November 29, 2023

Guide To HMO Health Insurance In The Philippines – Peso Lab


What are the best HMO plans in the Philippines? Are you looking for the best prepaid HMO cards?

This article is for all Pinoys looking for an affordable HMO plan: freelancers, self-employed, individuals, senior citizens, families, and employers (business owners of corporations and SME/small and medium enterprises).

The goal of this article is to let you have at least a survey of the providers and products available in the market. For details of a specific plan or information about the company, please consider contacting an authorized sales agent and the companies.

What is HMO or health maintenance organization?

According to studies, half of the country’s total costs are paid out of pocket. That means many of us Pinoys are uninsured and suffer financial hardship when sick. The costs of getting treatment for cancer, stroke and heart disease are rising and can easily run up to several million pesos.

The health maintenance organization or HMO is a company that allows people to be insured to avail medical services in exchange for a fixed monthly or annual fee. It acts as the middleman between the client and healthcare providers such as hospitals, clinics, laboratories, doctors, therapist, etc.

It can lower overall costs by being able to offer large number of potential clients to hospitals and physicians. They can negotiate for lesser prices on treatment, services, and medicines. In return, healthcare providers have a database of customers that would avail of their services.

It offers various plans. A standard HMO package might include outpatient care and hospitalization. Prepaid cards are also becoming popular recently. They are cheap and offer specific coverage such as one-time expenses for emergency care. Others might also offer a co-pay where the bill is split between the company and the customer.

Some might offer to provide coverage that can be hard to insure, such as pre-existing conditions, or to people usually refused for insurance such as senior citizens and those with pre-existing conditions.

How does an HMO plan work?

An HMO company offers customers the ability to sign up for a plan that would pay for expenses related to medical services that are covered in the policy. It is like getting a life insurance, but instead of the benefits paid during death the benefits are made towards any expenses in the hospital, for doctor’s consultation, etc.

Let’s imagine an example, an HMO plan that has an annual benefit limit (ABL) of ₱100,000. ABL can be used to pay for any costs due to a medical service such as check-ups, hospitalization or lab tests (X-ray, blood test) for a medical condition that is within the coverage for one year.

So let’s say that the insured person gets sick with pneumonia. He or she might consult a doctor who charges for a consultation (maybe for ₱1,000) and asks for X-ray (₱500) result and blood test (₱500). The doctor might recommend confinement, and the person stayed in the hospital for several days for a total bill of ₱50,000. After being discharged, the person might be asked for follow-up check-ups and lab tests, which can mean another expense of ₱3,000.

Consultation 1,000.00
X-ray 500.00
Blood test 500.00
Hospital bill 50,000.00
Post-treatment 3,000.00
Total 55,000.00

So the total amount from diagnosis to treatment would be ₱55,000 (2,000 + 50,000 + 3,000). With an HMO plan that has an ABL of ₱100,000, the insured person doesn’t have to pay anything and has a remaining ₱45,000 that can be used for any medical services availed for the rest of the year.

ABL 100,000
Total bill 55,000
Remaining ABL 45,000

Now, this is a very simplified example. HMO companies would recommend doctors, hospitals, laboratories and other medical providers that are within their network (more of this later).

Secondly, on hospital costs, the bill is generally split between what’s going to be paid by Philhealth and by the HMO company. The insured pays any excess amount. You can check Philhealth medical case rates. If the patient is not a Philhealth member, the Philhealth portion needs to be paid out of pocket. In the case above:

Total bill 55,000
Philhealth 6,000
HMO 49,000
Remaining ABL 51,000

So the total bill from before, during, and after hospital admission for a pneumonia case is Php 55,000. Philhealth pays Php 6,000 according to the latest medical case rate, and the remaining Php 49,000 is paid for by the HMO plan. And that would also mean that for the rest of the year, the client in this imagined scenario has a remaining ABL of Php 51,000.

Disclaimer: The above is only a scenario. Actual plan benefits vary.

What does “in network” mean?

HMO companies have a network of hospitals, laboratories, and medical facilities with which they have existing partnership. They also have a list of doctors, specialists, and experts that are signed up with them.

When a member gets sick, they are recommended to get medical help within the network. Services can be performed faster because the HMO companies and healthcare providers may already have existing process in admitting members, determining the benefits and coverage, identifying medical experts who can best give treatment, etc.

When a member gets sick and seeks treatment out of network, HMO companies may not have established a way to deal with the hospital or medical facility. The member may be asked to pay the costs out of pocket, submit proofs of the medical services and expenses, and wait for a refund.

Another thing about out of network is that the HMO plan might have a limit on the benefits on each and every service, lab tests, medicine, etc. In which case, there is a likely chance the member would need to pay any excess amount even when they are still within their annual benefit limit.

Advantages of HMO

What are the pros and cons of getting an HMO plan? The following are the benefits in getting a plan.

