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Republic Act No. 9241

February 10, 2004 (http://www.gov.ph/2004/02/10/republic-act-no-9241/)

Republic of the Philippines

Congress of the Philippines

Metro Manila

Twelfth Congress

Third Regular Session

Begun and held in Metro Manila, on Monday, the twenty-eighth day of July, two thousand three.

[REPUBLIC ACT NO. 9241]

Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled:

AN ACT AMENDING REPUBLIC ACT NO. 7875, OTHERWISE KNOWN AS AN ACT INSTITUTING A
NATIONAL HEALTH INSURANCE PROGRAM FOR ALL FILIPINOS AND ESTABLISHING THE PHILIPPINE
HEALTH INSURANCE CORPORATION FOR THE PURPOSE

SECTION1. Section 4 of Republic Act No. 7875 is hereby amended to read as follows:

SEC. 4. Denition of Terms. For the purpose of this Act, the following terms shall be dened as
follows:

a) Beneciary Any person entitled to health care benets under this Act.

b) Benet Package Services that the Program offers to its members.

c) Capitation A payment mechanism where a xed 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 dened 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 benets 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 certicate; 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.

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 reasonable and equitable health care payment system under which physicians
and other health care providers receive a payment that does not exceed their billed charge for each
unit of service provided.
m) Global Budget An approach to the purchase of medical services by which health care provider
negotiations concerning the costs of providing a specic package of medical benets is based solely
on a predetermined and xed 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 sanitarial care; or inrmaries, 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 xed 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 Identication (ID) Card The document issued by the Corporation to members and
dependents upon their enrollment to serve as the instrument for proper identication, eligibility
verication, and utilization recording.

q) Indigent A person who has no visible means of income, or whose income is insufcient for the
subsistence of his family, as identied by the Local Health Insurance Ofce and based on specic
criteria set by the Corporation in accordance with the guiding principles set forth in Article I of this Act.

r) Inpatient Education Package A set of informational services made available to an individual who is
conned 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. He may be a paying member, an indigent member, or a pensioner/retiree member.

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 benets 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 benets in an area outside the
jurisdiction of his Local Health Insurance Ofce.

(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
deciencies identied 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 or who was retired on
account of disability.

(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.

SEC 2. Section 11 of the same Act shall now read as follows:

SEC. 11. Excluded Personal Health Services. The benets granted under this Act shall not cover
expenses for the services enumerated hereunder except when the Corporation, after actuarial studies,
recommends their inclusion subject to the approval of the Board:

(a) non-prescription drugs and devices;

(b) alcohol abuse or dependency treatment;

(c) cosmetic surgery;

(d) optometric services;

(e) fth and subsequent normal obstetrical deliveries; and

(f) cost-ineffective procedures, which shall be dened by the Corporation.

Provided, That, such actuarial studies must be done within a period of three (3) years, and then
periodically reviewed, to determine the nancial sustainability of including the foregoing personal
health services in the benet package provided for under SEC 10 of this Act.

SEC 3. Section 18 of the Law shall be amended to read as follows:

SEC. 18. The Board of Directors.-

a) Composition The Corporation shall be governed by a Board of Directors hereinafter referred to as

the Board, composed of the following members:

The Secretary of Health;

The Secretary of Labor and Employment or his representative;

The Secretary of the Interior and Local Government or his representative;

The Secretary of Social Welfare and Development or his representative;

The President of the Corporation;

A representative of the labor sector;

A representative of employers;

The SSS Administrator or his representative;

The GSIS General Manager or his representative;

The Vice Chairperson for the basic sector of the National Anti-Poverty Commission or his
representative;

A representative of Filipino overseas workers;

A representative of the self-employed sector; and

A representative of health care providers to be endorsed by the national associations of health care
institutions and medical health professionals.

