# Philippine Health Insurance Corporation

The Philippine Health Insurance Corporation (PhilHealth) is a tax-exempt, government-owned and controlled corporation (GOCC) of the Philippines that provides health insurance to the country. It was created on 1995 to implement universal health coverage in the Philippines, and is attached to the Department of Health. On August 4, 1969, Republic Act 6111 or the Philippine Medical Care Act of 1969 was signed by President Ferdinand E. Marcos and implemented in August 1971.
Its stated goal is to "ensure a sustainable national health insurance program for all", according to the company. In 2010, it claimed to have achieved "universal" coverage at 86% of the population, although the 2008 National Demographic Health Survey showed that only 38 percent of respondents were aware of at least one household member being enrolled in PhilHealth. Nevertheless, this social insurance program provides a means for the healthy to pay for the care of the sick and for those who can afford medical care to subsidize those who cannot.
The system works by having individuals who can afford to pay health insurance pay either monthly, quarterly, or yearly premiums to PhilHealth for their health insurance. The amount they pay is based on their employment status and salary. Individuals who cannot afford the premium such as indigents are subsidised by either the national or their local governments.

## History

The Philippine Medical Care Program began in 1971 following the Philippine Medical Care Act of 1969. It mandated creation of the Philippine Medical Care Commission (PMCC). In 1990, bills were passed that led to significant improvement of public health care insurance. House Bill 14225 and Senate Bill 01738 became Republic Act 7875, known as "The National Health Insurance Act of 1995". Approved by President Fidel Ramos on February 14, 1995, this become the basis of the Philippine Health Insurance Corporation. On its 16th anniversary, the song "PhilHealth: Tapat na Serbisyo, Tapat na Benepisyo, Lahat Panalo" was introduced .

## Mandate and functions

PhilHealth has six major membership categories covering nearly the entire population. Those who count under the (1) "Formal" sector are workers employed by public and private companies and other institutions. (2) "Indigents" (also called "PhilHealth Ng Masa") are subsidized by national government through the National Household Targeting System for Poverty Reduction. (3) "Sponsored Members" are subsidized by their respective Local Governments (LGU). (4) "Lifetime" (non-paying) members are retirees and pensioners which have already paid premiums for 120 months of membership. (5) "Senior Citizen" (under RA 10645) allows all Filipino citizens 60 years old and above to be eligible to have free PhilHealth coverage. (6) "The 'Informal Economy' is composed of informal sectors, self-earning individuals, organized groups, Filipinos with dual citizenship, and natural-born citizens. Although treated separately, the Overseas Filipino Workers (OFW) program or migrant workers are part of the informal economy. Migrant workers are sub-categorized as either land-based or sea-based (for seafarers).
Since 1996, the benefits package and delivery system have improved. PhilHealth now has an Outpatient and Diagnostic Package limited to indigent beneficiaries. This addition creates nearly comprehensive coverage for indigents. In 2011, 23 Case Rates was introduced and in 2013, All Case Rates was fully implemented. All other beneficiaries have access to nearly all comprehensive services, excluding some outpatient care. PhilHealth has an accreditation program for private hospitals.
Some key reform indicators to date include:
* Estimated coverage is 100% as of June 2013
* Average period for payment of providers is estimated at 70 to 75 days. The law requires PhilHealth to reimburse providers and/or members within 60 days. A recent move as of December 1, 2009, implemented a "simplified reimbursement scheme" wherein 95% of the amount of the claim is reimbursed after a rapid assessment of member and provider eligibility and the remaining 25% follows after detailed review of the claims.
On average, 90 out of every 100 claims are paid, 3 to 4 are denied, and 6 to 7 are returned to health care providers for more information. 28% of claims were submitted by public providers and 72% by private providers.