  • HMO companies offer a variety of healthcare solutions, including prepaid cards, coverage for senior citizens, etc.
  • An HMO plan can cushion the impact of not earning an income during sickness.
  • It can give peace of mind because it can help relieve financial worry brought about by being ill.
  • Some Pinoys choose to not seek treatment because they don’t have money. By having an HMO coverage, one may have the financial capacity to get cured. Patients and their families can focus on care.
  • It can help prevent families from using up their savings or making untimely financial decisions such as getting into huge debts, selling off properties, and/or redeeming stocksmutual funds, and other investments during a down market, etc.
  • It can protect your financial plan.
  • Coverage can include dependents such as parents, siblings and children.
  • An HMO plan may lower out-of-pocket spending during personal health crisis.
  • Depending on the benefits of the plans, people can seek medical care without putting up an amount for hospital deposit.
  • Depending on the plan, one can avail of preventive health measures like free annual medical and dental checkups.
  • It is used by companies to retain and acknowledge the value of employees.
  • Payment plans can be flexible: monthly, quarterly, semi-annually or annually.
  • Plans can be customizable with addition of riders, discounted rate for dependents, etc.

Disadvantages of HMO

What are some of the things that can be disadvantageous?

  • Most plans have limited annual benefit limit (ABL), and so people might still spend money to pay what remains of the bill. This can happen when one gets hospitalized for a long time, requires regular lab tests and treatment, or needs to go through a very expensive procedure.
  • Some plans may not cover certain diseases or medical procedures.
  • Some plans may also be a co-pay arrangement, where you’re asked to pay a portion of the bill.
  • You’re limited to a network of healthcare providers. Some plans may not offer reimbursement when you avail of healthcare services outside of the network.
  • Premiums can be quite expensive especially for people of advanced age or with pre-existing conditions.
  • Premiums are expected to go higher each time you renew.
  • People in poor health may have to pay more expensive premium, are not allowed to renew their plan or are not approved to get a plan.
  • You need to have Philhealth cover or else you’d have to pay the portion for Philhealth membership.
  • The plan may be tied to employment, so you may lose it when you resign or you retire from the job.

Best HMO plans in the Philippines

What are the best HMO plans that are available in the market today?

  1. Prepaid cards
  2. Individual plans
  3. Family plans
  4. Corporate and Small/Medium enterprises (SME)
  5. Senior Citizens

The lists that you are about to read are not meant to be complete data on all HMO products. Some companies have information about their products on their websites, others don’t. A few require that potential clients contact them via email or online form. So please do consider check each company or reach out to their representatives.

Secondly, the details that you can see here are just overview. Links are provided so that you can go to the website to learn more.

1. Best HMO prepaid cards

Prepaid HMO cards are the most affordable healthcare plans available in the Philippines today. Pinoys who are on a tight budget can actually get them. They’re becoming popular because they’re easy to get, comparatively affordable, and open for everyone. There are some that you can acquire without going through medical exam, underwriting, etc.

Their coverage is limited to whatever benefits they’re purchased for. So if you got one for emergency services, you can use the card at the admitting section of hospital so you can avail of the necessary medical attention. Healthcare services are also most of the time similarly limited within the network. The validity is generally good for one year and coverage commonly expires at the end of validity period.

So what are the best HMO prepaid cards in the Philippines?

  • Consultation
  • Dental
  • Diagnostic tests
  • Emergency
  • Hospitalization.

Some cards have a combination of two or more of the above types, so it’s best to follow the links on the table. They lead to company’s websites that offer updated and more complete information of their included services.

Best HMO prepaid cards for consultation

The cards offer consultation services with physicians that are within the network. They may or may not include annual physical exams, and may be offered only to certain age groups.

