Universal Health Care Act of 2019

and its Implementing Rules and Regulations

REMEA VERA R. DACUT

Membership and Marketing Section
PhilHealth Regional Office 10
 RA 11223 or the UHC Law
was signed on February 20,
2019

The UHC Act of 2019 –

Implementing Rules and
Regulations (IRR) was
signed on October 10, 2019
 Section 3 - General Objectives
Ensure that all Filipinos are guaranteed
equitable access to quality and affordable
health care goods and services, and protected
against financial risk.

Population Service Financial

Coverage Coverage Coverage
Population Coverage

Section 5 -

Every Filipino shall automatically

be included into the National
Health Insurance Program
PROGRAM MEMBERSHIP

DIRECT CONTRIBUTORS

INDIRECT CONTRIBUTORS
 Sec 8 Program Membership
Sec 8
There will only be two (2) membership types :

Direct Contributors Indirect Contributors

• Those who have the capacity to pay
premiums
• Gainfully employed and are bound
by employer-employee relationship
• Self-earning
• Professional practitioners
•Kasambahay
• Migrant Workers
• Filipinos with Dual Citizenship
• Lifetime Members
And their qualified dependents
• All those not included as direct
contributors whose premium shall be
subsidized by the national government
a. Indigents identified by the DSWD;
b. Beneficiaries of Pantawid Pamilyang
Pilipino Program/ Modified
Conditional Cash Transfer
(4Ps/MCCT);
c. Senior citizens who are not currently
covered by the Program;
d. Persons with Disability as defined in
RA 10754 (An Act Expanding the
Benefits and Privileges of Persons with
Disability);
And their qualified dependents
 Legal Dependents

Dependent: Children Dependent: Legal Spouse

• Who is not an active member
• 20 years old and below
• unmarried & unemployed
• legitimate, illegitimate
• adopted, stepchildren

Dependent: Foster Dependent: Parents

children 60 years old and above and who
are not PhilHealth members
as defined in RA 10165
(Foster Care Act of2012);
Chapter II Universal Health Care (UHC)
II I1
• Section 5 : Population Coverage

• Section 6 : Service Coverage

• Section 7 : Financial Coverage

Service Coverage
Every Filipino shall be granted
immediate eligibility and access to:
MEDICAL
• Preventive
• Promotive MENTAL
• Curative
• Rehabilitative, and
• Palliative care
DENTAL
Delivered either population-based EMERGENCY
or individual-based health services
 HEALTH SERVICE DELIVERY
Individual vs. Population-based
Services
Individual-based
health services refer to services
which can be accessed within a
health facility or that can be
definitively traced back to one
(1) recipient.
Population-based
health services refer to
interventions which have
population groups as
recipient, e.g. health promotion,
disease surveillance and vector
control.
 Registration of Filipinos to Primary Care Provider Networks

The DOHand LGUs shall endeavor to

provide a HEALTHCAREDELIVERYSYSTEMthat
will afford every Filipino a PRIMARYCARE
SPECIALIST
APEX PROVIDER that would act as:
HOSPITAL
CLINICS

HOSPITAL • Navigator
• Coordinator
• Initial and continuing Point of
Contact
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.
 PhilHealth Benefits

Existing PhilHealth benefit packages shall

continue to be implemented or enhanced.
 Current PhilHealth Packages

Inpatient Outpatient Catastrophic Special Primary

Benefits Benefits or Benefits Care
Z Benefits Benefits
Inpatient Benefits

Cases that require

admission of at least 24
hours

© PhilHealth – Social Health Insurance Academy//mcppa//05November2018

 PhilHealth Case Rates
MEDICAL CASES Amount of Benefit

Dengue I (dengue fever and dengue P 8,000

hemorrhagic fever Grades I & II)

Dengue II (dengue fever and dengue P 16,000

hemorrhagic fever Grades III & IV)

