National Health Insurance Act of 2013

Section 5

There is hereby created the National Health Insurance Program which shall provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines, in accordance with the policies and specific provisions of this Act. This social insurance program 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 programs I and II or Medicare and be expanded progressively to constitute one universal health insurance program for the entire population. The 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. The Program shall be limited to paying for the utilization of health services by covered beneficiaries or to purchasing health services in behalf of such 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.

Section 6

All citizens of the Philippines shall be covered by the National Health Insurance Program. In accordance with the principles of universality and compulsory coverage enunciated in Section 2(b) and 2(l) hereof, implementation of the Program shall ensure sustainability of coverage and continuous enhancement of the quality of service: Provided, That the Program shall be compulsory in all provinces, cities and municipalities nationwide, notwithstanding the existence of LGU-based health insurance programs: Provided, further, That the Corporation, Department of Health (DOH), local government units (LGUs), and other agencies including nongovernmental organizations (NGOs) and other national government agencies (NGAs) shall ensure that members in such localities shall have access to quality and cost-effective health care services. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013])

Section 7

The Corporation shall enroll beneficiaries in order for them to avail of benefits under this Act with the assistance of the financial arrangements provided by the Corporation under the following categories: (a) Members in the formal economy; (b) Members in the informal economy; (c) Indigents; (d) Sponsored members; and (e) Lifetime members. The process of enrollment shall include the identification of beneficiaries, issuance of appropriate documentation specifying eligibility to benefits, and indicating how membership was obtained or is being maintained. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013])

Section 8

In conjunction with the enrollment provided above, the Corporation through its local office shall issue a health insurance ID with a corresponding ID number which shall be used for purposes of identification, eligibility verification, and utilization recording. The issuance of this ID card shall be accompanied by a clear explanation to the enrollee of his rights, privileges and obligations as a member. A list of health care providers accredited by the Local Health Insurance Office shall likewise be provided to the member together with the ID card. The absence of the ID card shall not prejudice the right of any member to avail of benefits or medical services under the National Health Insurance Program (NHIP). This health insurance ID card with a corresponding ID number shall be recognized as a valid government identification and shall be presented and honored in transactions requiring the verification of a person's identity. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013])

Section 9

A citizen can be under only one Local Health Insurance Office which shall be located in the province or city of his place of residence. A person who changes residence, becomes temporarily employed, or for other justifiable reasons, is transferred to another locality should inform said Office of such transfer and subsequently transfer his Program membership.

Section 10

Members and their dependents are entitled to the following minimum services, subject to the limitations specified in this Act and as may be determined by the Corporation: (a) Inpatient hospital care: (1) room and board; (2) services of health care professionals; (3) diagnostic, laboratory, and other medical examination services; (4) use of surgical or medical equipment and facilities; (5) prescription drugs and biologicals, subject to the limitations stated in Section 37 of this Act; and (6) inpatient education packages; (b) Outpatient care: (1) services of health care professionals; (2) diagnostic, laboratory, and other medical examination services; (3) personal preventive services; and (4) prescription drugs and biologicals, subject to the limitations described in Section 37 of this Act; (c) Emergency and transfer services; and (d) Such other health care services that the Corporation and the DOH shall determine to be appropriate and cost-effective. These services and packages shall be reviewed annually to determine their financial sustainability and relevance to health innovations, with the end in view of quality assurance, increased benefits and reduced out-of-pocket expenditure. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013])

Section 11

The Corporation shall not cover expenses for health services which the Corporation and the DOH consider cost-ineffective through health technology assessment. The Corporation may institute additional exclusions and limitations as it may deem reasonable in keeping with its protection objectives and financial sustainability. (Amendment to R.A. No. 7875, Republic Act No. 9241, [February 10, 2004], as further amended by National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013])

Section 12

A member whose premium contributions for at least three (3) months have been paid within six (6) months prior to the first day of availment, including those of the dependents, shall be entitled to the benefits of the Program: Provided, That such member can show that contributions have been made with sufficient regularity: Provided, further, That the member is not currently subject to legal penalties as provided for in Section 44 of this Act. The following need not pay the monthly contributions to be entitled to the Program's benefits: (a) Retirees and pensioners of the SSS and GSIS prior to the effectivity of this Act; and (b) Lifetime members. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013])

Section 13

The corporation shall develop and enforce mechanisms and procedures to assure that benefits are portable across Offices.