Aventus Classic Card Aventus Unlimited consultations, fixed fee for specialists, free dental checkup, 10% discount on lab and diagnostic and other dental services
Aventus Elite Card Aventus Same as Classic, higher discount, free annual physical examination
Aventus Kiddie Aventus For 0 -17 years of age, same as Classic and higher discounts
Aventus Premium Card Aventus Same as Classic, higher discounts, free Basic Executive Check-up
Aventus Prestige Aventus Same as Classic, higher discounts, free Comprehensive Executive Checkup
Aventus Prime Aventus Same as Classic, higher discounts on services, free Annual Physical Examination
Diabetes Care Program FamilyDoc Unlimited doctor consult
Diabetes Prevention Program FamilyDoc Unlimited doctor consult
Unli-Konsulta FamilyDoc Unlimited doctor consultation for 3 people
MedConsult Adults Insular Health Care, Inc For 18 – 64 years old, 4 face to face medical consultations, 1 year unlimited telemedicine access, 1 year unlimited dental consultations
MedConsult Kids Insular Health Care, Inc For 1-17 years old, same as MedConsult Adults
MedConsult Seniors Insular Health Care, Inc For 65 years and older, same as MedConsult Adults
Individual KonsultaMD  KonsultaMD Unlimited medical consultation via telephone
Dual KonsultaMD KonsultaMD Same as Individual KonsultaMD, up to 2 people
Group KonsultaMD KonsultaMD Same as Individual KonsultaMD, up to 5 people
PRIMA Maxicare Unlimited outpatient consultations. Variants – Silver: 0 – 59 years old, Gold: 60 years old and above,
Health Check Medicard Philippines, Inc Annual Physical Exam and unlimited  check-up
HealthPlus Medicard Philippines, Inc Annual physical exam , unlimited  preventive and outpatient care
My MediCard Medicard Philippines, Inc unlimited consutlations in Medicard-accredited clinics and hospitals nationwide.
DigiMed Plus Consult (Single use)  PhilCare One-time video teleconsultation
Single-use DigiMed Consult PhilCare One-time teleconsultation
unli-CONSULT for 65+ PhilCare Unlimited consultation for 65 years old and older
unli-CONSULT for Adults PhilCare 18 – 64 years old, unlimited consultation
unli-CONSULT for Kids PhilCare 1 – 17 years old, unlimited consult
Unli-DigiMed Consult PhilCare Unlimited digital consultation
VidaCare CORE PhilCare 60 years older and above, unlimited consultation and lab/diagnostic tests

Best HMO prepaid cards for dental services

The following offer individual or group dental health services.

Family Smile Package MetroDental Dental care for four persons
MetroDental White Pass MetroDental One dental consultation, One oral prophylaxis, One panoramic (full mouth) X-ray 
MetroDental Platinum Pass MetroDental Same as White Pass, One fluoride gel treatment, one temporary filling (per tooth), one simple tooth extraction

Best HMO prepaid cards for diagnostic and laboratory tests

These cards can defray costs of certain diagnostic and lab procedures.

Best HMO prepaid cards for emergency services

These cards can pay expenses for specific emergency situations.

ER Care All-In 60 Adults Insular Health Care, Inc For 18 – 64 years old, one-time use up to P60K for emergency cases due to accident, viral illness, bacterial. Variants: Regular and Deluxe
ER Care All-In 60 Kids Insular Health Care, Inc For 1 – 17 years old, one-time use up to P60K for emergency cases due to accident, viral illness, bacterial. Variants: Regular and Deluxe
ER CARE ALL-IN 80 Adults Insular Health Care, Inc Same as ER Care All-In 60 Adults, limit up to 80K
ER Care All-In 80 Kids Insular Health Care, Inc Same as ER Care All-In 60 Kids, limit up to 80K
ER Care All-In 100 Adults Insular Health Care, Inc Same as ER Care All-In 60 Adults, limit up to 100K
ER Care All-In 100 Kids Insular Health Care, Inc Same as ER Care All-In 60 Kids, limit up to 100K
ER Care Basic 50 Insular Health Care, Inc One-time use up to P50K for emergency care due to accidents, including medicine
ER Care Booster 60 Insular Health Care, Inc Same as ER Care Basic 50 for up to P60K, plus outpatient and inpatient emergency care, room and board, diagnostic procedures, use of operating room, recovery room, and ICU diagnostic procedures, as medically necessary.
ER Care Booster 80 Insular Health Care, Inc Same as ER Care Booster 60, up to P80K.
ER Care Booster 100 Insular Health Care, Inc Same as ER Care Booster 60, up to P100K.
Total ProtectER Insular Health Care, Inc Term insurance + hospital benefit + emergency care for accident, viral and bacterial illnesses.
Maxicare EReady Maxicare One-time emergency related cases; two variants available
Maxicare EReady Advance Maxicare One-time emergency-related coverage, unlimited outpatient consultation; two variants available
RxER Medicard Philippines, Inc up to P20k limit for ER care, up to P5k for lab and diagnostic tests, emergency for trauma cases, preventive and outpatient care
ER Health Assist 40 for Adults PhilCare Unlimited medical and dental consult, single-use benefit up to P40K for outpatient emergency and hospital confinement for viral and bacterial illnesses or accident.
ER Health Assist 60 for Adults PhilCare Same as ER Health Assist 40 for Adults, benefit up to P60K
ER Health Assist 80 for Adults PhilCare Same as ER Health Assist 40 for Adults, benefit up to P80K
ER Shield PhilCare Emergency care for viral and bacterial illnesses and treatment as result of accident injuries, up to P50k
ER Vantage Plus 40 for Adults PhilCare 18 – 64 yeras old, same as ER Shield, up to P40K
ER Vantage Plus 40 for Kids PhilCare 6 months – 17 years old, same as ER Shield and up to P40K
ER Vantage Plus 60 for Adults PhilCare Same as ER Vantage Plus 40 Adults, up to P60K
ER Vantage Plus 60 for Kids PhilCare Same as ER Vantage Plus 40 Kids and up to P60K
ER Vantage Plus 80 for Adults PhilCare Same as ER Vantage Plus 40 Adults, up to P80K
Health Vantage 40 for Adults PhilCare 18 – 64 years old, same as ER Shield plus hospital confinement, up to P40K
PhilCare Rush PhilCare Travel emergency care, ambulance, outpatient emergency and hospitalzation up to P50k
VidaCare PREMIER PhilCare Same as VidaCare CORE, plus up to P20k emergency care for viral, bacterial illnesses or injuries due to accident

Best HMO prepaid cards for hospitalization

These are cards that can provide financial assistance on hospital bills due to confinement.

