23 September 2020
In our previous article, we discussed the Universal Health Care Act (“UHC Act”) and its health care delivery systems: (1) population-based health services, and (2) individual-based health services. Let us now take a look at the kinds of membership and the establishment of the health care provider network.
Every Filipino citizen is automatically included in the National Health Insurance Program (the “Program”) regardless of the presence or lack of contribution. Pursuant to the UHC Act, members are classified as either direct or indirect contributors.
Direct contributors refer to those who have the capacity to pay premiums, are gainfully employed and are bound by an employer-employee relationship, or are self-earning, professional practitioners, migrant workers, including their qualified dependents, and lifetime members. They include kasambahays, overseas Filipino workers, Filipinos living abroad, including those with dual citizenship. The premium rates of the direct contributors depend on their monthly income floor and ceiling. All basic benefits are available to all contributors, however, certain benefits may be made exclusive to direct contributors as determined by PhilHealth.
n the other hand, indirect contributors refer to all others not included as direct contributors, as well as their qualified dependents, whose premium shall be subsidized by the national government or as a result of special laws. They are (1) indigents identified by the Department of Social Welfare and Development (“DSWD”); (2) beneficiaries of Pantawid Pamilyang Pilipino Program/Modified Conditional Cash Transfer (4Ps/MCCT); (3) senior citizens who are not currently covered by the Program; (4) Persons with disability, as defined in RA 10754; (5) all Filipinos aged 21 years old and above without the capacity to pay premiums; (6) Sangguniang Kabataan officials, as defined in RA 10742; and those previously identified at point-of-service (POS) or during registration, members previously sponsored by local government units (“LGU”) and those who are not yet included in the PhilHealth database and are financially incapable to pay premiums. The premium subsidy for indirect contributors shall be gradually adjusted and included annually based on the national budget. A corresponding increase in benefits shall be provided for every increase in the premium subsidy of the indirect contributors.
Clearly, the UHC Act affords health care benefits to all Filipinos regardless of income status. Whether a direct or indirect contributor, a member shall be provided with basic health care services.
Another interesting feature of the UHC Act is the establishment of the health care provider network. Considering that navigating the Philippine healthcare system can be daunting and puzzling, where get patients may get confused as to what kind of doctors to consult, which tests to undergo, or where to access healthcare, the UHC Act responds accordingly by establishing a standardized procedure to access health care facilities. Thus, access to health care is a now two-step process – (1) initial contact with primary care provider, and (2) referral to secondary or tertiary health care providers, within the same network, if medically necessary.
What is a health provider network? A health care provider network refers to a group of hospitals, clinics, rehabilitation centers, health care professionals, pharmacies, and/or laboratory clinics, whether publicly or privately held, which offer comprehensive care in an integrated and coordinated manner with the primary care provider acting as the navigator and coordinator of health care within the network.
A member who wants to access health care services goes to a primary care provider. A primary care provider is a DOH certified health worker, like a local health worker or a health professional, who acts as the initial and continuing point of contact in health care delivery system. He/she will guide the member in decision making to make access to health care facilities cost-efficient while ensuring appropriate levels of care. In the UHC Act, every Filipino shall register with a public or private primary care provider. For public health care provider networks, LGUs shall register their respective constituents to a primary care provider within their territorial jurisdiction.
If determined by a private primary care provider as medically necessary, he/she shall refer the member to a secondary or tertiary health care provider within the same network to address the member’s health care needs. By referring to a health care provider within the same network, a member’s medical records are readily accessible by all those within the same network thus ensuring seamless, integrated and coordinated care.
With the establishment of the health care provider networks, the public and private health care industry is made more efficient, reliable and accessible. Members are guided throughout their journey to achieve good or better health.
For further information, please contact:
Nilo T. Divina, Managing Partner, DivinaLaw
nilo.divina@divinalaw.com
