PhilHealth Point of Care Enrollment Program

The Circular anchors itself on Republic Act No. 7875, as amended by Republic Act No. 10606, the National Health Insurance Act of 2013.
The Act requires that all citizens of the Philippines be covered by the National Health Insurance Program under the principles of universality and compulsory coverage.
The Act mandates compulsory implementation in all provinces, cities and municipalities nationwide, even if local government units have LGU-based health insurance programs.
The Act requires prioritization and acceleration of health services for Filipinos, especially those who cannot afford such services.
The Act provides that indigents not enrolled receive priority in the use and availment of services and facilities of government hospitals, health care personnel, and other health organizations, with government providers ensuring subsequent enrollment.
The Circular states the Universal Health Care (UHC) or Kalusugang Pangkalahatan (KP) goal of ensuring coverage of all Filipinos, especially the most vulnerable.

Qualified patients and their families receive PhilHealth coverage and are considered Hospital-Sponsored Members (Sponsored Program Members) when they qualify on assessment by the Medical Social Worker at the time of admission to Government Health Care Institutions.
Coverage applies to non-members assessed and classified as Class C-3 or D.
Coverage applies to members who are not covered due to lack of qualifying contribution and are classified as Class C-3 or D.
Patients availing outpatient services (e.g., Cataract Surgery, Hemodialysis, and the like) are not enrolled for this Point of Care program.
Hospital-Sponsored Members (HSMs) may avail the outpatient services only for their succeeding hospitalization.

All DOH-retained hospitals must mandatorily implement the program.
LGU hospitals participate only if the Corporation approves their participation upon submission of a Letter of Intent.
Other government hospitals (including DND hospitals, academic hospitals, state hospitals, and the like) may participate only upon Corporation approval of the Letter of Intent.
Participation is tied to the timing and admissions into Government Health Care Institutions subject to the program rules on enrollment and assessment.

The Medical Social Worker must interview and assess all non-members and non-eligible members for admission/admitted using the intake survey sheet prescribed in DOH Administrative Order 51, s-2001 and/or other issuances relative to it.
As much as practicable, the assessment must be conducted upon admission.
Patients classified as Class C-3 or Class D must be enrolled accordingly as Hospital-Sponsored Members.
The Health Care Institution (HCI) must serve as the premium donor for these HSMs.
The hospital must not ask the patient for any amount as the patient’s share for premium “under no circumstance.”

The premium rate for HSMs must be the same as the annual premium for Sponsored Program Members, which is currently Php2,400 per year.
The validity period of coverage runs from the first day of the confinement month and ends on the last day of the same year.
HSMs must receive immediate availment of NHIP benefits, including inpatient benefits, outpatient benefits (except Primary Care Benefit 1), and No Balance Billing.

HSM claims must be processed by PhilHealth within thirty (30) days upon receipt of completed claim documents.
HSM claims must not be returned to the hospital for membership and eligibility concerns.
PhilHealth’s claims processing policies continue to apply.
PhilHealth reserves the right to return or ultimately deny claims for other benefit availment and accreditation issues.

PhilHealth must submit a list of HSMs to the DSWD for validation.
Those validated as poor must be included in the National Household Targeting System (NHTS) list.
Once included in the NHTS list, validated poor HSMs must be covered for succeeding years under the Sponsored Program.

PhilHealth must devise a mechanism for monitoring and evaluation of the program.
Monitoring and evaluation must consider utilization of benefits and other pertinent statistical reports.

All provisions of previous issuances inconsistent with this Circular are amended, modified, or repealed accordingly.

The enrollment under this Circular operates at the time of admission through assessment by the Medical Social Worker in accordance with program qualification rules and the applicable DOH survey instrument(s).