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I.    RATIONALE

The Philippine Health Agenda aspires to achieve Universal Health Care by creating a health system that is equitable and inclusive to all; making sure that all Filipinos are provided essential health guarantees at every life stage. To accomplish this, the Department of Health (DOH) issued Administrative Order No. 2017-0024 “Guidelines in the Implementation of Philippine Health Agenda’s (PHA) Check-Up Service for All Filipinos” which aims to ensure that primary health care guarantees for Filipinos are realized within each community. Primary health care guarantees refers to a package of population-based and individual- based services that the State commits to provide to all Filipinos, as defined in DOH’s Administrative Order No. 2017-0012 “Guidelines on the Adoption of Baseline Primary Health Care Guarantees for All Filipinos”.

In support of these DOH initiatives, PhilHealth also adopts strategies to respond to the growing health needs of its members. With the issuance of PhilHealth Circular No. 2017-0024 on the Adjustment in the Premium Contributions of the Employed Sector to Sustain the National Health Insurance Program, and budget allocation provisions in the 2018 General Appropriations Act (GAA), the existing Primary Care Benefit (PCB) which is currently provided by rural health units (RHUs)/urban health centers to the less privileged population is being expanded to cover the Formal Economy, Lifetime members and Senior Citizens.

Cognizant of the limitations of RHUs as providers of the PCB, especially in providing extended consultation hours, other health care institutions both private and government are now being engaged to ensure accessibility to the program.

II.   OBJECTIVE

This Circular aims to provide guidelines on the expansion of PCB to the Formal Economy (Employed), Lifetime Members and Senior Citizens in PhilHealth accredited public and private Level 1, 2 and 3 hospitals, infirmaries/primary care facilities, Ambulatory Surgical Clinics (ASCs) and medical outpatient clinics.

III.  SCOPE

This Circular covers the expansion of the Primary Care Benefit to all eligible beneficiaries in the Formal Economy (employed), Lifetime members (retirees), and Senior Citizens. Parallel with this, the Corporation shall process accreditation of interested prospective public and private health care institutions (HCIs).

IV.  DEFINITION OF TERMS

A.  Assignment - electronic sign-in of a PCB eligible member with their chosen EPCB HCI. This shall be required for all qualified PCB beneficiaries prior to benefit availment.

B.   Co-payment - a fixed fee that a member is required to pay for consultation, laboratory/diagnostic intervention, and medicines at the time of visit

C.  Health screening/ assessment - refers to the initial outpatient consultation to include:

1.   Pediatric/Adult Risk-assessment for Noncommunicable Diseases (NCDs) and Communicable Diseases (CDs)

2. Provision of appropriate diagnostics as recommended by currently acceptable risk assessment guidelines such as “Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings” (PhilPEN) or may refer to the list of individual based interventions stated in DOH Administrative Order No. 2017-0012 “Guidelines   on   the   Adoption   of   Baseline   Primary   Health  Care Guarantees for All Filipinos” (see Annex A*).

D.   Per Family Payment (PFP) - is the fixed annual primary care benefit payment to cover for health screening/assessment/consultation with corresponding basic diagnostic/laboratory and medicines (mandatory and as necessary).

E. Registration - confirmation of electronic assignment through personal appearance of a PCB eligible member with their chosen EPCB HCl.

V.   GENERAL GUIDELINES

A.   All members under the Formal Economy (employed), Lifetime members, and Senior Citizens and their qualified dependents shall be eligible to avail of the expanded primary care benefit in accredited EPCB HCIs.

B.   The  expanded  PCB  shall  include  health  screening  and  assessment, diagnostic services, follow up consultations, and medicines. The health screening shall be based on life stage essential services as provided in DOH Administrative Order No. 2017-0012. The drugs/medicines shall cover for the following disease conditions: AGE, UTI, Pneumonia low risk, Upper Respiratory Tract Infection, Asthma, Hypertension, Diabetes Mellitus Type II (see Annex B*: Benefit Table).

C.   All Out-patient Department/Sections of accredited Level 1, 2 and 3 private and  government  hospitals  shall  be  deemed  accredited  as  EPCB  HCI; provided that the requirements in Annex C* are satisfied.

