I. RATIONALE

As provided under the General Appropriation Acts (GAA) of 2017 and 2018, specifically under Title XXXVI on Budgetary Support to Government Corporations, Special Provision on the Attainment of Universal Coverage under PhilHealth, to wit:

œThe Filipino citizens who will be covered under this provision, through a Point of Service (POS) Program, must be classified as financially incapable to pay his/her PhilHealth membership according to the DOH classification on indigence. Members availing of this Program shall be included in the PhilHealth membership database for possible inclusion in the list of beneficiaries whose premiums are to be shouldered by the National Government xxx

Filipino citizens who are financially capable shall be assessed and shall be enrolled based on their financial capability at the Point of Service to be covered as regular contributing PhilHealth member. They shall be included in the PhilHealth membership database and shall be billed annually. 

II. OBJECTIVES

To address the gaps in coverage of both 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.

III. SCOPE

This policy applies in capturing all unregistered Filipinos and in covering all Filipinos, especially those who are financially incapable and seeking medical care in all government facilities.

PhilHealth Circular No. 2018-0008  Guidelines on the Implementation of Point of Service (POS) Enrolment Program under the General Appropriations Act (GAA) 2018 Onwards

IV. DEFINITION OF TERMS

A. Point of Service (POS Program) - refers to the program provided in the GAA for the current year, to cover all Filipinos under the National Health Insurance Program (NHIP), including the unregistered and inactive registered members especially those who are financially incapable. B. POS Patient - refers to the patient or in cases where patient is a minor, the parent or guardian, who is classified as financially incapable according to the DOH classification on indigents. He/she shall be registered into the NHIP by the government facility. C. Financially Capable (Self-Earning Individuals) - individuals who render services or sell goods as a means of livelihood outside of an employeremployee relationship or as a career. These include professional practitioners including but not limited to doctors, lawyers, engineers, artists, architects and the like, businessmen, entrepreneurs, actors, actresses and other performers, news correspondents, professional athletes, coaches, trainers and such other individuals. D. National Government Facility (NGF) - refers to health facilities owned by a national government agency which includes DOH-retained hospitals, Philippine National Police (PNP) hospitals, Department of National Defense (DND) hospitals, and Corporate-Specialty hospitals. E. Local Government Owned Facilities - refers to health facilities owned and managed by Local Government Units. F. Medical Social Welfare Officer (MSWO)/Social Welfare Development Officer (SWDO) - refers to the DOH-trained social worker assigned in NGFs or LGU-owned hospitals/ facilities and tasked to conduct the assessment tool in the identification of qualified POS Patients.

V. COVERAGE

A. Under this Program, patients, who are unregistered with PhilHealth, or are inactive members (have not regularly paid contributions) shall be eligible to avail PhilHealth benefits on the following conditions:

1. The patient (or the parent or guardian if he/she is a minor) is assessed as financially incapable by the MSWO/SWDO; 

2. The patient and his/her parent or guardian are Filipino citizens; and 

3. 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.

B. For those who are assessed to be financially capable, eligibility to benefits at the point of availment shall be subject to VII.C.3 of this Circular and to existing rules on qualifying contribution and entitlement to PhilHealth benefits.

VI. PARTICIPATION OF HEALTH CARE FACILITIES

A. All NGFs, Local Government Units (LGUs) facilities, and other government hospitals and facilities shall be entitled to participate in the POS Program provided that they comply with the following requirements:

1. Submit a duly accomplished PhilHealth Online Access Form (POAF) (Annex A) and Non-Disclosure Agreement (NDA) (Annex B) to the nearest PhilHealth office; 

2. Ensure availability of a dedicated desktop computer and reliable internet connection that will connect to the IHCP Portal and POS System; 

3. Assign an I.T. personnel who will provide technical support to the staff assigned in the implementation of the Program; 

4. Assign a dedicated staff, trained or who shall undergo training in the membership and eligibility verification, enrolment using the POS System, and other activities required for the operation of the Program;

5. Ensure availability of personnel (e.g. licensed MSWO/SWDO) trained by the DOH on the administration of the DOH Means Test. However, in the event that the MSWOs/SWDOs have yet to undergo training, the facility shall submit a certificate of training to the nearest PhilHealth Office within the implementation of the program. In the interim, hospitals may be required to submit to the PhilHealth Regional Office (PRO) the name of their designated accountable person who will sign the certificate of assessment.

6. Existing ORE-POC/POS user need only to comply with item 5.

VII. GENERAL GUIDELINES

A. Identification of Qualified POS Patients

1. Patients or his/her parent or guardian (if patient is a minor) in ward type of accommodation shall be subject to verification through the IHCP Portal whether or not he/she is already a member or dependent and eligible to avail of benefits. 

2. Unregistered Filipinos or inactive members shall be interviewed and assessed by the Medical Social Welfare Officer (MSWO) for NGFs or by the Social Welfare Development Officer (SWDO) for LGUs facilities using the assessment tool prescribed by the DOH. 

3. Patients stated in Section VII.A.2, classified as financially incapable and their parents or guardian shall qualify for POS and may immediately avail of benefits.

B. Registration

1. POS Patients, if unregistered, shall accomplish and sign the PhilHealth Member Registration Form (PMRF).

2. The MSWO/SWDO or hospital-designated personnel shall register POS Patients through the POS System within 72 hours from the date of admission or prior to discharge.

