pesos annually
Bocal government handles
enrollment annually#
Aone
)etiree 0ree
/ge .0 with -0 years of
premium payments
Individually
&aying
-,600 pesos annually for members earning
&25,000 and below
7,.00 pesos annually for members earning
more than &25,000
5nrollment date#
!01
*Bandbased,
-,200 pesos annually 5migration date
Ao subsidy# &ayment is on
emigration date then annually#
/ll premiums are pooled nationally and in effect, there is cross+subsidization across districts# Aational government
payment is dependent on the availability of funds#
Coverage
'he benefits package is essentially the same for each group# 'he exception is for indigents and the !verseas 0ilipino
1orkers *!01s, who have additional outpatient primary care benefits *with the providers paid by capitation, however
these benefits are available only through public providers#
Benefits
&hil"ealth beneficiaries have access to a nearly comprehensive package of services, including inpatient care,
catastrophic coverage, ambulatory surgeries, deliveries, and outpatient treatment for malaria and tuberculosis# 'hose
identified as indigent and !01 are also entitled to outpatient primary care#
Inpatient care includes room and board, medicines, diagnostic and other services, professional fees and operating room
services# 'hese benefits are sub?ect to some limits, which differ based on the level of the health facility/hospital *level -
to > hospitals and the /mbulatory surgical centers e;uivalent to level 2 hospitals, and the severity of the cause of
admission *case+type /, C, D and ,# Datastrophic conditions, ambulatory surgeries including ambulatory dialysis,
deliveries and outpatient malaria and 'C+!'2 care#
5xcept for the outpatient primary care that the poor and !01s are entitled to via public providers, patients have free
choice of providers, both public and private#
/nnual or lifetime coverage limits exist# 'hese limits are expressed in terms of volumes of services *e#g#, days, rather
than a peso coverage limit# 0or example, households are eligible for >5 days of inpatient admission, sharing >5 days
among all household members# 5ach day of ambulatory surgery counts as a day of admission#
&roviders are allowed to charge the patient the difference between the total cost of care and what &hil"ealth pays *i#e#,
balance billing,#
Service delivery system
'he service delivery system includes both public and private centersE on average, .-8 of the networkFs providers are
private and 738 are public# In order to achieve accreditation, all in+network hospitals and day+surgery centers must be
licensed by the epartment of "ealth#
'he network includes hospitals, day surgery centers, maternity care clinics, midwife+operated clinics, freestanding
dialysis centers, physician clinics, dentists doing procedures in hospitals and day surgeries, government+run health
centers for primary care benefits, 'C+!'2 and malaria, and private 'C+!'2 clinics#
Aon+hospitals and day+surgery centers are not re;uired to be licensed by the !"E however, all facilities are evaluated
by an accreditation team from &hil"ealth#
Structure
'he scheme is entirely administered by &hil"ealth, a government corporation attached to the epartment of "ealth#
&hil"ealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms,
processes claims, and reimburses providers for their services#
&hil"ealth is responsible for oversight and administration of public sector insurance schemes# It has a governing board
chaired by the 2ecretary of "ealth with representation from other government departments *ministries, and agencies, and
the private sector including the !01 sector#
&hil"ealth has a governing board of -7 individuals, chaired by the 2ecretary of "ealth, with the &resident and D5! of
&hil"ealth as Gice+Dhairman# 1hile the law, )/ :6:5, that created the Aational "ealth Insurance &rogram provides that
the &resident and D5! has a fixed term of . years, with the passage )epublic /ct -0->3 or the (H!DD Hovernance /ct
of 20--(, the &resident and D5! of &hil"ealth now has a term of one *-, year *2ection -:, )/ -0->3, to be elected
among the ranks of the Coard of irectors and sub?ect to the disciplinary powers of the Coard and may be removed for
cause *2ection -6, )/ -0->3,#
2alaries and other operating expenses are derived from premium payments and the income of the funds under
management# &hil"ealth can use up to -28 of the previous yearIs premium and 78 of the income of the fund it manages
towards operating expenses#
Dongress mandated that the Aational Institutes of "ealth *based in the @niversity of the &hilippines, to conduct studies
to verify and validate performance#
Provider Payment Mechanism
&rovider payment methods differ based on the type of care delivered# 0ee+for+service reimbursements are used for
inpatient care, most day surgeries, and ambulatory procedures, while primary care providers are reimbursed based on a
capitation system# 0or 'C+!'2 treatment, malaria care, deliveries, surgical contraception, and cataract surgeries, a
case+based payment methodology is utilized#
Ao formal system sets deductibles or co+payments for beneficiaries, but health care providers are allowed to <balance
bill=, charging patients the balance between what &hil"ealth pays and the total cost of care# 'his is atypical of most
government health programs around the world and can lead to abuse by providers *e#g#, overcharging, and thus limited
access for the poorest# /t the same time, balance billing allows providers additional cost recovery in the case that the
reimbursement for services does not cover their cost#
Quality
&hil"ealth currently leverages internally developed ;uality standards# / new set of standards called the <&hil"ealth
Cenchbook= was implemented starting 9anuary -, 20-0# 'he Cenchbook was developed by &hil"ealth with the
assistance of various international health partners and several rounds of consultations with health providers#
'he previous and new ;uality standards are overseen by &hil"ealth# 'he new ;uality standards focus on patient rights,
organizational ethics, patient care, leadership and management, human resource management, information management,
safe practice and environment and mechanisms of improving performance# /s of 20--, hospitals accreditedation is good