D.   All non-hospital facilities• such as but not limited to Ambulatory Surgical Clinics  (ASCs),  Infirmary  /Primary  Care  Facilities  (PCF),  and  non-DOH licensed private medical outpatient clinics who are willing to be EPCB HCIs must comply with the accreditation standards specified in Annex C.

E.   The benefit shall be at Php800.00 per family per year with fixed co-payment Risk based capitation fee for Senior Citizen and Lifetime members shall apply

To illustrate:

Table 1: Sample computation for risk-based capitation fee

No . of newly assi gned member		Risk-based capitation fee		Tota l PFP
Sen i or Citi zen/ Lif eti me	Formal Economy	Senior Citizen/ Life- (Php900. 00)	Formal Economy (P hp700 . 00 )
750	750	675 , 000. 00	525 , 000. 00	1 , 200, 000. 00
700	500	630 , 000. 00	350 , 000. 00	980 , 000. 00

F.   All existing eligibility rules for benefit availment shall apply.

G.  Members in the Indigent sector, Sponsored, Organized Group and Land- based OFW who have previously been assigned, enlisted/registered in an accredited PCB HCI shall continue to avail of their benefit from their current provider (rural health units/health centers) as provided for in PhilHealth Circular No. 010, s. 2012 “Implementing Guidelines for Universal Health Care Primary Care Benefit 1 (PCB) Package for Transition Period CY 2012-2013” (as amended by PhilHealth Circular No. 2017-0033) unless a transfer has been requested. Transfer request forms shall be available at any accredited PCB HCI (see Annex D*). Sponsored and Indigent members requesting  to  be  transferred  to  accredited  private  EPCB  HCIs  shall  be allowed effective the following calendar year; provided they are willing to shoulder the fixed co-payment.

H.  Fixed co-payment shall apply in accordance to guidelines as provided for in this policy.

I.    The No Balance Billing (NBB) policy shall apply based on existing guidelines. J.    All existing guidelines on Person with Disabilities (PWD) and Senior Citizens
discount shall apply.

VI.  SPECIFIC GUIDELINES

A.   Assignment

1.   This will be initiated by members or the employers on behalf of their respective employees at the start of the program or calendar year.

2.   The assignment shall be done yearly and fixed for one calendar year.

Transfer to another EPCB HCI may be allowed subject to submission of transfer request form and shall take effect on the following calendar year.

3.   Members from the Formal Economy (employed), Senior Citizens and Lifetime members who opt to be assigned in rural health units/health centers shall be entitled to avail of the PCB services in accordance to the guidelines provided for in PhilHealth Circular No. 010, s. 2012 “Implementing  Guidelines  for  Universal  Health  Care  Primary  Care Benefit 1 (PCB) Package for Transition Period CY 2012-2013” (as amended by PhilHealth Circular No. 2017-0033).

4.   Assignment shall be on a per family basis. No separate assignment shall be allowed for the principal member and their qualified dependents. In cases of separate assignment, the assignment of principal member shall prevail.

5.   Assignment shall be allowed by the system until the end of September of every year or once the committed target number of assigned members by the HCI has been met, whichever comes first.

B.   Benefit availment (see Annex B: Benefit Table)

1.   All qualified beneficiaries availing of the benefit during initial or follow up consultations shall be required to obtain an authorization transaction code (see Annex E*). The authorization transaction code shall only be valid for 1 day within which the beneficiary shall visit the provider/ clinic. If the beneficiary fails to visit the clinic within the validity period of the transaction code, the beneficiary may request for another transaction code.

2.  Essential services according to life stage (see age range on the table) shall be performed during initial health screening and assessment for free  or  at  no  cost  to  the  member  or  to  one  of  his/her  qualified dependents. Health screening shall be done every year. If on initial screening the qualified beneficiary requires other services from the essential list that are not included in his/her lifestage guarantees due to an existing disease condition, such services shall still be provided for free.

3.   Regular fees or charges shall be applicable to the following:

a.    Other  qualified  dependents  who  also  wish  to  undergo  initial screening for the essential services.

b.    Other laboratory services not included in the essential list.

c.    All other prescribed drugs/ medicines not included in the list.