3. In lieu of the Medical Social Services (MSS) intake form, the pro-forma œCertificate of Assessment  signed by the MSWO/SWDO shall be issued to the financially incapable and capable POS patient. (Annex C)

4. In case the POS System is not available or not functioning (e.g. connection problem), submission shall be allowed following procedures, to wit:

a. Within 72 hours of admission, duly accomplished PMRF shall be sent to PhilHealth for PIN assignment through any of the following:

i. Email scanned copy;

ii. Fax; and 

iii. Other means as may be agreed or arranged by the hospital/facility with the PRO/LHIO.

b. Upon securing PIN from PhilHealth, the same shall be indicated in the original PMRF to be attached to the claim documents upon filing.

5. Should a patient be admitted on a weekend, holiday, or outside the working hours or schedule of the MSWO/SWDO, the patient shall immediately be assessed upon return of the MSWO/SWDO and registered in the Program the next working day of the MSWO/SWDO prior to discharge.

6. Women about to give birth may likewise be registered in this program subject to the applicable existing policy on Social Health Insurance Coverage and Benefits for Women About to Give Birth (WATGB).

7. A patient below 21 years old who is an undeclared dependent shall require updating of Member Data Record (MDR) of parents to include the patient as dependent. The parent if without current coverage shall be subject to assessment under this program.

8. Orphaned and abandoned children and mentally-ill vagrants shall be registered as principal members. The PMRF shall be accomplished and signed by the guardian or the MSWO/SWDO.

In case of abandoned patients with unknown address, the address of the hospital shall be used. In case of vagrant/street dwellers, the address where they were found shall be used.

9. Upon registration in POS, the system will prompt the PRO Membership Section or LHIO to conduct validation and PIN assignment. PINs of newly registered members shall be emailed/transmitted to the HCIs to be indicated in the claim form and POS registration slip.

10. The MSWO/SWDO shall advise patients or their respective representatives to request their MDRs at any Local Health Insurance Office (LHIO).

C. Entitlement to Benefits

1. POS financially incapable patients and their dependents shall immediately be entitled to PhilHealth benefits within the validity period subject to compliance to all other requirements to benefits availment, to wit:

a. In-patient/Out-patient benefits under All Case Rates (ACR) (e.g. preauthorization surgery requirement)

b. Z Benefits (e.g. PhilHealth dialysis database registration for all dialysis patients); and  c. No Balance Billing (NBB).

2. Patients who are financially capable shall be eligible to avail of inpatient/ out-patient benefits upon payment of annual premium as prescribed by the Corporation. They are also eligible for Z benefits based on existing rules for availment.

3. Financially capable patients who paid the prescribed annual premium shall be covered and entitled to benefits within the calendar year.

4. Succeeding availment of POS-patients, in case the POS system or portal is not available, shall secure a CEl from the nearest PhilHealth Office or PhilHealth CARES Form (PCF) from the PhilHealth Customer Assistance, Relations and Empowerment Staff (PCARES) personnel assigned in the health facility.

5. Availment of benefits under the POS Program shall be allowed in private facilities, subject to the following conditions:

a. There is an appropriate referral from a government facility;

A copy of the referral form or certification from the referring government hospital shall be attached to the claim form.

b. Dengue patients immunized under the DOH School/Community Based Immunization (SBI) program;

A copy of RHU/Physician/School issued immunization record or certificate of immunization with Dengvaxia shall be attached to claim document.

c. Emergency cases with resuscitation package; and

d. Financially incapable patients affected by fortuitous events in declared calamity areas (PhilHealth Circular No. 0034 series 2013).

D. Claims Filing

1. Only claims for POS Patients registered in POS/Phi!Health with PIN shall be submitted for processing. The PIN shall be indicated in the Claims Form 1. 

2. Duly accomplished and signed PMRF, Registration Slip and MSWO/ SWDO certificate of assessment shall be required for filing of first claim of POS patients. 

3. Manual filing of claims shall be allowed for government HCIs not yet enrolled in eClaims. For government HCis under eClaims, the MSWO/ SWDO certificate of assessment shall form part of the documentary requirements to be scanned in the uploading of electronic claims.  4. All other rules and requirement in benefit availment shall apply.

E. Sustainability of Coverage

PhilHealth shall endorse to the DSWD, on a quarterly basis the list of POS financially incapable registered patients for assessment. Those assessed as poor shall be included in the Listahanan by the DSWD for coverage as Indigent Members in succeeding years.

F. Monitoring and Evaluation

The Corporation shall device a mechanism for monitoring and evaluation of the Program based on benefit utilization and other pertinent statistics.

VIII. FUND SOURCE

The required annual premium contribution for the coverage of Sponsored Members through POS enrolment program shall be sourced from the annual General Appropriations.

IX. TRANSITORY CLAUSE

The Implementation of the Point of Care (POC) Enrollment Program (Revision 1) under PhilHealth Circular No. 033-2015 is deemed fully transitioned to POS effective July 1, 2018. The POC-ORE system shall be deactivated starting on the said date.

All enrolled patients under POC on or prior to June 30, 2018 shall be reimbursed subject to the existing rules in the availment of benefits under the POC enrollment scheme and shall remain to be entitled to benefits until December 31, 2018.

X. REPEALING CLAUSE

All other previous issuances that are inconsistent with any provision of this Circular are amended, modified or repealed accordingly.

XI. EFFECTIVITY

This Circular shall have a retroactive effect starting January 1, 2018 and shall be deposited with the National Administrative Register at the University of the Philippines Law Center.