Guide To HMO Health Insurance In The Philippines – Peso Lab

Best HMO prepaid cards for emergency services

These cards can pay expenses for specific emergency situations.

Best HMO prepaid cards for hospitalization

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

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.

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.

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.

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.

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.

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.