for up to 7 years# &hil"ealth accreditation staff physically check and verify compliance# &hil"ealth has peer review
committees mostly composed of health care providers who review specific cases#
&hil"ealth planned to implement ;uality+based purchasing but had not executed on this plan as of ecember 2003#
Performance-based Payment
&hil"ealth has been developing incentive payments focused on payment to health care professionals# octors are usually
independents who JpracticeI in hospitals# 2alaried government physicians are allowed to also engage in private practice#
5fforts to implement case payments essentially focus on bundling the payment for the health facilities#
/mong &hil"ealthIs work in incentive+based payments is a scheme that has been piloted in 70 local government
hospitals since 2002 but has not spread# 'he scheme is called the Kuality Improvement emonstration 2tudy *KI2,# It
utilizes clinical vignettes to measure ;uality of care# If a hospital meets a set ;uality of care index score, physician
payments are increased# Dlinical vignettes focus on the illnesses of children less than six years of age#
/nother incentive scheme is increased payment for health professionals practicing in areas where there is a lack of
doctors#
Claims Processing
Dlaims processing is manual# "ospitals or members fill out claim forms that are then submitted to &hil"ealth within .0
days from hospital or health facility discharge# 'wo forms are usually submitted4 !ne documents the member and
premiums paid# 'he other details the service provided# Dlaims are submitted to -: regional claims processing centers#
'hese centers initially review claims for eligibility# )eview is input manually with data encoded into the claims
processing information system# !nce the claim is approved for payment, checks are prepared for the signature of
regional heads# 5lectronic reimbursements are planned but not implemented#
Monitoring and Evaluation
&hil"ealth conducts its own monitoring and evaluation, though the law mandates that the @niversity of the &hilippinesF
Aational Institutes of "ealth engages in monitoring of the scheme# 5valuations on the &hil"ealth program are ongoing#
'he epartment of "ealth *to which &hil"ealth is an attached agency, monitors and analyses data, including number and
value of claims, number of accredited providers, number and value of premiums paid, number of members, etc#
Fraud and Controversies
In 20-- fraudulent claims against the state+health insurer were estimated at > billion pesos# It failed to prosecute erring
doctors and hospital# /0& Ledical Denter, 2t# BukeIs "ospital, &hilippine !rthopedic "ospital, @niversity of 2to# 'omas
"ospital, 5ast /venue Ledical Denter, Dardinal 2antos Ledical Denter, Ledical Dity, Aational Midney, Heneral 2antos
istrict "ospital *H2", and 'ransplant Institute were investigated for health insurance fraud#
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In Iloilo, eye doctor
claims 2, 0:- operations amounting to &-. million professional fees in 200.# / hospital in avao Dity notice that a
?anitor lying in bed and claiming to be a &hil"ealth accredited patient#
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In 200. &hil"ealth revoked the accreditation of
2ara Ledical Dlinic in Lidsayap for ghost patients#
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History
'he &hilippine Ledical Dare &rogram began in -3:- following the &hilippine Ledical Dare /ct of -3.3#
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It mandated
creation of the &hilippine Ledical Dare Dommission *&LDD,# In -330 bills passed that led to significant improvement
of public health care insurance# "ouse Cill ->225 and 2enate Cill 0-:76 became )epublic /ct :6:5, known as ('he
Aational "ealth Insurance /ct of -335(# /pproved by &resident 0idel )amos on 0ebruary ->, -335# 'his become the
basis of the &hilippine "ealth Insurance Dorporation#
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!n its -.th anniversary the song (&hil"ealth4 'apat na 2erbisyo,
'apat na Cenepisyo, Bahat &analo( was introduced#
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/ premier government corporation that ensures sustainable, affordable
and progressive social health insurance which endeavors to influence the
delivery of accessible ;uality health care for all 0ilipinos#
/s a financial intermediary, &hil"ealth shall continuously evolve a
sustainable Aational "ealth Insurance &rogram that shall 4 *-, lead
towards universal coverage, *2, ensure better benefits for its members at
affordable premiums, *7, establish close coordination with its clients
through a strong partnership with all stakeholdersE and *>, provide
effective internal information and management systems to influence the
delivery of ;uality health care services#
0rancisco '# u;ue III, &resident N D5!
Agencys Mandate and Functions
8andate
'he Aational "ealth Insurance &rogram was established to provide health insurance coverage and ensure affordable,
acceptable, available and accessible health care services for all citizens of the &hilippines# It shall serve as the means for
the healthy to help pay for the care of the sick and for those who can afford medical care to subsidize those who cannot#
It shall initially consist of &rograms I and II or Ledicare and be expanded progressively to constitute one universal
health insurance program for the entire population# 'he program shall include a sustainable system of funds constitution,
collection, management and disbursement for financing the availment of a basic minimum package and other
supplementary packages of health insurance benefits by a progressively expanding proportion of the population# 'he
program shall be limited to paying for the utilization of health services by covered beneficiaries# It shall be prohibited
from providing health care directly, from buying and dispensing drugs and pharmaceuticals, from employing physicians
and other professionals for the purpose of directly rendering care, and from owning or investing in health care facilities#
(Article III, Section 5 of RA 7875 as amended)
Powers and 9unctions