Pneumonia I (moderate risk) P 15,000

Pneumonia II (high risk) P 32,000

Essential Hypertension P 9,000

Cerebral Infarction (CVA I) P 28,000

 PhilHealth Case Rates
MEDICAL CASES Amount of Benefit

Cerebro-vascular Accident with Hemorrhage P 38,000

(CVA II)

Acute Gastroenteritis (AGE) P 6,000

Asthma P 9,000

Typhoid Fever P 14,000

Newborn Care Package P 1,750

-May also be availed at accredited lying-in
clinics
 PhilHealth Case Rates

SURGICAL PROCEDURES Amount of Benefit

Maternity Care Package (MCP) P 8,000

Normal Spontaneous Delivery Package sa Level 1 P 8,000

Hospitals (Panganganak ng Normal)

Normal Spontaneous Delivery Package sa Levels P 6,500

2, 3, & 4 Hospitals (Panganganak ng Normal)

Cesarean Section P 19,000

Appendectomy P 24,000
 PhilHealth Case Rates
SURGICAL PROCEDURES Amount of Benefit

Cholecystectomy P 31,000

Thyroidectomy P 31,000

Herniorrhaphy P 21,000

Mastectomy P 22,000

Hysterectomy P 30,000
Outpatient Benefits

Day surgeries and

treatment procedures
performed at accredited
hospital or free-standing
clinics that do not require
confinement
Outpatient Benefits (partial list only)

P 16,000.00 kada
1 Cataract Package mata o parehong mata sa
isang operasyon lamang
Radiation Treatment Delivery
2 P 3,000.00
or Radiotherapy
3 Outpatient Blood Transfusion P 3,640.00

4 Hemodialysis P 2,600.00

© PhilHealth – Social Health Insurance Academy//mcppa//05November2018

Catastrophic or Z-Benefits

For life threatening

illnesses that require
prolonged and costly
treatment.

© PhilHealth – Social Health Insurance Academy//mcppa//05November2018

Z Benefits - Catastrophic Benefits

1. Breast Cancer (stage 0 to IIIA) P 100,000

Prostate Cancer
2. P 100,000
(low to intermediate risk)
Coronary Artery Bypass Graft Surgery
3. P 550,000
(standard risk)
End-state renal disease eligible for
4. P 600,000
requiring kidney transplantation (low risk)
5. Cervical Cancer P 120,000 - P 175,000
P 150,000 (Low Risk)
6. Colon Cancer
P 300,000 (High Risk)
P 150,000 –
7. Rectum Cancer
P400,000

© PhilHealth – Social Health Insurance Academy//mcppa//05November2018

Z Benefits - Catastrophic Benefits

8. Acute Lymphocytic/Lymphoblastic Leukemia P 210,000

9. Tetralogy of Fallot (TOF) P320,000

10. Ventricular Septal Defect (VSD) P250,000
Cervical Cancer
11. Low Dose P120,000
High Dose (Linear Accelerator) P175,000
Z – MORPH (Mobility, Orthosis, Rehabilitation,Prosthesis)
12. Right or Left below the knee P15,000
Both Limbs P30,000
Selected Orthopedic Implants
Implant for Hip Prosthesis 103,400
13. Total Hip Prosthesis 169,400
Partial Hip Prosthesis
73,180

© PhilHealth – Social Health Insurance Academy//mcppa//05November2018

Current PhilHealth package

Primary Care Benefits

Primary preventive services, diagnostic examinations,
and drugs and medicines, available to Indigent/
Sponsored members, land-based migrant worker-
members and dependents. Availed through Rural Health
Units & OPD of government hospitals

Expanded Primary Care Benefits

Primary preventive services, diagnostic examinations,
and drugs and medicines for PhilHealth under FORMAL
SECTOR, SENIOR CITIZENS and LIFETIME MEMBERS
and their qualified dependents
 BENEFIT
AVAILMENT
 Benefit Availment
Section9

9.1. Every member shall be granted

immediate eligibility for health benefit
packages without the need of presentment
of PhilHealth identification card under the
Program;

Provided, That this does not preclude the

necessity to present any valid
identification for purposes of proving
identity.

