Title
Guidelines on PhilHealth POS Enrollment Program
Law
Philhealth Circular No. 2018-0008
Decision Date
Jun 21, 2018
The Point of Service (POS) Enrolment Program aims to provide immediate PhilHealth coverage to financially incapable Filipinos seeking medical care in government facilities, ensuring universal health access by registering unregistered and inactive members under the National Health Insurance Program.
point of
service
universal coverage

Policy rationale and program objectives

  • The POS Program is implemented under the GAA for 2017 and 2018, particularly Title XXXVI on Budgetary Support to Government Corporations, and the Special Provision on the Attainment of Universal Coverage under PhilHealth.
  • The POS Program covers Filipino citizens who are classified as financially incapable to pay PhilHealth membership according to the DOH classification on indigence, through enrollment via a Point of Service (POS).
  • The Program ensures that financially incapable members are included in the PhilHealth membership database for possible inclusion in the list of beneficiaries whose premiums are shouldered by the National Government.
  • The Program also covers Filipino citizens who are financially capable, who are assessed and enrolled at the POS based on financial capability and are billed annually as regular contributing members.
  • The objectives are to address coverage gaps for financially capable and incapable Filipinos, and registered inactive members, and to ensure 100% availment rate in covering the poor under the National Health Insurance Program.

Definitions and key program terms

  • A Point of Service (POS) Program refers to the GAA-provided program for the current year to cover all Filipinos under the NHIP, including unregistered and inactive registered members, especially those who are financially incapable.
  • A POS Patient refers to the patient (or, if the patient is a minor, the parent or guardian) classified as financially incapable according to the DOH classification on indigents; the patient is registered into the NHIP by the government facility.
  • Financially Capable (Self-Earning Individuals) are individuals who render services or sell goods as livelihood outside an employer-employee relationship or as a career, including listed professional and other self-earning categories (e.g., doctors, lawyers, engineers, architects, artists, businessmen, entrepreneurs, actors/actresses and performers, news correspondents, professional athletes, coaches, trainers, and similar individuals).
  • A National Government Facility (NGF) refers to health facilities owned by a national government agency, including DOH-retained hospitals, PNP hospitals, DND hospitals, and Corporate-Specialty hospitals.
  • Local Government Owned Facilities refers to health facilities owned and managed by Local Government Units.
  • A Medical Social Welfare Officer (MSWO)/Social Welfare Development Officer (SWDO) refers to a DOH-trained social worker assigned in NGFs or LGU-owned hospitals/facilities and tasked to conduct the assessment tool in identifying qualified POS Patients.

Coverage and eligibility rules

  • The Program applies to capturing all unregistered Filipinos and covering all Filipinos, especially those who are financially incapable and seeking medical care in all government facilities.
  • Under the Program, a patient who is unregistered or an inactive member is eligible to avail PhilHealth benefits if:
    • the patient (or parent/guardian if the patient is a minor) is assessed as financially incapable by the MSWO/SWDO; and
    • the patient and his/her parent or guardian are Filipino citizens; and
    • the patient is assessed and admitted in a ward type of accommodation of a government facility, or referred to a private healthcare institution (HCI) after assessment by a government facility.
  • For patients assessed as financially capable, benefit eligibility at point of availment is subject to Section VII.C.3 of the Circular and existing rules on qualifying contribution and entitlement to PhilHealth benefits.
  • POS patients who meet the Program conditions are entitled to benefits within the validity period subject to compliance with other requirements to benefits availment.

Participation requirements for health facilities

  • All NGFs, Local Government Units (LGUs) facilities, and other government hospitals and facilities are entitled to participate in the POS Program if they comply with required participation steps.
  • Facilities must submit a duly accomplished PhilHealth Online Access Form (POAF) (Annex A) and Non-Disclosure Agreement (NDA) (Annex B) to the nearest PhilHealth office.
  • Facilities must ensure availability of a dedicated desktop computer and reliable internet connection connecting to the IHCP Portal and POS System.
  • Facilities must assign an IT personnel to provide technical support to staff implementing the Program.
  • Facilities must assign dedicated staff trained (or undergoing training) in membership and eligibility verification, enrollment using the POS System, and other activities required for Program operation.
  • Facilities must ensure availability of personnel (e.g., licensed MSWO/SWDO) trained by the DOH on administration of the DOH Means Test; if MSWOs/SWDOs have yet to undergo training, the facility must submit a certificate of training to the nearest PhilHealth Office within the implementation period.
  • In the interim case where MSWOs/SWDOs are not yet trained, hospitals must submit to the PhilHealth Regional Office (PRO) the name of the designated accountable person who signs the certificate of assessment.
  • Existing ORE-POC/POS user need only comply with item 5 under participation requirements.

