IMPLEMENTATION OF THE POINT OF CARE ENROLLMENT PROGRAM

Republic Act (RA) 7875, as amended by RA 10606, otherwise known
as The
National Health Insurance Act of 2013 under Section 6 states that:
“All citizens of
the Philippines shall be covered by the National Health Insurance
Program. In
accordance with the principles of universality and compulsory
coverage
enunciated in Section 2(b) and 2(l) hereof, implementation of the
Program shall ensure sustainability of coverage and continuous
enhancement of the quality of
service: Provided, That the Program shall be compulsory in all
provinces, cities
and municipalities nationwide, notwithstanding the existence of
LGU-based
health insurance programs xxx”

Furthermore, Section 3(c) of the same Act emphasizes the need to “prioritize
and accelerate the provision of health services to all Filipinos, especially that
segment of the population who cannot afford such services”. Moreover, Section 7
clearly mentions that “all indigents not enrolled in the Program shall have priority
in the use and availment of the services and facilities of government hospitals,
health care personnel and other health organizations: Provided, however that
such government health care providers shall ensure that said indigents shall
subsequently be enrolled in the Program”.

Under the ambit of Universal Health Care (UHC) or Kalusugang
Pangkalahatan (KP), the Corporation aspires to ensure that all Filipinos,
especially the most vulnerable are covered by PhilHealth. Despite the national
government appropriations, sin tax collections, local government sponsorship
and other sources, statistics and anecdotes have shown that a vast number of
poor are not yet covered by PhilHealth. Ergo, it is deemed necessary that as the
other mechanisms of capturing the poor are being undertaken, a mechanism of
enrolling these patients at the Point of Care shall be established to ensure that all
poor in dire need of quality health services in government hospitals are covered
by PhilHealth.

II. COVERAGE

The following patients, and their families, shall be provided with PhilHealth
coverage and shall be considered as Sponsored Program Members by the
Hospital if they qualify on the assessment administered by the Medical Social
Worker at the time that they were admitted to Government Health Care
Institutions:

1. Non-members, who were assessed and classified as Class C-3 or D.
2. Members who are not covered due to lack of qualifying contribution and
   classified as Class C-3 or D.

Corollary to this, patients availing of outpatient services (e.g. Cataract
Surgery, Hemodialysis and the like) shall not be enrolled. However, Hospital-
Sponsored Members (HSMs) may avail of these outpatient services for their
succeeding hospitalization.

III. PARTICIPATION OF HEALTH CARE INSTITUTIONS

All DOH-retained hospitals shall mandatorily implement the program while
participation of Local Government Unit (LGU) hospitals shall be subject to the
Corporation’s approval upon submission of Letter of Intent. Other government
hospitals (i.e. DND hospitals, academic hospitals, state hospitals and the like)
may also participate in the program upon approval of the Corporation on the
Letter of Intent submitted.

IV. GENERAL POLICIES

1. Identification of Qualified Hospital-Sponsored Members. All nonmembers
   and non-eligible members for admission/admitted shall be
   interviewed and assessed by the Medical Social Worker using the intake
   survey sheet prescribed in DOH Administrative Order 51, s-2001 and/or
   other issuances relative to it. As much as practicable, assessment by the
   MSW shall be conducted upon admission. Patients classified as Class C3 or
   Class D shall be enrolled accordingly.

2. Sponsor. The Health Care Institution (HCI) shall be the premium donor for
   these HSMs. Under no circumstance shall the hospital ask the patient of any
   amount as their share for premium.

3. Premium Cost & Coverage

   a. Rate. The amount of premium shall be the same rate as the annual
   premium for Sponsored Program Members. (Currently at Php2,400 per
   year)
   
   b. Validity. The coverage of HSMs shall be from the first day of the
   confinement month and shall end on the last day of the same year.

4. Benefits. HSMs shall be provided an immediate availment of NHIP benefits,
   including but not limited to: inpatient benefits, outpatient benefits (except
   Primary Care Benefit 1) and No Balance Billing.

5. Claims Reimbursement
   1. HSM claims shall be processed by PhilHealth within thirty (30) days upon
      receipt of completed claim documents.
   2. HSM claims shall not be returned to hospital for membership and
      eligibility concerns. However, policies for claims processing shall still
      apply and the Corporation reserves its right to return or ultimately, deny
      claims for other benefit availment and accreditation issues.

6. Ensuring Sustainability of Coverage. PhilHealth shall submit a list of
   HSMs to DSWD for validation. Those validated as poor shall be included in
   the National Household Targeting System (NHTS) list and thus, shall be
   covered for the succeeding years under the Sponsored Program.

7. Monitoring and Evaluation. The Corporation shall device a mechanism for
   monitoring and evaluation of the program with consideration to utilization of
   benefits and other pertinent statistical reports.

V. REPEALING CLAUSE

All provisions of previous issuances that are inconsistent with any provisions
of this Circular are hereby amended/modified or repealed accordingly.

VI. EFFECTIVITY

This Circular shall take effect fifteen (15) days after publication in any
newspaper of general circulation and shall be deposited thereafter with the
National Administrative Register at the University of the Philippines Law Center.

(SGD) ALEXANDER A. PADILLA
President and CEO