National Health Insurance Act of 2013

Section 4 · cited in the answer

For the purpose of this Act, the following terms shall be defined as follows: a) Beneficiary — Any person entitled to health care benefits under this Act. b) Benefit Package — Services that the Program offers to its members. c) Capitation — A payment mechanism where a fixed rate, whether per person, family, household, or group, is negotiated with a health care provider who shall be responsible for delivering or arranging for the delivery of health services required by the covered person under the conditions of a health care provider contract. d) Contribution — The amount paid by or in behalf of a member to the Program for coverage, based on salaries or wages in the case of formal sector employees, and on household earnings and assets, in the case of self-employed, or on other criteria as may be defined by the Corporation in accordance with the guiding principles set forth in Article 1 of this Act. e) Coverage — The entitlement of an individual, as a member or as a dependent, to the benefits of the Program. f) Dependent — The legal dependents of a member are: 1) the legitimate spouse who is not a member; 2) the unmarried and unemployed legitimate, legitimated, illegitimate, acknowledged children as appearing in the birth certificate; legally adopted or stepchildren below twenty-one (21) years of age; 3) children who are twenty-one (21) years old or above but suffering from congenital disability, either physical or mental, or any disability acquired that renders them totally dependent on the member of our support; (4) the parents who are sixty (60) years old or above whose monthly income is below an amount to be determined by the Corporation in accordance with the guiding principles set forth in Article I of this Act; and (5) parents with permanent disability that render them totally dependent on the member for subsistence. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013]) g) Diagnostic Procedure — Any procedure to identify a disease or condition through analysis and examination. h) Emergency — An unforeseen combination of circumstances which calls for immediate action to preserve the life of a person or to preserve the sight of one or both eyes; the hearing of one or both ears; or one or two limbs at or above the ankle or wrist. i) Employee — Any person who performs services for an employer in which either or both mental and physical efforts are used and who receives compensation for such services, where there is an employer-employee relationship. j) Employer — A natural or juridical person who employs the services of an employee. k) Enrollment — The process to be determined by the Corporation in order to enlist individuals as members or dependents covered by the Program. l) Fee for Service — A fee pre-determined by the Corporation for each service delivered by a health care provider based on the bill. The payment system shall be based on a pre-negotiated schedule promulgated by the Corporation. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013]) m) Global Budget — An approach to the purchase of medical services by which health care provider negotiations concerning the costs of providing a specific package of medical benefits is based solely on a predetermined and fixed budget. n) Government Service Insurance System — The Government Service Insurance System created under Commonwealth Act No. 186, as amended. o) Health Care Provider — Refers to: (1) a health care institution, which is duly licensed and accredited devoted primarily to the maintenance and operation of facilities for health promotion, prevention, diagnosis, treatment, and care of individuals suffering from illness, disease, injury, disability or deformity, drug addiction or in need of obstetrical or other medical and nursing care. It shall also be construed as any institution, building, or place where there are installed beds, cribs, or bassinets for twenty-four hour use or longer by patients in the treatment of diseases, injuries, deformities, or abnormal physical and mental states, maternity cases or sanitary care; or infirmaries, nurseries, dispensaries, rehabilitation centers and such other similar names by which they may be designated; or (2) a health care professional, who is any doctor of medicine, nurse, midwife, dentist, or other health care professional or practitioner duly licensed to practice in the Philippines and accredited by the Corporation; or (3) a health maintenance organization, which is an entity that provides, offers, or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium; or (4) a community-based health care organization, which is an association of indigenous members of the community organized for the purpose of improving the health status of that community through preventive, promotive and curative health services. p) Health Insurance Identification (ID) Card — The document issued by the Corporation to members and dependents upon their enrollment to serve as the instrument for proper identification, eligibility verification, and utilization recording. q) Indigent — A person who has no visible means of income, or whose income is insufficient for the subsistence of his family, as identified by the Department of Social Welfare and Development (DSWD) based on specific criteria set for this purpose in accordance with the guiding principles set forth in Article I of this Act. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013]) r) Inpatient Education Package — A set of informational services made available to an individual who is confined in a hospital to afford him with knowledge about his illness and its treatment, and of the means available, particularly lifestyle changes, to prevent the recurrence or aggravation of such illness and to promote his health in general. s) Member — Any person whose premiums have been regularly paid to the National Health Insurance Program who may be a paying member, a sponsored member, or a lifetime member. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013]) t) Means Test — A protocol administered at the barangay level to determine the ability of individuals or households to pay varying levels of contributions to the Program, ranging from the indigent in the community whose contributions should be totally subsidized by the government, to those who can afford to subsidize part but not all the required contributions for the Program. u) Medicare — The health insurance program currently being implemented by the Philippine Medical Care Commission. It consists of: (1) Program I, which covers members of the SSS and GSIS including their legal dependents; and (2) Program II, which is intended for those not covered under Program I. v) National Health Insurance Program — The compulsory health insurance program of the government as established in this Act, which shall provide universal health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines. w) Pensioner — An SSS or GSIS member who receives pensions therefrom. x) Personal Health Services — Health Services