Published 20 March 2020, The Daily Tribune

Our country’s tenacity and preparedness to respond to public health emergencies are once again put to test by the recent declaration of the outbreak of COVID-19. In a time of uncertainty, it is a great source of comfort that the Philippine Health Insurance Corporation (PhilHealth) will cover costs related to testing for the novel coronavirus for individuals seeking treatment of the disease, on top of coverage for quarantine and isolation costs, pursuant to recent government announcements.

Relating to the COVID-19 outbreak, PhilHealth recently announced that member-patients under investigation (PUI) for possible 2019-nCoV infection who are admitted in health care facilities for isolation and quarantine as advised by competent physicians, including those referred to appointed hospitals and those with moderate to severe pneumonia related thereto are entitled to various benefit packages under PhilHealth.

PhilHealth, a government corporation attached to the Department of Health (DOH) for policy coordination and guidance, is the agency mandated to administer the country’s National Health Insurance Program (NHIP). Its power includes the formulation and implementation of policies for the sound administration of the program and the supervision of the provision of health benefits to members and their dependents.

The NHIP under Republic Act (RA) 7875, as amended, aims to provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines. It serves as a 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.RA 11223 or the Universal Health Care Act, signed into law on 20 February 2019, expanded access to the NHIP by automatically enrolling all Filipinos in PhilHealth. It seeks to ensure that all Filipino citizens have access to a comprehensive set of health services without financial hardship. Under RA 11223, non-members are assured that every Filipino will be treated by any PhilHealth accredited hospital.

Benefits administered by PhilHealth include entitlement of members and their dependents to the following minimum services:

a. For in-patient care, the services include: Room and board; Services of health care professionals; Diagnostic, laboratory, and other medical examination services; Use of surgical or medical equipment and facilities; Prescription drugs and biologicals, subject to the limitations of the law; and, Health Education.

These benefits are paid to the accredited Health Care Institution (HCI). The case rate amount, which includes hospital charges and professional fees of attending physician, shall be deducted by the HCI from the member’s total bill, which shall include professional fees of attending physicians, prior to discharge. To avail, the member must have six months contributions preceding the three months qualifying contributions within the 12-month period prior to the first day of confinement.

b. For out-patient medical and surgical care, these include: Services of health care professionals; Diagnostic, laboratory and other medical services; Personal preventive services; Prescription drugs and biologicals, subject to the limitations of the law; and, Health Education. These include day surgeries (ambulatory or outpatient surgeries), radiotherapy, hemodialysis, outpatient blood transfusion, primary care benefit and extended primary care benefit.

c. Emergency and transfer services

d.Health Education Packages

e. Such other health care services that the Corporation and the DOH shall determine to be appropriate and cost-effective.

Beware however, of criminal sanctions for those who will abuse or take undue advantage of the healthcare benefits granted under the law. Health care providers who violate any provision of RA 11223 and related law, who commit unethical practices, abuse their authority or performs a fraudulent act may be fined P200,000 and its contract suspended for at least three months. This is without prejudice to possibility of imprisonment of six months to six years.

If the erring health care provider is a juridical person such as a corporation, its responsible officers and employees who acted negligently or with intent or have caused the commission of the violation shall be held liable. Employers who fail to register or contribute for their members shall also be held liable.

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