&hil"ealth is a tax+exempt Hovernment Dorporation attached to the epartment of "ealth for policy coordination and
guidance# (Article IV, Section 15 of RA 7875 as amended,# It shall have the following powers and functions (Article IV,
Section 16 of RA 7875 as amended by RA 10606)4
a, 'o administer the Aational "ealth Insurance &rogramE
b, 'o formulate and promulgate policies for the sound administration of the &rogramE
c, 'o supervise the provision of health benefits and to set standards, rules and regulations necessary to ensure ;uality of
care, appropriate utilization of services, fund viability, member satisfaction, and overall accomplishment of &rogram
ob?ectivesE
d, 'o formulate and implement guidelines on contributions and benefitsE portability of benefits, cost containment and
;uality assuranceE and health care provider arrangements, payment, methods, and referral systemsE
e, 'o establish branch offices as mandated in /rticle G of this /ctE
f, 'o receive and manage grants, donations, and other forms of assistanceE
g, 'o sue and be sued in courtE
h, 'o ac;uire property, real and personal, which may be necessary or expedient for the attainment of the purposes of this
/ctE
i, 'o collect, deposit, invest, administer, and disburse the Aational "ealth Insurance 0und in accordance with the
provisions of this /ctE
?, 'o negotiate and enter into contracts with health care institutions, professionals, and other persons, ?uridical or natural,
regarding the pricing, payment mechanisms, design and implementation of administrative and operating systems and
procedures, financing, and delivery of health services in behalf of its membersE
k, 'o authorize Bocal "ealth Insurance !ffices to negotiate and enter into contracts in the name and on behalf of the
Dorporation with any accredited government or private sector health provider organization, including but not limited to
health maintenance organizations, cooperatives and medical foundations, for the provision of at least the minimum
package of personal health services prescribed by the DorporationE
l, 'o determine re;uirements and issue guidelines for the accreditation of health care providers for the &rogram in
accordance with this /ctE
m, 'o visit, enter and inspect facilities of health care providers and employers during office hours, unless there is reason
to believe that inspection has to be done beyond office hours, and where applicable, secure copies of their medical,
financial, and other records and data pertinent to the claims, accreditation, premium contribution, and that of their
patients or employees, who are members of the &rogramE
n, 'o organize its office, fix the compensation of and appoint personnel as may be deemed necessary and upon the
recommendation of the president of the DorporationE
o, 'o submit to the &resident of the &hilippines and to both "ouses of Dongress its /nnual )eport which shall contain
the status of the Aational "ealth Insurance 0und, its total disbursements, reserves, average costing to beneficiaries, any
re;uest for additional appropriation, and other data pertinent to the implementation of the &rogram and publish a
synopsis of such report in two *2, newspapers of general circulationE
p, 'o keep records of the operations of the Dorporation and investments of the Aational "ealth Insurance 0undE
;, 'o establish and maintain an electronic database of all its members and ensure its security to facilitate efficient and
effective servicesE
r, 'o invest in the acceleration of the DorporationIs information technology systemsE
s, 'o conduct information campaign on the principles of the A"I& to the public and to accredited health care providers#
'his campaign must include the current benefit packages provided by the Dorporation, the mechanisms to avail of the
current benefit packages, the list of accredited and disaccredited health care providers, and the list of offices/branches
where members can pay or check the status of paid health premiumsE
t, 'o conduct post audit on the ;uality of services rendered by health care providersE
u, 'o establish an office, or where it is not feasible, designate a focal person in every &hilippine Donsular !ffice in all
countries where there are 0ilipino citizens# 'he office or the focal person shall, among others, process, review and pay
the claims of the overseas 0ilipino workers *!01s,E
v, Aotwithstanding the provisions of any law to the contrary, to impose interest and/or surcharges of not exceeding three
percent *78, per month, as may be fixed by the Dorporation, in case of any delay in the remittance of contributions
which are due within the prescribed period by an employer, whether public or private# Aotwithstanding the provisions of
any law to the contrary, the Dorporation may also compromise, waive or release, in whole or in part, such interest or
surcharges imposed upon employers regardless of the amount involved under such valid terms and conditions it may
prescribeE
w, 'o endeavour to support the use of technology in the delivery of health care services especially in farflung areas such
as, but not limited to, telemedicine, electronic health record, and the establishment of a comprehensive health databaseE
x, 'o monitor compliance by the regulatory agencies with the re;uirements of this /ct and to carry out necessary actions
to enforce complianceE
y, 'o mandate the national agencies and BH@s to re;uire proof of &hil"ealth membership before doing business with a
private individual or groupE
z, 'o accredit independent pharmacies and retail drug outletsE and
aa, 'o perform such other acts as it may deem appropriate for the attainment of the ob?ectives of the Dorporation and for
the proper enforcement of the provisions of this /ct#
:;liations
International 0ocial 0ecurit1 :ssociation
:0<:/ 0ocial 0ecurit1 :ssociation
Philippine 0ocial 0ecurit1 :ssociation
!ision" Mission" Core !alues
=ision
(Cawat &ilipino, Liyembro,
Cawat Liyembro, &rotektado,
Malusugan Aatin, 2egurado(
8ission
(2ulit na Cenepisyo sa Cawat Liyembro,
ekalidad na 2erbisyo para sa Bahat(
#ore =alues
Innovation
Kuality 2ervice
@tmost Integrity
5;uity
2ocial 2olidarity N
'otal Dare
Board of #irectors
Board Mem$ers Representative%Alternate
"on# 5nri;ue '# !na, L##
!" 2ecretary
Dhairperson

