Guidelines on the Implementation of Point of Service (POS)

May 10, 2017

PHILHEALTH CIRCULAR NO. 011-17

 

I. RATIONALE

Republic Act 10924, otherwise known as the General Appropriations Act of Fiscal Year 2017 (GAA 2017), specifically under Title XXXVI on Budgetary Support to Government Corporation, Special Provision No. 3 on the Attainment of Universal Coverage under PhilHealth, provides, to wit:

To attain Universal Health Coverage, the amount of Three Billion Pesos (P3,000,000,000) appropriated herein shall cover all Filipino citizens xxx.

The 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. PHILHEALTH shall bill, on a quarterly basis, the Department of Budget and Management of the actual cost of availment, chargeable against the amount herein appropriated. Members availing of this Program shall be included in the PHILHEALTH membership data base for possible inclusion in the list of beneficiaries whose premiums are to be shouldered by the National Government.

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 data base and shall be billed annually.

xxx xxx xxx.

This Circular provides guidelines for the implementation of the Point of Service (POS) Program in compliance with GAA 2017 and as approved by the PhilHealth Board in Resolution No. 2210, s. 2017.

II. DEFINITION OF TERMS

A. Point of Service (POS Program) — refers to the program provided by the GAA 2017 to register non-PhilHealth members into the NHIP thereby providing them immediate entitlement to PhilHealth benefits.

B. POS Patient — refers to the patient or, in cases where patient is a minor, the parent or guardian who is not yet a PhilHealth member and is classified as financially incapable. He/she shall be registered into the NHIP by the government facility.

C. 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.

D. Onsite Rapid Enrollment (ORE) System — refers to the IT system deployed by PhilHealth in health care institutions/facilities which allow membership registration into the NHIP.

E. Medical Social Welfare Officer (MSWO) — refers to the DOH-trained social worker assigned in NGFs and tasked to conduct the assessment tool in the identification of qualified POS Patients.

F. Social Welfare Development Officer (SWDO) — refers to the DOH-trained social worker assigned in LGU-owned hospitals/facilities and tasked to conduct the assessment tool in the identification of qualified POS Patients.

III. COVERAGE

A. Under this Program, a POS Patient, or in cases where patient is a minor, his/her guardian, if assessed as financially incapable by the MSWO/SWDO, shall be qualified to avail of PhilHealth benefits on the following conditions:

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

2. 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; and

3. The patient is not a registered PhilHealth member or dependent at the time of availment.

B. For those who are assessed to be financially capable, eligibility to benefits at the point of availment shall be subject to V. B. 9 of this Circular and to existing rules on qualifying contributions and entitlement to benefits.

IV. PARTICIPATION OF HEALTH CARE FACILITIES CAIHTE

A. All NGFs, Local Government Unit (LGU) facilities, and other government hospitals and facilities shall be entitled to participate in the POS Program subject to the following conditions:

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 ORE 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, enrollment using the ORE System, and other activities required for the operation of the Program;

5. Ensure availability of personnel, e.g., MSWO/SWDO, trained by the DOH on the administration of the DOH Means Test.

B. Availment of benefits under this scheme shall be allowed in private facilities subject to appropriate referral by a government facility.

V. PROCEDURES

A. Identification of Qualified POS Patients

1. PhilHealth membership status of a patient — or his/her parent or guardian if patient is a minor — for admission 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. Non-PhilHealth members shall be interviewed and assessed by the Medical Social Welfare Officer (MSWO) for NGFs, or by the Social Welfare Development Officer (SWDO) for LGU facilities, using the assessment tool prescribed by the DOH.

3. Non-PhilHealth member patient classified as financially incapable and his/her parent or guardian shall qualify for POS and may immediately avail of benefits.

B. Registration

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

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

3. In case the ORE System is not available or not functioning (ex: connection problem), the MSWDO/SWDO shall manually submit to PhilHealth the duly accomplished PMRF and assessment tool, labeled "POS Patient" on the upper right hand of each form, together with Benefit Claim application.

