Coverage of Hospital-Sponsored Members (HSMs)
- Patients admitted to government healthcare institutions assessed as Class C-3 or D by a Medical Social Worker are eligible.
- Includes non-members and members not covered due to qualifying contribution deficiency.
- Enrollment limited to admitted patients; outpatient-only availing patients are excluded.
- HSMs can access outpatient services only when linked to subsequent hospitalizations.
Participation of Healthcare Institutions
- Mandatory participation for Department of Health (DOH)-retained hospitals.
- Local Government Unit (LGU) hospitals participate subject to PhilHealth approval via Letter of Intent.
- Other government hospitals (e.g., Department of National Defense, academic, state hospitals) may join if approved by PhilHealth.
General Policies on Identification, Sponsorship, and Benefits
- Qualified patients are identified and assessed by Medical Social Workers using prescribed intake forms at admission.
- The healthcare institution acts as the premium donor; patients are not charged any premium share.
- Annual premium rate for HSMs is aligned with existing Sponsored Program Members (currently Php2,400).
- Coverage period runs from the month of admission to the end of the calendar year.
- HSMs immediately avail of National Health Insurance Program benefits including inpatient, outpatient (excluding Primary Care Benefit 1), and No Balance Billing.
- Claims are processed within 30 days without return for member eligibility issues but may be denied for accreditation or benefit claim concerns.
- PhilHealth collaborates with the Department of Social Welfare and Development (DSWD) for listing and validation of poor members for sustained coverage.
- Monitoring and evaluation mechanisms will be established to assess program implementation and benefits utilization.
Repealing Clause
- Previous inconsistent issuances are amended, modified, or repealed to conform with the provisions of this Circular.
Effectivity
- The Circular takes effect 15 days post-publication in a newspaper of general circulation.
- A copy is deposited with the National Administrative Register at the University of the Philippines Law Center for record.