in which benefits accrue to the individual person. These are categorized into inpatient and outpatient services. y) Philippine Medical Care Commission — The Philippine Medical Care Commission created under Republic Act No. 6111, as amended. z) Philippine National Drug Formulary — The essential drugs list for the Philippines which is prepared by the National Drug Committee of the Department of Health in consultation with experts and specialists from organized professional medical societies, medical academe and the pharmaceutical industry, and which is updated every year. (aa) Portability — The enablement of a member to avail of Program benefits in an area outside the jurisdiction of his Local Health Insurance Office. (bb) Prescription Drug — A drug which has been approved by the Bureau of Food and Drug and which can be dispensed only pursuant to a prescription order from a physician who is duly licensed to do so. (cc) Public Health Services — Services that strengthen preventive and promotive health care through improving conditions in partnership with the community at large. These include control of communicable and non-communicable diseases, health promotion, public information and education, water and sanitation, environmental protection, and health-related data collection, surveillance, and outcome monitoring. (dd) Quality Assurance — A formal set of activities to review and ensure the quality of services provided. Quality assurance includes quality assessment and corrective actions to remedy any deficiencies identified in the quality of direct patient, administrative, and support services. (ee) Residence — The place where the member actually lives. (ff) Retiree — A member of the Program who has reached the age of retirement as provided for by law or who was retired on account of permanent disability as certified by the employer and the Corporation. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013]) (gg) Self-employed — A person who works for himself and is therefore both employee and employer at the same time. (hh) Social Security System — The Social Security System created under Republic Act No. 1161, as amended. (ii) Treatment Procedure — Any method used to remove the symptoms and cause of a disease. (jj) Utilization Review — A formal review of patient utilization or of the appropriateness of health care services, on a prospective, concurrent or retrospective basis. (kk) Rehabilitation Center — Refers to a facility, which undertakes rehabilitation of drug dependents. It includes institutions, agencies and the like which have for their purpose, the development of skills, or which provides counselling, or which seeks to inculcate, social and moral values to clientele who have a drug problem with the aim of weaning them from drugs and making them drug free, adapted to their families and peers, and readjusted into the community as law-abiding, useful and productive citizens. (ll) Home Care and Medical Rehabilitation Services — Refer to skilled nursing care, which members get in their homes/clinics for the treatment of an illness or injury that severely affects their activities or daily living. Home care and medical rehabilitation services include hospice or palliative care for people who are terminally ill but does not include custodial and non-skilled personal care. (Amendment to R.A. No. 7875, Republic Act No. 9241, [February 10, 2004]) (mm) Abandoned Children — Children who have no known family willing and capable to take care of them and are under the care of the DSWD, orphanages, churches and other institutions. (nn) Case-based Payment — Hospital payment method that reimburses to hospitals a predetermined fixed rate for each treated case or disease; also called per case payment. (oo) Health Technology Assessment — A field of science that investigates the value of a health technology such as procedure, process, products, or devices, specifically on their quality, relative cost-effectiveness and safety. It usually involves the science of epidemiology and economics. It has implications on policy, decision to adopt and invest in these technologies, or in health benefit coverage. (pp) Informal Sector — Units engaged in the production of goods and services with the primary objective of generating employment and income for the persons concerned. It consists of households, unincorporated enterprises that are market and nonmarket producers of goods, as well as market producers of services. These enterprises are operated by own-account workers, which may employ unpaid family workers as well as occasional, seasonally hired workers. To this sector belong, among others, street hawkers, market vendors, pedicab and tricycle drivers, small construction workers and home-based industries and services. (qq) Other Self-earning Individuals — Individuals who render services or sell goods as a means of livelihood outside of an employer-employee relationship, or as a career, but do not belong to the informal sector. These include businessmen, entrepreneurs, actors, actresses and other performers, news correspondents, professional athletes, coaches, trainers, and other individuals as recognized by the Department of Labor and Employment (DOLE) and/or the Bureau of Internal Revenue (BIR). (rr) Out-patient Services — Health services such as diagnostic consultation, examination, treatment, surgery and rehabilitation on an out-patient basis. (ss) Professional Practitioners — Include doctors, lawyers, certified public accountants, and other practitioners required to pass government licensure examinations in order to practice their professions. (tt) Traditional and Alternative Health Care — The application of traditional knowledge, skills and practice of alternative health care or healing methods which include reflexology, acupuncture, massage, accupressure, chiropractics, nutritional therapy and other similar methods in accordance with the accreditation guidelines set forth by the Corporation and the Food and Drug Administration (FDA). (uu) Lifetime Member — A former member who has reached the age of retirement under the law and has paid at least one hundred twenty (120) monthly premium contributions. (vv) Members in the Formal Economy — Workers with formal contracts and fixed terms of employment including workers in the government and private sector, whose premium contribution payments are equally shared by the employee and the employer. (ww) Members in the Informal Economy — Workers who are not covered by formal contracts or agreements and whose premium contributions are self-paid or subsidized by another individual through a defined criteria set by the Corporation. (xx) Migrant Workers — Documented or undocumented Filipinos who are engaged in a remunerated activity in another country of which they are not citizens. (yy) Sponsored Member — A member whose contribution is being paid by another individual, government agency, or private entity according to the rules as may be prescribed by the Corporation. (National Health Insurance Act of 2013, Republic Act No. 10606, [June 19, 2013])