Operational procedures, registration, and claims

  • Identification of qualified POS patients requires ward type patients to be verified through the IHCP Portal to determine whether the patient is already a member or a dependent and eligible for benefits.
  • Unregistered Filipinos and inactive members must be interviewed and assessed by the MSWO (for NGFs) or SWDO (for LGU facilities) using the DOH-prescribed assessment tool.
  • Patients assessed as financially incapable by the MSWO/SWDO, and their parents/guardians, qualify for POS and may immediately avail of benefits.
  • Registration for POS patients (unregistered): POS patients must accomplish and sign the PhilHealth Member Registration Form (PMRF).
  • The MSWO/SWDO (or hospital-designated personnel) must register POS patients through the POS System within 72 hours from the date of admission or prior to discharge.
  • In lieu of the Medical Social Services (MSS) intake form, the MSWO/SWDO must issue a pro-forma Certificate of Assessment signed by the MSWO/SWDO to financially capable and incapable POS patients (Annex C).
  • If the POS System is not available or not functioning (e.g., connection problem), PIN assignment can be done by submitting the PMRF for PIN assignment within 72 hours of admission via:
    • email scanned copy;
    • fax; or
    • other means agreed/arranged with the PRO/LHIO.
  • After securing the PIN, the PIN must be indicated in the original PMRF to attach to claim documents upon filing.
  • If the patient is admitted on a weekend, holiday, or outside the working hours/schedule of the MSWO/SWDO, assessment must occur upon the MSWO/SWDO’s return, and the patient must be registered in the Program the next working day prior to discharge.
  • Women about to give birth may be registered under the Program subject to the applicable existing policy on Social Health Insurance Coverage and Benefits for Women About to Give Birth (WATGB).
  • A patient below 21 years old who is an undeclared dependent must have the parents’ Member Data Record (MDR) updated to include the patient as dependent; if the parent has no current coverage, the parent is assessed under the Program.
  • Orphaned and abandoned children and mentally-ill vagrants must be registered as principal members, with PMRF accomplished and signed by the guardian or the MSWO/SWDO.
  • For abandoned patients with unknown address, the address of the hospital must be used; for vagrants/street dwellers, the address where they were found must be used.
  • After POS registration, the system prompts the PRO Membership Section or LHIO to conduct validation and PIN assignment; newly registered members’ PINs must be emailed/transmitted to HCIs to be indicated in the claim form and POS registration slip.
  • The MSWO/SWDO must advise patients or their representatives to request their MDRs at any Local Health Insurance Office (LHIO).
  • Entitlement to benefits for POS financially incapable patients and dependents: benefits are immediate within the validity period subject to compliance with requirements to benefits availment, including:
    • In-patient/Out-patient benefits under All Case Rates (ACR) (including preauthorization surgery requirement);
    • Z Benefits (including PhilHealth dialysis database registration for all dialysis patients); and
    • No Balance Billing (NBB).
  • Financially capable patients: eligibility to inpatient/outpatient benefits depends on payment of annual premium as prescribed by the Corporation, and eligibility for Z benefits follows existing rules.
  • Financially capable patients who paid the prescribed annual premium are covered and entitled to benefits within the calendar year.
  • If POS-patient availment occurs when the POS system or portal is not available, the patient must secure a CEI from the nearest PhilHealth Office or a PhilHealth CARES Form (PCF) from the PhilHealth Customer Assistance, Relations and Empowerment Staff (PCARES) personnel assigned in the health facility.
  • Benefit availment in private facilities is allowed if conditions are met:
    • there is an appropriate referral from a government facility, and a copy of the referral form or certification from the referring government hospital is attached to the claim form;
    • the case involves dengue patients immunized under the DOH School/Community Based Immunization (SBI) program, supported by a copy of RHU/Physician/School-issued immunization record or certificate of immunization with Dengvaxia attached to claim documents;
    • the case is an emergency case with a resuscitation package; or
    • the patient is financially incapable affected by fortuitous events in declared calamity areas (PhilHealth Circular No. 0034 series 2013).
  • Claims filing: only claims for POS patients registered in POS/PhilHealth with a PIN are submitted for processing, and the PIN must be indicated in Claims Form 1.
  • For first claim filing, the following are required:
    • duly accomplished and signed PMRF;
    • Registration Slip; and
    • MSWO/SWDO Certificate of Assessment.
  • Manual claims filing is allowed for government HCIs not yet enrolled in eClaims.
  • For government HCIs under eClaims, the MSWO/SWDO Certificate of Assessment must be scanned as part of documentary requirements for uploading electronic claims.
  • All other rules and requirements for benefit availment apply.

Sustainability, monitoring, and implementation mechanics

  • PhilHealth must endorse to the DSWD, on a quarterly basis, the list of POS financially incapable registered patients for assessment.
  • Patients assessed as poor are included in Listahanan by the DSWD for coverage as Indigent Members in succeeding years.
  • PhilHealth must devise a mechanism for monitoring and evaluation of the Program based on benefit utilization and other pertinent statistics.

Fund source, transitory transition, and repeal

  • The required annual premium contribution for the coverage of Sponsored Members through POS enrolment is sourced from the annual General Appropriations.
  • The POC Enrollment Program (Revision 1) under PhilHealth Circular No. 033-2015 is transitioned to POS effective July 1, 2018, and the POC-ORE system is deactivated starting July 1, 2018.
  • Enrolled patients under POC on or prior to June 30, 2018 are reimbursed subject to existing rules for availment under the POC enrollment scheme and remain entitled to benefits until December 31, 2018.
  • All previous issuances inconsistent with any provision of the Circular are amended, modified, or repealed accordingly.

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