MyMaxicare Lite Maxicare One-time confinement due to 8 covered diseases. Variants: Yellow and Blue
MediCard Select Medicard Philippines, Inc Individual and family, with option to include 5-star hospitals, A revolving fund the unused portion is added to the next year’s ABL plus access fee 
Dengue Assist PhilCare 18 – 64 years old, up to P30K limit for confinement due to dengue
Dengue RX Plus for Adults PhilCare 21 – 64 years old, same as Dengue Assist
Dengue RX Plus for Family PhilCare Same as Dengue Assist for two children and two adults
Dengue RX Plus for Kids PhilCare Same as Dengue Assist for individuals 20 years old or younger.
Health Vantage 40 for Kids PhilCare 6 months – 17 years old, same as ER Shield plus hospital confinement, up to P40K
Health Vantage 60 for Adults PhilCare Same as Health Vantage Plus 40 Adults, up to P60K
Health Vantage 60 for Kids PhilCare Same as Health Vantage Plus 40 Kids, up to P60K
Health Vantage 80 for Adults PhilCare Same as Health Vantage Plus 40 Adults, up to P80K
Health Vantage 80 for Kids PhilCare Same as Health Vantage Plus 40 Kids, up to P80K
PhilCare Agapay 700 PhilCare 16 – 65 years old, one-time availment of healthcare services up to P40k for viral, bacterial illnesses and injuries sustained from accident
PhilCare Agapay 900 PhilCare 16 – 65 years old, one-time availment of healthcare services up to P40k for viral, bacterial illnesses and injuries sustained from accident
MediCash Dengue Insurance Pioneer Up to P10K assistance on diagnosis of dengue
MediCash Leptospirosis Insurance Pioneer Up to P10K assistance on diagnosis of Leptospirosis

2. Best HMO for single, freelancers, self-employed and other individuals

Pinoys who are single, freelancers, self-employed and other individuals may want to avail of a healthcare insurance too. The easiest way to do that would be to get a prepaid card as discussed above. However as you can see from the above table, you might be looking for a more comprehensive coverage that includes in-patient, outpatient, emergency, and dental care services.

Consider getting a health/HMO plan if you’re not a dependent or qualified member of any family, group or corporate plans. There could be many reasons why this is so: age requirements, no longer employed by the company, or you’re engaged in your own small business or freelancing career.

Again, the list below is by no means the only products out there. Reach out to any rep or company and see if they have an individual plan that might suit you.

OptimumCare Program CareHealthPlus Systems International Build up healthcare plan with a five year saving period
Quantum Gold CareHealthPlus Systems International Helathcare coverage for 7 years and pay for only five years
QuantumCare Program CareHealthPlus Systems International Five-year renewal HMO plan
ValuePlus Program CareHealthPlus Systems International Three-year renewal HMO plan
Enhanced Core 10 Caritas Health Shield, Inc. 5 year renewal, 10 years plan
ENHANCED CORE 6 Caritas Health Shield, Inc. 5 year renewal, 6 years plan
KIDDIE HEALTH PLAN Caritas Health Shield, Inc. Healthcare plan for kids
Ultimate Kaiser Health Builder Plan Kaiser lnternational Healthgroup, Inc Comes in four variants: K50, K75, K100, and K125; long-term health care
Short Term Health Care Kaiser lnternational Healthgroup, Inc Comes in variants of H500, H800, H1200, H1900, H2600 and H160, H2800, H3200, H4200
MyMaxicare Maxicare HMO plan for individuals, comes in four variants
Health Assure Plus Classic MetroCare Heallh Systems, Inc. Plans depend on room and board type, as well as the annual benefit limit
Health Assure Plus Prestige MetroCare Heallh Systems, Inc. Same as Health Assure Plus Classic, with major hospitals
Blue Royale Pacific Cross Health Care. Inc USD 2 million ABL, travel abroad coverage for less than 90 days, comes in three variants
Lifestyle Pacific Cross Health Care. Inc Issue age 21 – 35 y.o. 250K ABL per illness per lifetime, renewable until age 40
AIA MED-ASSIST Philam Life Co-pay of 10%, benefit up to P4million
Global Health Access Philippine AXA Life 100 million ABL, plan can be taken advantage within and outside the country

3. Best HMO for family and Overseas Filipino Workers (OFWs)

A family HMO plan is perfect for Pinoys with children, elderly parents and siblings. There is even one product that is designed for overseas Filipino Workers, the Kabayan plan from Medicard Philippines, Inc.

