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Filipino’s Entitlement of NHIP Benefits

NHIP is short for National Health Insurance Program which was been approved by President Benigno Aquino III in this year 2013. This law amended the National Health Insurance Act of 1995 otherwise known as the Republic Act 7875. This law requires that the State shall provide comprehensive health care services to all Filipinos through socialized insurance program. This will prioritize the health care needs of those who are underprivileged, persons with disabilities (PWDs), women and children, sick, indigents and elderly individuals. The implementation of this program is mandated to be compulsory in all municipalities, cities and provinces nationwide.

Here are five principles that abide the National Health Insurance Program:

  1. Universality – This law shall give all citizens of the Philippines to have an accessto financial assistance of health services.
  2. Social Solidarity – This law shall be influenced with community spirit. It will encourage Filipinos to share resources among individuals of any group.
  3. Care for Indigents – This law mandates the government to present a basic package of health needs for the indigents by giving direct service to them.
  4. Quality Assurance for Health Services –This law shall encourage the government for the delivery of quality health services.
  5. LGU and/or Community Participation – These are the sectors of the government where devolution of roles and responsibilities are passed into.

The classification of its members is categorized into the following criteria:

  1. Overseas Filipino Workers (OFWs)
  2. Individually Paying Members
  3. Qualified Sponsored Members
  4. Retirees and Pensioner – This includes people who are sixty years old with a monthly contribution of one hundred twenty pesos (120.00).
  5. Employed Individuals – This includes individuals who either work in the government sector or private sectors.

For members of NHIP, there are individuals who are included as their beneficiaries: First, children who are twenty-one (21) years old below and those who have physical and mental disabilities. Second, parents who are sixty years old (60) and above. For the benefits to be successfully entitled to its members, this law enlists the following criteria to be met: one, there should be at least three (3) consecutive monthly contributions within the immediate six (6) months prior to admission. Two, the forty-five (45) days allowance given for room and board has not been consumed yet. Lastly, the confinement should not less than twenty-four hours (24) and must be in an accredited hospital. An exception to this is when a patient was transferred to another hospital, emergency case as defined by PhilHealth and/or the patient died. When a member is been confined to a non-accredited hospital, it is still possible if and only if: (1) the hospital has a current Department of Health (DOH) License; (2) the case is emergency; and (3)transfer/referral to a PhilHealth accredited hospital is physically impossible. Providing benefits are categorized into two: outpatient care and inpatient hospital care.

1. Out Patient Care

      • Prescription of drugs and biologicals (subject to the limitations stated in Section 37)
      • Laboratory, diagnostic and other medical examination services
      • Personal preventive services
      • Services of health care team

2. Inpatient Hospital Care

      • Accommodation (room and board)
      • Inpatient education packages
      • Diagnostic, laboratory and other medical examination services
      • Services of health care team
      • Use of surgical or medical equipment and facilities
      • Prescription of drugs and biologicals (subject to the limitations stated in Section 37)

To avail the benefits mentioned above, here are the procedures: (1) the member needs to accomplish the PhilHealth Claim Form 1. (2) They must submit the accomplished form along with other proof of contribution (plus supporting documents) payment and a copy of PhilHealth number card to the hospital’s billing station. (3) The hospital then accomplishes PhilHealth Claim Form 2 and submits it together with PhilHealth Form 1 for reimbursement. The hospital will deduct PhilHealth benefits from hospital bill prior to discharge of the patient.

Not all medical services or treatment can be granted in using the National Health Insurance Program. The following are the exclusions in using the benefits of this law: alcohol abuse or dependency treatment, cosmetic surgery, fourth and subsequent normal obstetrical deliveries; optometric services, non-prescription drugs and services and cost-ineffective procedures as defined by the Corporation.

Image credit: (1)
Source: PhilHealth_Subic_Forum_BenefitsPkg.pdf



About Akisan Macatulad RN

The writer is twenty-two years of age who passed the NLE on July 2011. She graduated as an Academic Distinction Awardee and being the Florence Nightingale Awardee. Currently pursuing to finish her degree in Masters of Arts in Nursing major in Nursing Service Administration (Thesis Program). As of now, she is a Professional Nurse and a Certified Intravenous Therapist. She believes that there is always something in everything that we do. A career-driven, goal-oriented, and a God-centered person.

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