Those who are not in the PhilHealth

database shall be duly registered by
health care facilities, subject to the
guidelines that will be issued by PhilHealth.
 No Co-payment Policy

• No other fees or expenses, including professional fees, shall be

charged to all members admitted in any basic or ward
accommodations.

BASIC OR WARD ACCOMMODATION - refers to the

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

• Members who opt for basic or ward accommodations shall be

provided all necessary services and complete quality care to attain the
best possible health outcomes.
• In the absence of available beds and transfer to
another facility is not feasible, members who opt for
basic/ward accommodation but admitted in non-basic
accommodation shall be entitled to no co-payment for
services, professional fees, and amenities.

BASIC ACCOMMODATION REQTS:

• at least 90% for government hospitals
• at least 70% for specialty hospitals
• at least 10% for private hospitals

AMENITIES - refers to features of the health

services provide comfort or convenience, such
as private accommodation, air conditioning,
telephone, and choice of meals, among others
-> with CO-PAYMENT
 NoCo-paymentPolicy

• In the event of change in level of care, members who opt

for basic or ward accommodation shall be treated with the
same unless otherwise chosen by the patient or legal next
of kin.

• Members who opt for admissions in non-basic

or non-ward accommodations may be charged
co-payments/co-insurance for services,
professional fees, and amenities.

• PhilHealth shall issue guidelines operationalizing this

provision.
PhilHealth shall:
● Develop benefit complementation
between PhilHealth and Private Health
Insurance (PHIs) and Health Maintenance
Organizations (HMOs)
● The complementation shall be set up to
ensure that no unnecessary benefits shall be
dropped
Order of Payment for Health Services:

JAO DTI PhilHealt PHIs/HMO

Provision h s
s

PWD, Senior Special

Citizen, Health
Other Fund/
Discounts. Global
Budget
Chapter II Universal Health Care (UHC)
II I1
• Section 5 : Population Coverage

• Section 6 : Service Coverage

• Section 7 : Financial Coverage

Financial Coverage
Section 7

Population-based health
services shall be financed by
the National Government
through the DOH and
provided free of charge at
point of service
Financial Coverage
Section 7

Individual-based shall be
financed through pre-
payment such as SHI,
private health insurance
and HMO plans
FUNDING
Sec 37 Appropriations

In addition, the DOH,

Total incremental sin tax collections coordination with
PhilHealth, may
50% of the National Government share from the
request Congress to
income of the PAGCOR appropriate
40% of the Charity Fund, net of Documentary Stamp supplemental funding
Tax Payments and mandatory contributions of the to meet targeted
PCSO ** milestones

Premium contributions of members

Annual appropriations of the DOH included in the GAA

National Government subsidy to PhilHealth included
in the GAA
** For the first 2 years from the effectivity of this Act, the PCSO. Shall transfer at least 50%
of the 40% of the charity fund per year, in accordance with Section 37 (c) of this Act, to
enable the PCSO to conclude and liquidate its Individual Medical Assistance Program at
Source - Ang - Processing (IMAP-ASAP) obligations.
CONTRIBUTION
Sec 10 Premium Contributions

For Direct contributors, premium rates shall be in accordance

with the following schedule and monthly income floor and
ceiling:

Year Premium Rate Income Floor Income Ceiling

2019 2.75% Php 10,000.00 Php 50,000.00
2020 3.00% Php 10,000.00 Php 60,000.00
2021 3.50% Php 10,000.00 Php 70,000.00
2022 4.00% Php 10,000.00 Php 80,000.00
2023 4.50% Php 10,000.00 Php 90,000.00
2024 5.00% Php 10,000.00 Php 100,000.00
2025 5.00% Php 10,000.00 Php 100,000.00
 NATIONAL HEALTH INSURANCE PROGRAM

OTHER DIRECT CONTRIBUTORS

 Overseas Filipino Workers

Minimum
PESO
Monthly Monthly Quarterly Semi- Annual
EQUIVALENT
Salary in Premium Premium Annually Premium
@ $1=52.00
Dollars