These plans are structured such that either one or both the parents are account-holder/s. Dependents can include the spouse and their children. Some policies also allow children to purchase plans for their parents and siblings.

The advantage of signing up for a family policy is that you are only going to deal with one company. Regularly, there will be one agent or contact person who acts as the liaison officer between you and the company. More than that, during the time of emergency, it can be real convenient.

Secondly, more often than not family plans have built-in discounts. Additional dependents can be added on without having to pay the full price as that of the account-holder’s.

However, there are disadvantages. On the whole, there are age restrictions. When a parent, sibling or a child reaches a certain age, they may be no longer be eligible for coverage.

Care and Share Program CareHealthPlus Systems International Outpatient, dental care
Emergency Medical Expense Eastwest Healthcare, Inc For one time emergency care
Health Emergency Pampamilya Program (HELPP) Eastwest Healthcare, Inc Emergency care plus hospital daily allowance while confined
INFINITY HEALTH ADVANTAGE (Individuals / Family) Eastwest Healthcare, Inc Comprehensive HMO program
Short Term Health Care Kaiser International Healthgroup, Inc Variants: Health 600, Health 800 and then Health 1200, Health 1600
MyMaxicare Maxicare Offered for individuals and families, four variants available
Individual and Family Medicard Philippines, Inc Hospital confinement. Variants: 50k, 60k, 100k, and 120k ABK
Kabayan Medicard Philippines, Inc for OFWs, White Plan (60K), Blue Plan (100K), and Purple Plan (150k)
VIP Medicard Philippines, Inc Global Healthcare assistance for travelling 150km or more for less than 90 days
Health Assure Plus Classic MetroCare Health Systems, Inc. Plans depend on room and board type, as well as the annual benefit limit
Health Assure Plus Prestige MetroCare Health Systems, Inc. Same as Health Assure Plus Classic, plus access to major hospitals
Select Plus Pacific Cross Health Care. Inc ABL of P1.5 million reimbursement
Select Plus with Access Pacific Cross Health Care. Inc ABL of 1.5 million with no cash outlay
Select Standard Pacific Cross Health Care. Inc Up to P1.5 million reimbursement for each disability per lifetime
Select Standard with Access Pacific Cross Health Care. Inc Up to 1.5 million per disability per lifetime with no cash outlay

4. Best HMO for Senior Citizens

You may have a tough time looking for a healthcare insurance specific for your parents or siblings who are in advanced age. And that’s because they are more likely to be in frail health, susceptible to diseases, higher chances to succumb to dreaded diseases or sick (currently or have recovered) from a pre-existing medical condition.

Because of the reasons above, companies either have no plans that are made available to them or the ones they offer come with higher costs and subject to many exclusions.

However by saying that, there are still a few plans that you can choose from.

Plan 1M Kaiser lnternational Healthgroup, Inc 61 years old and above, 1m annual benefit limit
Plan 250k Kaiser lnternational Healthgroup, Inc 250k annual benefit limit
Plan 500k Kaiser lnternational Healthgroup, Inc 500k annual benefit limit
Blue Royale Premier Pacific Cross Health Care. Inc 66 and above
Premier Pacific Cross Health Care. Inc 66 years old and above, reimbursement, 10% co-pay

5. Best HMO for corporate and small/medium enterprises (SME)

Are you a business-owner? Do you want to protect your workers from the worst during times of sickness?

A corporate or SME (small/medium enterprises) HMO plan is built specifically for the needs of businesses. It can accommodate more enrollees that what can be offered in a family plan. Clients may have to reach the required minimum number of employees as principals and there may be a limit to the total number of enrollees.

There are two options that companies can go for: premium-based or third party administration (TPA). In a premium-based HMO plan, there’s fixed cost, fixed or pre-defined benefits and exclusions, and the risks are shouldered by the HMO provider.

Under TPA on the other hand, the business sets up a health fund. Whenever an employee avails of any of the healthcare services, it gets deducted. Costs of the services are generally lesser due to the volume discounts especially when there are many enrollees. The business needs to make sure that the health fund is replenished. The HMO provider meanwhile will charge fees for administrative service, access, and other such expenses. The benefit is that the business only has to pay what is utilized rather than paying a fixed premium.

HMO companies have different sets of plans for SME and corporate accounts. While there are a few that provide information on these group plans, some don’t have any. There might also be a need to look at the demographics of your employees, age, dependents, etc.

Please take the time to contact the HMO companies and schedule for a meeting. The list of products below is in no way a complete representative of what is available in the market.

