Question & AnswerQ&A (PHIC PHILHEALTH CIRCULAR NO. 13, S. 2002)
The OPB is implemented to facilitate universal health coverage by providing outpatient consultation and diagnostic benefits to indigent members nationwide, subject to LGUs' health service capability and PhilHealth's work program.
Priority is given to LGUs identified as Health Sector Reform Agenda (HSRA) Convergence Sites and Urban Areas as defined in PhilHealth Circular No. 21, series of 2001.
Implementation is subject to: a) Percentage of RHUs/HCs capable of implementing the package; b) Accessibility of LGU-owned hospitals from RHUs/HCs without capability; and c) Enrollment threshold of indigent households, which should be at least 200 households per RHU/HC or a reasonable number determined by PhilHealth.
Added preventive services include visual acetic acid screening for cervical cancer, regular blood pressure measurement, annual digital rectal exams, body measurements, periodic clinical breast examinations, smoking cessation counseling, and lifestyle modification counseling.
The requirement may be waived if there is an operational referral system to a central or zonal laboratory that meets the provisions of PhilHealth Circular No. 30, series of 2001. The laboratory can be an attached facility of a hospital or RHU/HC, or an independent LGU-owned entity.
Payments for referred diagnostic services are charged against the PhilHealth Capitation Fund of the accredited RHU, following the guidelines of PhilHealth Circular No. 30, series of 2001. The LGU is responsible for enacting the referral and payment system.
The hospital must be LGU-owned and managed, accredited by PhilHealth, have the service and human resource capability to provide OPB services, and be accessible to non-accredited RHU/HCs.
Twenty percent (20%) of the PCF is to be used for administrative expenses, divided among RHU personnel: 50% to physicians and 50% to other administrative costs of RHU staff involved in OPB services.
Yes. Partial implementation is allowed if the province and its component cities/municipalities enter into a Memorandum of Agreement with PhilHealth and based on assessment of city/municipality-owned RHUs/HCs and accessibility of accredited LGU hospitals.
The Health Finance Policy and Service Sector of PhilHealth spearheads monitoring and evaluation. The Benefits Development Office monitors delivery, while the Accreditation Department and the PhilHealth Regional Offices monitor facility compliance.