"on# 0rancisco '# u;ue III, L##, L2c
D2D Dhairperson
Lember

"on# Lanuel /# )oxas II
IBH 2ecretary
Lember
"on# /ustere /# &anadero
@ndersecretary
"on# Dorazon 9# 2oliman
21 2ecretary
Lember

"on# )osalinda # Caldoz
!B5 2ecretary
Lember
"on# Beah '# 0ortuna
Dhief of 2taff, !25D
"on# 5milio 2# e Kuiros, 9r#
222 &resident N D5!
Lember
"on# /gnes 5# 2an 9ose
Gice &resident, Cenefits /dministration ivision
"on# )obert H# Gergara
H2I2 &resident N Heneral Lanager
Lember
"on# Bourdes D# orado
Gice &resident, Lindanao !peration
"on# Larlon 9# Lanuel
A/&D+C2 Gice Dhairperson

"on# Desar G# &urisima
!0 2ecretary
Lember

"on# /lexander /# &adilla
5mployers 2ector and &hil"ealth &resident and D5!
Lember

"on# 9uan L# 0lavier, L##
"ealth Dare &roviders 2ector
Lember

"on# /lexander /# /yco, L##
Babor 2ector
Lember

"on# 0rancisco Gicente 0# Bopez, L##
2elf 5mployed 2ector
Lember

Board Mem$ers Representative%Alternate
"on# 9ane L#A# 2ta# /na
0ilipino !verseas 1orkers 2ector
Lember

Independent irector of the
Lonetary Coard
*'o be appointed,
Lember

)epresentative of the
5lected Bocal Dhief 5xecutives
*'o be appointed,
Lember

)epresentative of the
0ormal/Informal 5conomy
*'o be appointed,
Lember

Outpatient coverage:
$a1 surgeries dial1sis and cancer treatment
procedures such as chemotheraph1 and radiotheraph1 in accredited hospitals and free-standing
clinics.
Special beneft packages:
<nhanced "utpatient 6ene>t Pac3age
#overage for up to the fourth normal deliver1?
/ew&orn #are Pac3age
T6 treatment through $"T0
0:@0 and :vian InAuen5a Pac3age
InAuen5a : (%1/1) Pac3age
Exclusions/non-compensables