GreatValue Program CareHealthPlus Systems International Renewable healthcare plan available for Group/Corporate
ROYAL HEALTH ADVANTAGE Eastwest Healthcare, Inc 5 to 99 members
Exceptional Care for Group Fortune Medicare, Inc At least 20 enrollees
Group Account for small group Fortune Medicare, Inc Minimum of 10 enrollees
SME Fit Plan Intellicare 20 to 50 enrollees (including depdnents) 
Short Term Healthcare mini-group, group, SME Kaiser International Healthgroup, Inc Group Rates 50 – 99 members, variants: H500, H800, H1200, H1900, H2600 and H160, H2800, H3200, H4200
Short-term healthcare Corporate Kaiser lnternational Healthgroup, Inc Group Rates 100 to 299 members, variants: H500, H800, H1200, H1900, H2600 and H160, H2800, H3200, H4200
H500, H800, H1200, H1900, H2600 and H160, H2800, H3200, H4200 Kaiser lnternational Healthgroup, Inc Group rates 10-49
Maxicare BusinessEssential Maxicare 3 employees, 99 enrollees
Maxicare Plus Maxicare 10 principals, 99 enrollees
Maxicare Starter Plan Maxicare At least 3 – 9 principals and up to 99 enrollees
Corporate Group Plan  MetroCare Heallh Systems, Inc. Baby Group (5 to 19), Regular group (20 to 100), Third Party Agreement for more than 300 members
Comprehensive Premium Based Optimum Medical & Health Care At least 10 employees
Third Party Administration Optimum Medical & Health Care Based on corporate needs
BC Flexi Access Pacific Cross Health Care. Inc at least 20 employees

How can an HMO plan help you?

But why pay for an HMO plan when we can go directly to a doctor for a check-up or hospital for confinement? Why do you need to buy insurance?

The reason is that medical expenses can be huge. When you are admitted in a hospital, the bills can run up to tens of thousands to millions of pesos. An admission to an emergency ward to get immediate medical attention, undergo surgeries, or receive intensive care can be costly too.

It’s good if money is available to pay for them, but that may not be enough to cover the bills. And for most of us Filipinos, we have limited savings or even none at all. We can become poor or even poorer, forced to sell properties, borrow money, declare bankruptcy, or even refuse to be treated for fear of being a burden to the family.

An HMO plan is a safety net from the personal crisis of being sick. In exchange for a fee and as a form of insurance, it pays the hospital bill up to a certain benefit limit. Plan-holders generally don’t have to pay any deposit for admission especially when admitted in hospitals within the network of healthcare providers accredited by the HMO company, while those who don’t have a plan might be asked to pay a deposit amount upfront.

What is the difference between Philhealth, HMO, critical illness insurance and life insurance?

Philhealth, HMO, critical illness plan and life insurance can be helpful on life’s most trying times: sickness and death.

Philhealth is required by the government for all people who are working, and membership is open to voluntary members such as freelancers, self-employed, and those who are out of work. It is a means to provide universal health care in the country as established by “The National Health Insurance Act of 1995” (Republic Act 7875), and it pays a certain amount for a particular disease that is being treated in the hospital.

However, Philhealth coverage can be inadequate and this is where private HMO plan can provide relief. It can pay up to a limit for any covered medical services. Both Philhealth and HMO pay healthcare providers directly. In case that you’ve availed of the service outside of the network, reimbursement may be an option.

The critical illness policy can add more cover than what Philhealth membership and HMO plan can provide. It is beneficial especially when coming down with any one of the diseases whose treatments can be quite expensive, such as a heart surgery. Unlike Philhealth and HMO plan, the amount is given to the client.

The purpose of life insurance is to take care of end-of-life expenses.

List of HMO companies in the Philippines

In the Philippines, HMO companies are regulated by the Insurance Commission. Here is the official list in alphabetical order below.

  1. Asalus Corporation (Intellicare)
  2. Asian Care Health Systems, Inc.
  3. Avega Managed Care, Inc.
  4. CareHealthPlus Systems International
  5. Carewell Health Systems, Inc.
  6. Caritas Health Shield, Inc.
  7. Cooperative Health Management Federation
  8. Dynamic Care Corporation
  9. Eastwest Healthcare, Inc
  10. Fortune Medicare, Inc
  11. Getwell Health Systems, Inc.
  12. Health Care & Development Corporation of the Philippines
  13. Health Maintenance, Inc
  14. Health Plan Phils., Inc.
  15. IMS Wellth Care, Inc
  16. Insular Health Care, Incorporated
  17. Kaiser International Healthgroup, Inc
  18. Life & Health HMP, Inc
  19. Marzan Health Care, Inc
  20. Maxicare Healthcare Corporation
  21. Medicard Philippines, Inc
  22. Medicare Plus, Inc.
  23. Medicare Health Systems, Inc
  24. MetroCare Health Systems, Inc.
  25. Optimum Medical & Health Care
  26. Pacific Cross Health Care. Inc
  27. Philhealth Care, Inc.
  28. Stotsenberq Healthcare Systems
  29. Transnational Medical & Diagnostic Center, Inc
  30. Ultima Health Systems, Inc
  31. Value Care Health System, Inc.