4.   Fixed co-payment shall be applicable to the following:

a.    Follow up consultations and laboratories/ diagnostics listed under the essential list.
For government HCIs, fixed co-payment for follow up consultation fees  shall  apply  if  the  consultation  was  sought  beyond  the prescribed extended OPD consultation hours; otherwise, no consultation fee shall be required from the eligible beneficiary.

b.    For all drugs/medicines included in the expanded PCB prescribed during both initial and follow up consultation.

5.   Fixed co-payment, whenever applicable, shall be on a per beneficiary basis.

6.  The HCI shall apply the same fixed co-payment rules for other disease conditions not covered by the expanded PCB that will require any of the laboratories and medicines included in the list of essential services and drugs (e.g. CBC for suspected dengue case, chest X-ray for suspected TB, antibiotics for infected wounds, impetigo and other skin infections).

C.   Per Family Payment (PFP)

1.   Computation shall be based on the number of newly assigned members every month until September.

a.    Monthly releases shall be 60% of the computed PFP. The monthly release of PFP shall be computed based on the following formula:

PFP months = (No. of newly assigned members x Php 800.00) x 60% Please see Annex F for sample computation.

b.    Accomplishment of targets 1-4 shall be the basis for the release of the remaining 40% of the total PFP for the applicable year. It shall be released on the first month of the succeeding year. The EPCB HCI that will meet all the performance targets shall be accorded the privilege to be recommended for Center of Excellence.

Table 2. Formula to compute Performance Target

Ta r get	Description	Formula
1	50% of the assigned families are registered and assessed	( To t al no. of r egi st ered an d assesse d members ) x 100   ( Tot al no. of assi gned f amili es* )
2	90% of the registered and assessed are provided with the complete essential services based on lifestage	(To t al no. of regi st ered and assessed ) ( w ith comp l ete essen ti al serv i ces ) x 100 ( Tot al no. of regi st ered and assessed)
3	At least 70% of hypertensive cases are given monthly maintenance drugs	(To t al no. of hypert ensi ve cases gi ven) ( mon t hly ma i nt enance drug s ) x 100 ( Tot al no. of hypert ensi ve cases )
4	At least 70% of diabetes cases are given monthly maintenance drugs	(To t al no. of di abet es cases gi ven) ( mon t hly ma i nt enance drug s ) x 100   ( Tot al no. of di abet es cases )
5	<5% of assigned families were admitted for **any of the conditions covered by the PCB **admissions will be subject to field validation	(To t al no. of admitt ed f or any conditi on) ( covere d b y t he PC B ) x 100 ( Tot al no. of assi gned f amili es* )

*unique member PhilHealth Identification Number (PIN)
**AGE, UTI, URTI, Low risk Pneumonia, Asthma, Hypertension, Diabetes Mellitus Type II

2.   Disposition and allocation of the PFP:

a.    PFP reimbursements in government HCIs shall be utilized to cover all essential services and medicines provided for in this Circular. Any remaining fund may be utilized for Professional Fee sharing based on existing DOH guidelines.

D.   Existing  guidelines  on  appeal  and  motion  for  reconsideration (MR)  shall apply.

VII. ROLES AND RESPONSIBILITIES

A.   Member and dependents

1. Regularly update his/her membership data record (e.g. additional dependents, etc) to facilitate benefit eligibility. Eligible dependents are encouraged to register with the member’s HCI of choice to avail of their PCB entitlements;

2.   Choose  from  the  list  of  accredited  EPCB  HCIs  published  in  the PhilHealth website their preferred EPCB HCI for the current calendar year;

3.   Assign to an EPCB HCI;

a.    Employees,  Senior  Citizens  and  Lifetime  members  shall  choose their EPCB HCI from among the list of accredited EPCB HCIs and initiate online assignment through any of the following:

1.  Individual assignment (see Annex G* for details)

1.1  PhilHealth Member Online Inquiry
1.2  PhilHealth Cares
1.3  Customer Service Management System (CSMS)
1.4  UPCM Internal
1.5  Health Care Institutional (HCI) Portal

