Supreme Court E-Library
Information At Your Fingertips

Republic Act (RA) 7875, as amended by RA 10606, otherwise known as The National Health Insurance Act of 2013 under Section 6 states that: “All citizens of the Philippines shall be covered by the National Health Insurance Program. In accordance with the principles of universality and compulsory coverage enunciated in Section 2(b) and 2(l) hereof, implementation of the Program shall ensure sustainability of coverage and continuous enhancement of the quality of service: Provided, That the Program shall be compulsory in all provinces, cities and municipalities nationwide, notwithstanding the existence of LGU-based health insurance programs xxx”

Furthermore, Section 3(c) of the same Act emphasizes the need to “prioritize and accelerate the provision of health services to all Filipinos, especially that segment of the population who cannot afford such services”. Moreover, Section 7 clearly mentions that “all indigents not enrolled in the Program shall have priority in the use and availment of the services and facilities of government hospitals, health care personnel and other health organizations: Provided, however that such government health care providers shall ensure that said indigents shall subsequently be enrolled in the Program”.

Under the ambit of Universal Health Care (UHC) or Kalusugang Pangkalahatan (KP), the Corporation aspires to ensure that all Filipinos, especially the most vulnerable are covered by PhilHealth. Despite the national government appropriations, sin tax collections, local government sponsorship and other sources, statistics and anecdotes have shown that a vast number of poor are not yet covered by PhilHealth. Ergo, it is deemed necessary that as the other mechanisms of capturing the poor are being undertaken, a mechanism of enrolling these patients at the Point of Care shall be established to ensure that all poor in dire need of quality health services in government hospitals are covered by PhilHealth.

II. COVERAGE

The following patients, and their families, shall be provided with PhilHealth coverage and shall be considered as Sponsored Program Members by the Hospital if they qualify on the assessment administered by the Medical Social Worker at the time that they were admitted to Government Health Care Institutions:

1. Non-members, who were assessed and classified as Class C-3 or D.
   
2. Members who are not covered due to lack of qualifying contribution and classified as Class C-3 or D.

Corollary to this, patients availing of outpatient services (e.g. Cataract Surgery, Hemodialysis and the like) shall not be enrolled. However, Hospital- Sponsored Members (HSMs) may avail of these outpatient services for their succeeding hospitalization.

III. PARTICIPATION OF HEALTH CARE INSTITUTIONS

All DOH-retained hospitals shall mandatorily implement the program while participation of Local Government Unit (LGU) hospitals shall be subject to the Corporation's approval upon submission of Letter of Intent. Other government hospitals (i.e. DND hospitals, academic hospitals, state hospitals and the like) may also participate in the program upon approval of the Corporation on the Letter of Intent submitted.

IV. GENERAL POLICIES

1. Identification of Qualified Hospital-Sponsored Members. All nonmembers and non-eligible members for admission/admitted shall be interviewed and assessed by the Medical Social Worker using the intake survey sheet prescribed in DOH Administrative Order 51, s-2001 and/or other issuances relative to it. As much as practicable, assessment by the MSW shall be conducted upon admission. Patients classified as Class C3 or Class D shall be enrolled accordingly.
   
   
2. Sponsor. The Health Care Institution (HCI) shall be the premium donor for these HSMs. Under no circumstance shall the hospital ask the patient of any amount as their share for premium.
   
   
3. Premium Cost & Coverage
   
   a. Rate. The amount of premium shall be the same rate as the annual premium for Sponsored Program Members. (Currently at Php2,400 per year)
   b. Validity. The coverage of HSMs shall be from the first day of the confinement month and shall end on the last day of the same year.
   
   
4. Benefits. HSMs shall be provided an immediate availment of NHIP benefits, including but not limited to: inpatient benefits, outpatient benefits (except Primary Care Benefit 1) and No Balance Billing.
   
   
5. Claims Reimbursement
   
   
   1. HSM claims shall be processed by PhilHealth within thirty (30) days upon receipt of completed claim documents.
   2. HSM claims shall not be returned to hospital for membership and eligibility concerns. However, policies for claims processing shall still apply and the Corporation reserves its right to return or ultimately, deny claims for other benefit availment and accreditation issues.
      
      
6. Ensuring Sustainability of Coverage. PhilHealth shall submit a list of HSMs to DSWD for validation. Those validated as poor shall be included in the National Household Targeting System (NHTS) list and thus, shall be covered for the succeeding years under the Sponsored Program.
   
   
7. Monitoring and Evaluation. The Corporation shall device a mechanism for monitoring and evaluation of the program with consideration to utilization of benefits and other pertinent statistical reports.

V. REPEALING CLAUSE

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

VI. 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) ALEXANDER A. PADILLA
President and CEO