In addition, there are life insurance companies that also offer HMO plans including

The top 10 HMO companies in the Philippines

See below the list of Philippine HMO companies with the highest membership fees for 2018.

Maxicare HealthCare 13.8 billion 
Intellicare 11.8 billion 
Medicard Philippines 8.1 billion 
Caritas Health Shield 2.4 billion 
Philhealth Care 2.22 billion 
Value Care Health System 1.68 billion 
Eastwest Health Care 877 million 
Avega Managed Care 648 million 
Insular Health Care 433 million 
Pacific Cross Health Care 250 million
  1. Maxicare HealthCare has a network of over 56,000 healthcare professionals and over a thousand institutions for a client base of 1.3 million Filipinos. Under the Equicom group, the company is founded in 1987.
  2. Intellicare was established as Asalus Corporation on November 21, 1995. In 2003, it became known by its present name. It has a network of over 43,500 doctors and specialists, and it reached a million members in 2016.
  3. MediCard Philippines Inc. has a network of 1,000 medical institutions across the country and boasts of over 51,000 physicians addressing healthcare needs of nearly a million members. The company was founded in 1986.
  4. Instituted in 1995, Caritas Health Shield has over 92 offices located nationwide servicing 650,000 members. The company has 13,000 healthcare practitioners of various fields and specializations.
  5. PhilCare was established as Philippine Health Systems in 1982 and when it was acquired by Philippine American Life Insurance Company two years later it was known as PhilamCare and then by its current corporate brand upon acquisition by Maestro Holdings in 2009.
  6. Established in 1997, Value Care Health System has branches in major cities Cebu, Davao and Iloilo.
  7. Eastwest Health Care is HMO providing services for the medical needs of over 132,000 members in the country. With almost 600 companies as members, the company has 900 accredited hospitals and clinics and 12,000 medical professionals.
  8. Avega Managed Care has 49,000 physicians from various medical specializations and 2,800 partner medical institutions. The company has 15 offices spread across the archipelago.
  9. Insular Health Care is a subsidiary of the Insular Life, a life insurance company.
  10. Pacific Cross Health Care was organized and known as State Bonding and Insurance Company, Inc. in 1949. The medical insurance division was established in 1977 and by 1986, the company rebranded as Blue Cross. In line with its regional reach in Asia, the company changed to the current name in 2015 and has sister companies in Thailand, Indonesia and Vietnam.

What are the things to look for in an HMO plan?

With so many options to choose from, you may now be at a loss on what to do. Here are some of the important things that can help you make a decision in purchasing a PH HMO plan.

These are very salient points that you should go over with the provider or sales agent. You need to ask about them so that your expectations are set right from the get-go.

Here are the things that you may want to discuss.

  1. Coverage
  2. Exclusion
  3. Issue age
  4. Cover age
  5. Dependents
  6. Mode of availment
  7. Premium

1. Coverage

What benefits are you expecting to get? What healthcare services are guaranteed to be paid and under what conditions? Remember that a less costly plan such as a prepaid card may mean there are only very specific situations that they can be used. A few of the things worth looking into are:

  • ABL
  • daily rate for room and board (ward, semi-private, private, suite, etc)
  • any benefit limit of any healthcare services
  • any benefit limit on certain diseases
  • network of hospitals, clinics, diagnostic laboratories, etc.

2. Exclusion

The plan’s coverage may also spell out exclusions. Exclusions are circumstances, services, or conditions where no benefits are released. This can include pre-existing conditions, certain dreaded diseases, conditions (such as pregnancy), even elective medical procedures, surgeries, etc.

3. Issue age

Issue age is the range of ages that customers are eligible to purchase the plan. Falling outside of this range means that you are not qualified. For instance, a kid’s plan may require that the child is at least 6 months old and no older than 17 years old. An individual policy may require issue age between 18 and 60 years old, and one that’s for senior citizens 61 until 100 years old.

4. Cover age

Cover age is the age that the plan terminates. For example, a plan might have an issue age of 18 – 60 years old with coverage up until 65 years old. This means clients who are within the range can apply, while the coverage continues until they are 65 years old. By which time it terminates. Stated differently, while potential clients who are 61 – 65 years old can no longer apply, existing clients who activated the plan on or before 60th birthday can still enjoy the coverage until the age of 65.

5. Dependents

Does the plan allow dependents?

If not, then it is strictly an individual plan. If yes, then that means that it is a group (SME, corporate, etc) or family plan. At times the coverage for dependents are the same as the principal insured, other times they may have an entirely different, sometimes lower, set of benefits.