## Frauds and controversies

In 2013, fraudulent claims Juan Miguel of Regional 1 started fire with against the state-health insurer were estimated at 4 billion pesos. However, the state failed to prosecute erring doctors, private and public hospitals, and public officials. AFP Medical Center, St. Luke's Hospital, Philippine Orthopedic Hospital, University of Santo Tomas Hospital, East Avenue Medical Center, Cardinal Santos Medical Center, Medical City, National Kidney and Transplant Institute, General Santos Doctors Hospital (GSDH) were investigated for health insurance fraud. In Iloilo, eye-doctor claims for 2,071 operations in 2006 amounting to PHP16 million in professional fees were also investigated. A hospital in Davao City also noticed that a janitor, not a PhilHealth member, had been lying in bed to claim benefits as a PhilHealth-accredited patient. Also in 2006, PhilHealth revoked the accreditation of Sara Medical Clinic in Midsayap for admitting ghost patients. 2018, A lawmaker was shocked to find out that Philhealth interim president Celestina Dela Serna spent one year living at a hotel worth P3,800 per night instead of renting a condominium unit or apartment in Metro Manila. Negros Oriental Rep. Arnulfo Teves said he and House Speaker Pantaleon Alvarez had the chance to talk to Dela Serna during an event at the House of Representatives, and they were appalled at her extravagant lifestyle. "She admitted to staying in the hotel for one year or more… More or less one year sa hotel siya nakatira charged to Philhealth and she said she thought it was okay, that's why she did it," he said. Teves said Dela Serna told him and Alvarez that she stayed at Legend Villas, where rooms are worth at least P3,800 a night.
A Change.org petition was made by a group of overseas Filipino workers (OFWs) to scrap the agency's directive to increase the mandatory contribution collection to 3%. The petition refers to PhilHealth Circular 2020-0014, dated April 2, 2020, in which the current OFW salaries are affected especially in the ongoing pandemic. President Rodrigo Duterte then suspends the collections, and the agency is looking at a longer payment period following backlash.
On July 24, 2020, anti-fraud legal officer Thorrsson Montes Keith resigned due to rampant corruption and anomalies within the agency. His salary and hazard pay have been delayed from the time he started and his resignation would be effective August 31. According to Presidential Spokesman Harry Roque, it would be looking into the alleged overpricing of the proposed IT system supposedly costing around PHP 2 billion, with one laptop allegedly bought at a staggering cost of 115.32 million pesos. PhilHealth has yet to receive the resignation letter and a statement in response. The Senate is looking to investigate the allegation.
On August 25, 2021, Senator Richard Gordon presented the Senate blue ribbon committee report containing the findings of its 2019 investigation into the alleged fraud and corruption within the state-run health insurer. Video footage inside the report included a PhilHealth Regional Vice President receiving a gift which turned out to be a girl wearing a bra and underwear dancing in front of the RVP, and employees shouting as one could expect a show from a nightclub.
On August 26, 2021, the President and chief executive officer of PhilHealth, Ricardo Morales resigned from his post over anomalies in the agency. Morales said that he will submit his resignation letter to the Malacanang Palace. PhilHealth SVP for Legal Sector Rodolfo del Rosario Jr. also resigned.
In September 2023, Philhealth was hacked with the Medusa ransomware. Multiple employee and other internal data were breached, with a possibility of member data as well. The hackers responsible for the ransomware demanded $300,000 or around PHP 17 million. Philhealth refused to pay the ransom, thus the hacker group published all the stolen data in the dark web. Multiple sensitive data became available publicly such as hospital billing, internal memos, and identification documents. Philhealth has said that member data has not been compromised as it is located in a separate server. The National Privacy Commission has begun investigating in regards to the true extent of the leak.
On August 2, 2024, the Senator Koko Pimentel public health advocates group filed certiorari and prohibition with restraining order to stop the transfer of P89.9 billion PhilHealth funds to the national budget. The petitioners challenged the constitutionality of DOF Circular No. 003-2024. Secretary Ralph Recto, however, defended the remittance of unused government subsidies to the national treasury. He explained that the Circular merely implements of a Congressional order under Section XLIII (1)(d) Republic Act No. 11975, the General Appropriations Act 2024.