2.  Group assignment (see Annex G for details)

2.1  Employer on behalf of employees may assign via Electronic
Premium Remittance System (EPRS)

b.    For some Senior Citizen and Lifetime members who have no access or have difficulty using information technology (IT), assignment to provider may be done through their respective Office for Senior Citizens Affairs (OSCA) or the HCI thru its portal.

c.    For Senior Citizen and persons with disabilities (PWDs) who may have physical incapability to do the assignment process, they may authorize a representative to do the task for them provided that they present a recognized valid ID (e.g. senior citizens ID or PWD) and authorization letter to their preferred EPCB HCI.

4.   Register at their preferred HCI for health screening and assessment/
consultation;

5.   Inform the EPCB HCI if non-ambulatory beneficiaries (e.g. senior citizen, PWD) shall require mobile assistance. Inquire if the EPCB HCI may opt to    conduct   registration   and   health   screening   and   assessment/ consultation at the patient’s domicile;

6.   Visit the facility for health screening and assessment at least once a year or as advised by the attending physician;

7.   Send patient feedback using the application provided by PhilHealth;

8.   Report erring providers and/or employers to the PhilHealth Corporate Action Center (02-441-7442) due to but not limited to the following reasons:

a.    refusing a member and dependent to be registered in their facility (except when maximum patient load has already been reached)

b.    failure to conduct health screening and assessment/ consultation, dispensing of medicines and other mandatory services

c.    charging beyond fixed co-payment rate

d.    Mandatory   EPCB   HCI   assignment   by   the   employer   against employee’s preference

9.   The member shall get an authorization transaction code from PhilHealth for every visit to an accredited EPCB HCI. (see Annex E)

B.   Employers

1.  Comply with existing policies on the adoption and use of the Electronic Premium Reporting System (EPRS) as the mode of preparation and transmission of all remittance reports;

2.   Ensure regular monthly remittance and reports of premium contributions of respective employees;

3.   Facilitate updating of Member Data Records of employees;

4.   Assign employees based on their preference.

C.  Health care providers

1.   Interested and qualified providers to comply with the requirements in Annex C to be accredited;

2. Accredited facilities shall comply with electronic data reporting and submission through any of the following means:

a.    functioning  health  information  system  with  data  extraction  and formatting capability;

b.    PhilHealth Expanded Primary Care Benefit (PCB) System (eXPS);

c.    installed  Electronic  Medical  Record  (EMR)  system  provided  by certified EMR providers.

3. Regularly check the HCI Portal/EPCB Service for updates on the assignment list. In areas where there is slow or no internet connectivity and member assignment was done through the Updated Primary Care Module (UPCM) Internal at the Local Health Insurance Office (LHIO), the softcopy of assignment list shall be forwarded by the LHIO to the HCI;

4.  Conduct health screening and assessment/initial consultation (baseline health  data)  and  follow  up  care  to  all  assigned  members  and  their qualified dependents; and to establish an updated health record which shall be kept electronically;

5.   Perform gatekeeping and referral functions for patients depending on their needs in accordance with accepted norms and ethical practice;

6.   Provide mandatory services based on clinically acceptable standards on health screening and assessment and as necessary;

7. Encode  all  health  screening  and  assessment/consultation  data, diagnostic tests done and their results, and prescribed/ dispensed medicines in the EMR system;

8.   Ensure availability of EPCB services in the facility;

9.   Ensure all data fields in the patient medical record are completely and properly filled out. Secure informed consent from the patient prior to data transmission;

10. Establish  linkages  or  network  with  other  accredited  EPCB  HCIs  for laboratory/  diagnostic  services  not  available  in  the  facility,  and  for referral;

11. Referral facilities shall issue a signed certification (see Annex H*) as provider of specific services on behalf of the referring facility. The issued certification shall be in the official letterhead of the referral facility;

12. Utilize the fund efficiently while ensuring delivery of quality care;

13. Not  engage  in  “active  patient  seeking”  activities  for  the  purpose  of populating assignment registry in order to exceed declared maximum patient load;