6. Availment

Another salient point to talk about is the mode of availment. Unlike critical illness insurance where cash is given directly to you, an HMO plan may facilitate the payment directly to the healthcare industry so no money goes through you. Unless if it has a term insurance or hospital income protection clause where you get a lump sum or an allowance for each day being confined.

You may also need to see if the plan is a co-pay. A co-pay arrangement means that you pay a portion of the final bill. Some plans would also require that you pay the first ₱10,000 and then the remaining amount is split to be paid by you, Philhealth, and the HMO company.

Another thing that is also worth noting is that there is consequence if you avail of the service outside of the network. You may be asked an LOA (letter of authorization) before you can get medical care. Some plans would reimburse any amount you’ve paid, others will not honor the bill so you end up paying all of it.

7. Premium

How much are you going to pay?

Premium, which is the amount that you’re going to be asked to pay to the HMO company, is going to depend on a lot of things. Some plans would have a fixed premium based on your age and gender. Others would rely on many factors such as your state of health, result of some lab tests, medical history, your family’s history of illnesses, any past hospital admission, diagnosis of any diseases, etc.

Check too on other extra charges such as access fee, membership dues, etc.

One other thing to take note of is the required mode of payment: deposit, online cash transfer, payment center, cash, etc. See if they also accept premium paid every month, quarter, semi-annual or year. Some companies offer discount if you choose an annual payment.

How to apply for HMO plan in the Philippines

1. Know your healthcare cover needs

The first thing to do is know your financial status. Check how vulnerable you can be financially speaking if you, your family or an employee gets sick.

  • Is your emergency fund enough? Think of how much cash you have available that can be accessed during uncertain times (accident, injuries, illness, etc). Think of assets that you’re willing to liquidate to get through the tough times.
  • Check existing Philhealth benefits, any existing critical illness plan, and insurance to ensure that you do not get over- or under-insured.
  • See if you’ve already been included in an HMO plan through your parents, sibling, or employer.
  • Generally speaking, it is better to get a plan while you’re still young and healthy.
  • Would you want an individual, family, SME/corporate plan, or senior citizens?

2. Shop around

Once you identify what you need, then it is time that you look for a plan and provider. If you just want an inconvenient way to get coverage for basic services such as unlimited consultations, one-time use of outpatient or emergency care, then you may be better off with prepaid cards.

On the other hand, if you’re looking for a comprehensive package you may the review the tables of the HMO plans above. You may want to visit the website of the companies. You may send them an email or reach out to them via telephone.

If you know someone like a friend or family or even an acquaintance is into health care insurance industry, then you can ask for a quote. Make sure that you spell out exactly what you need, your budget, etc.

You may check the following:

  • Is the company legit? Check this article and the Insurance Commission if they’re licensed to do business in the country. You may want to know their general reputation, feedback from others, etc.
  • Compare coverage. Check similar plans in terms of premium, coverage, exclusions, and other the items discussed above about what to look for in a plan.
  • First impression. Are they responsive? Is the customer service great?
  • Convenience. Are the accredited clinics, hospitals and other medical facilities near your place of work or residence?
  • Feedback. Ask around. There may be someone you know who has acquired a plan, had availed of the service, and has many first-hand feedback about the provider.

How can you make sure that it is a legitimate HMO company?

The company should be registered with Insurance Commission (IC) so you’d know they’re legitimate. Some companies are members of national groups, such as Philippine Association of Health Maintenance Organization Companies (PAHMOC) or the Association of Health Maintenance Organizations of the Philippines, Inc. (AHMOPI). So you might want to check the company whether they are registered with IC or

3. Fill out the application forms in good faith.

Once you have narrow down your choices and decide on one plan, prepare the initial premium payment. Several company would require that you put up at least the first month’s payment, others would ask you to pay six months in advance.

When you fill out the forms, you’d be asked to declare information regarding your state of health. Please be honest. Fill out past confinement, diagnosis, prescribed medicines, results of lab/diagnostic tests, treatments received, etc.

If you conceal, fail to disclose or misrepresent any relevant medical information, there is a chance that the contract is going to be voided and cannot be enforced. The company may refuse to cover expenses at the moment you’d need to avail of a medical service.

At this point, you might be asked too to undergo some tests such as X-ray, urine test, etc. Follow the instructions as given to you by the company. Your ability to open a plan might depend on the results.

4. Wait for the contract.

Once your plan is approved, wait for the contract to be delivered. Some companies would give out a health card. The card is presented when you’d like to avail of services within or outside of the network. Make sure that you understand the contract so there won’t be any snags during the time that you’d need the coverage.

It is likewise important to take note of the contact details of agents, reps, liaison officers, healthcare providers, etc. You may need them if you’d like to ask updates of your account, clarify some questions, or in times of emergency.

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