The Secretary of Health shall be the ex ofcio Chairperson while the President of the Corporation shall
be the Vice Chairperson of the Board.

b) Appointment and Tenure The President of the Philippines shall appoint the Members of the Board
upon the recommendation of the Chairman of the Board and in consultation with the sectors
concerned. Members of the Board shall have a term of four (4) years each, renewable for a maximum
of two (2) years, except for members whose terms shall be co-terminous with their respective
positions in government. Any vacancy in the Board shall be lled in the manner in which the original
appointment was made and the appointee shall serve only the unexpired term of his predecessor.

c) Meetings and Quorum. The Board shall hold regular meetings at least once a month. Special
meetings may be convened at the call of the Chairperson or by a majority of the members of the
Board. The presence of a majority of all the members shall constitute a quorum. In the absence of the
Chairperson and Vice Chairperson, a temporary presiding ofcer shall be designated by the majority of
the quorum.

d) Allowances and Per Diems The members of the Board shall receive a per diem for every meeting
actually attended subject to the pertinent budgetary laws, rules and regulations on compensation,
honoraria and allowances.

SEC 4. Section 29 of the Law shall now read as follows:

SEC. 29. Payment of Indigent Contributions. Contributions for indigent members shall be subsidized
partially by the local government unit where the member resides. The Corporation shall provide
counterpart nancing equal to the LGUs subsidy for indigents: Provided, That in the case of fourth, fth
and sixth class municipalities, the National Government shall provide up to ninety percent (90%) of the
subsidy for indigents until such time that they shall have been upgraded to rst, second or third class
municipalities. The share of the LGUs shall be progressively increased until such time that its share
becomes equal to that of the National Government.

SEC 5. Section 32 of the same Act shall now read as follows:

SEC. 32. Accreditation Eligibility All health care providers, as enumerated in SEC 4(o) hereof and
operating for at least three (3) years may apply for accreditation: Provided, That a health care provider
which has not operated for at least three (3) years may likewise apply and qualify for accreditation if it
complies with all the other accreditation requirements of and further meets any of the following
conditions:

(a) Its managing health care professional has had a working experience in another accredited health
care institution for at least three (3) years;

(b) It operates as a tertiary facility or its equivalent;

(c) It operates in a local government unit where the accredited health care provider cannot adequately
or fully service its population; and

(d) Other conditions as may be determined by the Corporation.

SEC 6. The third paragraph of section 44 (Penal Provisions) of the same Act shall be amended to read
as follows:

Where the violations consist of failure or refusal to deduct contributions from the employees
compensation or to remit the same to the Corporation, the penalty shall be a ne of not less than Five
hundred pesos (500) but not more than One thousand pesos (1,000) multiplied by the total number
of employees employed by the rm and imprisonment of not less than six (6) months but not more
than one (1) year.

SEC 7. Section 54 of the Law shall be amended to read as follows:

SEC. 54. Oversight Provision. Congress shall conduct a regular review of the National Health
Insurance Program, which shall entail a systematic evaluation of the Programs performance, impact or
accomplishments with respect to its objectives or goals. Such review shall be undertaken by the
Committees of the Senate and the House of Representatives, which have legislative jurisdiction over
the Program.

The National Economic and Development Authority, in coordination with the National Statistics Ofce
and the National Institutes of Health of the University of the Philippines shall undertake studies to
validate the accomplishments of the Program. The budget required to undertake such study shall
come from the income of the PhilHealth.

SEC 8. Separability Clause. If any part or provision of this Act shall be held unconstitutional or invalid,
other provisions, which are not affected thereby, shall continue to be in full force and effect.

SEC 9. Repealing Clause. All laws, presidential decrees, executive orders, rules and regulations or
parts thereof which are inconsistent with the provisions of this Act are hereby repealed, amended or
modied accordingly.
SEC 10. Effectivity. This Act shall take effect fteen (15) days after its publication in at least (3)
national newspapers of general circulation.

Approved,

(Sgd.) JOSE DE VENECIA JR.

(Sgd.) FRANKLIN M. DRILON Speaker of the House
President of the Senate of Representatives

This Act which is a consolidation of House Bill No. 5547 and Senate Bill No. 2630 was nally passed
by the House of Representatives and the Senate on October 15, 2003 and October 14, 2003,
respectively.

(Sgd.) ROBERTO P. NAZARENO

(Sgd.) OSCAR G. YABES Secretary General
Secretary of the Senate House of Representatives

Approved: FEB 10 2004

(Sgd.) GLORIA MACAPAGAL-ARROYO

President of the Philippines

Source: CDAsia (http://www.cdasia.com/)

RESOURCES

[PDF] Republic Act No. 9241, February 10, 2004

(http://www.gov.ph/downloads/2004/02feb/20040210-RA-9241-GMA.pdf)

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