14. All   consultation   data   including   laboratories/diagnostics   done   and prescribed medicines shall be encoded in the EMR as reference for future  enhancements  of  the  benefit  policy  (e.g.  mammography  to diagnose Breast CA);

15. Submit reports as required by PhilHealth;

16. Provide feedback to PhilHealth regarding policies and reimbursement issues, as necessary;

17. Government HCIs shall create a trust fund and/or ledger to account for the release of PCB funds.

D.   Local Government Units

1.   Supervise the implementation of the program;

2.   Provide  technical  and  administrative  assistance  to  the  facilities  as needed;

3. Upgrade/maintain       the       operational       capabilities       (e.g. laboratory/diagnostics, medicines, monitor, CPU, internet connectivity, etc.)  of  the  facilities  to  conform  with  the  accreditation  standards prescribed by PhilHealth.

E.   EMR providers

1.   Train the EPCB HCIs on how to use the EMR system;

2.   Provide technical assistance to their users;

3.   Promptly comply with PhilHealth requirements and data privacy rules.

F.   PhilHealth

1.   Post and update the list of accredited EPCB HCIs;

2.   Release the PFP based on reimbursement guidelines;

3.   Conduct provider performance monitoring;

4.   Create a system that will link PCB and inpatient availment for monitoring purposes;

5.   Review and enhance the benefit periodically;

6.  Develop and maintain an application that will allow immediate feedback and documentation of actual patient encounter transactions;

7.   Establish  needed  mechanisms  to  ensure  that  patients  receive  the primary care services;

8.   Develop and deploy an electronic reporting system that will enable EPCB HCIs with no EMR provider engagements to electronically transmit data to PhilHealth;

9.   Certify EMR system providers singly or jointly with the DOH;

10. Provide  immediate  action  on  feedback  received  due  to  policies  or reimbursement issues.

VIII.    MONITORING AND EVALUATION

The  PhilHealth,  through  its  Healthcare  Provider  Performance  Assessment System (HCPPAS) shall employ mechanisms to assure members of the guaranteed quality health care they deserve. A monitoring and feedback system shall  be  implemented  to  assist  providers  to  identify  possible  gaps  in  their practices  or  recommend  mechanisms  to  ensure  that  they  render  the  best possible service to their clients. Performance targets shall be identified to guide all concerned stakeholders of their accountability towards providing essential primary care services especially to the poor and marginalized families. Failure to meet any of the performance targets shall be a ground for close monitoring, and subsequent sanctions and penalties.

Monitoring shall consist of periodic facility and patient visits, satisfaction and/ or exit surveys, utilization review, and others as may be identified by PhilHealth.

IX.  SANCTIONS AND PENALTIES

Any violation of this Circular, terms and conditions of the Performance Commitment and all existing related PhilHealth circulars, Office Orders and directives shall be dealt with accordingly.

X.   TRANSITORY CLAUSE

1.   Assignment to EPCB HCI for CY 2018 coverage shall be extended until December 31, 2018.

2.    PCB 1 eligible beneficiaries who already availed of PCB services this year shall remain assigned in PCB 1 providers until the end of CY 2018. Request for transfer shall be allowed effective the following calendar year; provided they are willing to shoulder the fixed co-payment.

3.    All senior citizens may avail of Expanded PCB, provided they are enrolled as member under the Senior Citizen Program or declared as dependent of member under the Formal sector or Lifetime Membership Program.

4.    Facilities without existing PCB data recording system shall be allowed to use the eXPS.

XI.  REPEALING CLAUSE

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

XII. ANNEXES

A.   DOH Administrative Order No. 2017-0012 “Guidelines on the Adoption of Baseline Primary Health Guarantees for All Filipinos” B.   Benefit table

C.   Accreditation standards and requirements

D.   Transfer Request Form

E.   Steps on acquiring authorization transaction code

F.   Sample computation

G.  How to assign

H.   Certification of Service Delivery Support

XIII. DATE OF EFFECTIVITY

This Circular shall take effect starting October 1, 2018. It shall be published in any newspaper of general circulation and a copy shall be deposited with the National Administrative Register at the University of the Philippines Law Center.