Floor $ 400.00 ₱20,800.00 ₱572.00 ₱1,716.00 ₱3,432.00 ₱6,864.00

Ceiling $ 961.54 ₱50,000.00 ₱1,375.00 ₱4,125.00 ₱8,250.00 ₱16,500.00

Note: Based on draft IRR of UHC as September 26, 2019

 NATIONAL HEALTH INSURANCE PROGRAM

OTHER DIRECT CONTRIBUTORS

Persons with Disability – Premium payments or contributions of formally

employed persons with disability shall be shared equally by their employers and
the National Government.

NO PERSONAL SHARE

Note: Based on draft IRR of UHC as October 7, 2019

Section 38: Penal Provisions
 Offenses of Health Care
Providers of Individual-based
Health Services

Classification of Offenses – classified as fraudulent acts,

unethical acts and abuse of authority acts

Penalties – Php 200,000 for each count or suspension

of contract of up to 3 months, or both at PhilHealth’s
discretion
 Offenses of Members

Any violation of the UHC Act or failure to pay all missed

premiums with interest, compounded monthly, as
provided in Section 9

Classification of Offenses – Knowingly and deliberately

cooperates or agrees, whether explicitly or implicitly, to the
commission of a violation by a contracted HCP or employer,
including the filing of a fraudulent claim for benefits

Penalties – Php 50,000 for each count or suspension of

availment of benefits for 3-6 months or both at PhilHealth’s
discretion
 Offenses of Employers

Failure or refusal to register employees

Classification of Offenses – deliberately or through

inexcusable negligence fails or refuses to register
employees regardless of employment status

Penalties – Php 50,000 for every violation per affected

employee or imprisonment of 6 months to 1 year or both,
at the court’s discretion
 Offenses of Employers

Failure or refusal to deduct contributions from

employees

Classification of Offenses – deliberately or through

inexcusable negligence fails or refuses to accurately and
timely deduct the employees contributions

Penalties – Php 50,000 for every violation per affected

employee or imprisonment of 6 months to 1 year or both,
at the court’s discretion
 Offenses of Employers

Failure or refusal to accurately and timely remit

contributions

Classification of Offenses – deliberately or through

inexcusable negligence fails or refuses to accurately and
timely remit the employees contributions

Penalties – Php 50,000 for every violation per affected

employee or imprisonment of 6 months to 1 year or both,
at the court’s discretion
 Offenses of Employers

Failure or refusal to submit report

Classification of Offenses – deliberately or through

inexcusable negligence fails or refuses to submit the report of
the contributions to PhilHealth

Penalties – Php 50,000 for every violation per affected

employee or imprisonment of 6 months to 1 year or both,
at the court’s discretion
 Presumption of Misappropriation

Any employer, officer, or employee authorized to collect

contributions who, after collecting or deducting the monthly
contributions from the employee’s compensation, fails or
refuses for whatever reason to accurately and timely remit
the contributions to PhilHealth within thirty (30) days from
due date shall be presumed prima facie to have
misappropriated the same and to have been obligated to
hold the same in trust for and in behalf of the employees and
PhilHealth, and shall be immediately obligated to return or
remit the amount.
 Unlawful Deductions

Any employer or its officers or employees who deducts,

directly or indirectly, from the compensation of the covered
employees or otherwise recover from them the employer’s
own contribution on behalf of such employees shall be
punished, after due notice and hearing, with a fine of Five
thousand pesos (P5,000.00) multiplied by the total number
of affected employees or imprisonment of not less than six
(6) months but not more than one (1) year, or both such fine
and imprisonment, at the discretion of the court.
 To summarize, Universal Health Care
is all about...

Service Coverage
Population Coverage • immediate eligibility and
access Financial Coverage
automatic inclusion of • comprehensive outpatient • Zero co-payment
every Filipino citizen into benefit • Fixed, predictable co-
the NHIP • provision of primary care payment
provider
Sama-Sama sa UHC!

THANK YOU!