4. 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 but prior to discharge.

5. Patients who are below 21 years old shall be declared as dependent of the parent. Women about to give birth shall be registered in accordance with PhilHealth Circular No. 025-2015: Social Health Insurance Coverage and Benefits for Women About to Give Birth Revision 1.

6. 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.

7. 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.

a. In case of abandoned patients with unknown address, the address of the hospital shall be used.

b. In case of vagrant/street dwellers, the address where they were found shall be used.

8. Upon registration in the ORE, the system will prompt the PRO Membership Section or LHIO to conduct validation and PIN assignment. PINs of newly registered POS Patients shall be emailed/transmitted to the HCIs.

 The MSWO/SWDO shall advise POS Patients or their respective representatives to collect their MDRs at the nearest PhilHealth office.

9. Patients classified as financially capable shall be registered in the ORE System but shall have the following options:

a. Pay the prescribe annual premium to immediately avail of benefits; or

b. Not pay the annual premium and just be advised on regular premium payments for future benefit availment.

C. Entitlement to Benefits

1. POS Patients and their dependents shall immediately be entitled to PhilHealth benefits, to wit:

a. In-patient/Out-patient All Case Rates;

b. Z Benefits; and

c. No Balance Billing (NBB).

2. POS Patients shall remain entitled to the benefits mentioned in C.1 above within the calendar year.

3. Patients who are financially capable shall be eligible to avail of benefits except NBB upon payment of annual premium as prescribed by the Corporation.

4. Financially capable patients who paid the prescribed annual premium shall be covered and entitled to benefits within 12 months from the confinement month.

5. Existing PhilHealth members shall be subject to current eligibility rules on benefit availment.

D. Claims Filing

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

2. Duly accomplished and signed PMRF and MSS intake form/assessment tool shall be additional requirements for claims.

3. 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 registered patients for assessment. Those assessed as poor shall be included in the Listahanan by the DSWD for coverage as Indigent Members in the 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.

VI. FUND SOURCE

PhilHealth shall bill the Department of Budget and Management (DBM), on a quarterly basis, the actual cost of availment of POS Patients as provided in the GAA 2017.

VII. REPEALING CLAUSE

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

VIII. EFFECTIVITY

This Circular shall take effect fifteen (15) days after publication in any newspaper of general circulation and shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.

(SGD.) DR. CELESTINA MA. JUDE P. DE LA SERNAInterim/OIC President and CEO

ANNEX A

 

PhilHealth Online Access Form

ANNEX B

 

NON-DISCLOSURE AGREEMENT

________________________ is given the facility to connect to the PhilHealth network and access applicable services offered by it, subject to the provisions of a digital certificate to be issued by PhilHealth. In addition to the duties and responsibilities provided under the digital certificate, ____________________ acknowledges the importance of its legal obligation to protect the information that it receives from PhilHealth. In this regard, ____________________________ hereby agrees to the following non-disclosure policies:

1. It shall not give or provide access to any information received or generated in the course of utilizing the PhilHealth Online Access System to any unauthorized individuals.

2. It shall store the digital certificate only in specific designated computers within its premises access to which shall be restricted to persons duly authorized by the hospital and PhilHealth. Any changes in the designated computers as well as the authorized persons shall take effect/be implemented only upon approval by PhilHealth.

3. It shall use the digital certificate only for business purposes and will utilize all resources and capabilities available to prevent any unauthorized access.

4. It shall keep in utmost confidentiality the digital certificate and any other form of security token/device issued or provided by PhilHealth.

5. It shall similarly bind its employees under a binding formal contract wherein the latter shall undertake to observe the confidentiality and non-disclosure undertakings of the health care provider.

6. It shall formulate/implement guidelines and systems to ensure confidentiality and non-disclosure.

7. It shall acknowledge liability of any breach of the non-disclosure agreement by any of its employees.

_________________________________, through the herein duly authorized representative, hereby enters into this agreement voluntarily and with full knowledge of its meaning and legal implications. HTcADC

_______________________________________