QuestionsQuestions (PHILHEALTH CIRCULAR NO. 0032, S. 2013)
The Circular cites RA 7875 as amended by RA 10606, particularly: (1) Section 6 (universality and compulsory coverage), (2) Section 2(b) and 2(l) (principles of universality and compulsory coverage), (3) Section 3(c) (prioritize and accelerate health services, especially for those who cannot afford them), and (4) Section 7 (indigents not enrolled have priority in government hospitals/health providers and should be subsequently enrolled).
Patients, and their families, who qualify on assessment by the Medical Social Worker at the time of admission in government health care institutions, specifically: (1) non-members assessed and classified as Class C-3 or D; and (2) members not covered due to lack of qualifying contribution and classified as Class C-3 or D.
The MSW interviews and assesses all non-members and non-eligible members using the intake survey sheet prescribed in DOH Administrative Order 51, s. 2001 (and/or related issuances). Those classified as Class C3 or Class D are enrolled accordingly.
As much as practicable, assessment by the MSW is conducted upon admission. Enrollment follows the classification of the patient as Class C3 or D at that time.
No. Patients availing outpatient services (e.g., cataract surgery, hemodialysis, and the like) shall not be enrolled. However, HSMs may avail these outpatient services for their succeeding hospitalization.
Outpatient services are not covered for enrollment at the point of care. Specifically stated that patients availing of outpatient services shall not be enrolled; outpatient benefits may be availed only for subsequent hospitalization.
The Health Care Institution (HCI) shall be the premium donor. Under no circumstance shall the hospital ask the patient for any amount as the patient’s share for premium.
The Circular states that the premium amount for HSMs shall be the same rate as the annual premium for Sponsored Program Members, currently Php 2,400 per year.
Coverage starts on the first day of the confinement month and ends on the last day of the same year.
HSMs are entitled to immediate availment of NHIP benefits, including inpatient benefits, outpatient benefits except Primary Care Benefit 1, and No Balance Billing.
It means the patient should not be required to pay additional amounts beyond what PhilHealth covers for eligible benefits, consistent with the NHIP policy embedded in the Circular’s grant of benefits to HSMs.
PhilHealth must process HSM claims within thirty (30) days upon receipt of completed claim documents.
No. HSM claims shall not be returned to the hospital for membership and eligibility concerns, though claims may still be returned or ultimately denied for other issues such as benefit availment, processing rules, or accreditation concerns.
PhilHealth submits the list of HSMs to the DSWD for validation. Those validated as poor are included in the National Household Targeting System (NHTS) list and thereby become covered for succeeding years under the Sponsored Program.
All DOH-retained hospitals must mandatorily implement it. Participation of LGU hospitals is subject to PhilHealth’s approval upon submission of a Letter of Intent. Other government hospitals (e.g., DND, academic, state hospitals) may also participate upon PhilHealth approval via Letter of Intent.
It provides that all provisions of previous issuances inconsistent with any provisions of the Circular are amended/modified or repealed accordingly.
It takes effect fifteen (15) days after publication in any newspaper of general circulation, and thereafter it must be deposited with the National Administrative Register at the University of the Philippines Law Center.