Guide to HMO health insurance in the Philippines

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The Philippine HMO (health maintenance organization) is a company that offers health insurance. However, according to studies, over half of the country’s total healthcare costs are paid out-of-pocket, which means many of us Pinoys are uninsured. The costs of getting treatment for cancer, stroke and heart disease are rising and can easily run up to several million pesos.

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?

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

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

HMO companies offer various plans. A standard HMO package might include outpatient care and hospitalization. Prepaid cards are also becoming popular recently, and they are cheap but they have limited 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.

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. 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, doctor’s consultation, etc.

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

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.

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 for the remainder of the year.

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.

In the case above:

Total bill₱50,000
Philhealth (2020 rate)₱6,600
HMO₱43,400

And this means that the remaining ABL is ₱51,600 (100k – 2,000 – 43,400 – 3,000).

If the patient is not a Philhealth member, the Philhealth portion needs to be paid out of pocket.

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

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 or undergoing surgeries can be costly too.

It’s good if we have the money to pay for them. And even if we do have savings, it may not be enough to cover the bills. For most of us Filipinos, that’s just not the case. We can become poor or even poorer, forced to sell properties, borrow money, declare bankruptcy, or even refuse to be admitted 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 or coverage. HMO planholders generally don’t have to pay any deposit for admission especially in private hospitals, 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.

Health insurance/HMO companies in the Philippines

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

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.

CompanyMembership Fees
Maxicare HealthCare13.8 billion 
Intellicare11.8 billion 
Medicard Philippines8.1 billion 
Caritas Health Shield2.4 billion 
Philhealth Care2.22 billion 
Value Care Health System1.68 billion 
Eastwest Health Care877 million 
Avega Managed Care648 million 
Insular Health Care433 million 
Pacific Cross Health Care250 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.

Advantages of HMO

What are the pros and cons of getting an HMO plan?

  • 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, you can get cured of what ails you.
  • 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 stocks, mutual funds, and other investments during a down market, etc.
  • Protects your financial plan.
  • Coverage can include dependents such as parents, siblings and children.
  • Lowers 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.
  • Patients and their families can focus on care.
  • 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.
  • HMO companies offer a variety of healthcare solutions, including prepaid cards, coverage for senior citizens, etc.
  • Payment plans can be flexible: monthly, quarterly, semi-annually or annually.
  • They can be customizable with addition of riders or upgrades.

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.
  • It can be limited. Some plans may not cover certain diseases or medical procedures. They 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.
  • Thinking of using multiple HMO plans? Only one can be used at any one time.
  • Premiums can be quite expensive especially for people of advanced age or with pre-existing conditions.
  • 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 lose it when you resign or you retire from the job.

HMO plans and coverage in the Philippines

What are the types of HMO plans that are available in the market today? Below are some of the products that you can buy.

  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. They are meant as

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. HMO prepaid cards

Pinoys who are a tight budget can actually get HMO prepaid cards, which are becoming popular recently. They’re easy to get, cheap, and open for everyone. There are some that you can acquire without going through medical exam, underwriting, etc.

Also, in return their coverage is limited to whatever benefits they’re purchased for. Healthcare services are also most of the time similarly limited within the network. The validity is generally good for one year. The coverage of the prepaid cards commonly expires at the end of validity.

NameCompanyDetails
Aventus Classic CardAventusUnlimited consultations, fixed fee for specialists, free dental checkup, 10% discount on lab and diagnostic and other dental services
Aventus Elite CardAventusSame as Classic, higher discount, free annual physical examination
Aventus KiddieAventusFor 0 -17 years of age, same as Classic and higher discounts
Aventus Premium CardAventusSame as Classic, higher discounts, free Basic Executive Check-up
Aventus PrestigeAventusSame as Classic, higher discounts, free Comprehensive Executive Checkup
Aventus PrimeAventusSame as Classic, higher discounts on services, free Annual Physical Examination
Diabetes Care ProgramFamilyDocUnlimited doctor consult
Diabetes Prevention ProgramFamilyDocUnlimited doctor consult
Unli-KonsultaFamilyDocUnlimited doctor consultation for 3 people
ER Care All-In 60 AdultsInsular Health Care, IncFor 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 KidsInsular Health Care, IncFor 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 AdultsInsular Health Care, IncSame as ER Care All-In 60 Adults, limit up to 80K
ER Care All-In 80 KidsInsular Health Care, IncSame as ER Care All-In 60 Kids, limit up to 80K
ER Care All-In 100 AdultsInsular Health Care, IncSame as ER Care All-In 60 Adults, limit up to 100K
ER Care All-In 100 KidsInsular Health Care, IncSame as ER Care All-In 60 Kids, limit up to 100K
ER Care Basic 50Insular Health Care, IncOne-time use up to P50K for emergency care due to accidents, including medicine
ER Care Booster 60Insular Health Care, IncSame 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 80Insular Health Care, IncSame as ER Care Booster 60, up to P80K.
ER Care Booster 100Insular Health Care, IncSame as ER Care Booster 60, up to P100K.
MedConsult AdultsInsular Health Care, IncFor 18 – 64 years old, 4 face to face medical consultations, 1 year unlimited telemedicine access, 1 year unlimited dental consultations
MedConsult KidsInsular Health Care, IncFor 1-17 years old, same as MedConsult Adults
MedConsult SeniorsInsular Health Care, Inc
For 65 years and older, same as MedConsult Adults
Total ProtectERInsular Health Care, IncTerm insurance + hospital benefit + emergency care for accident, viral and bacterial illnesses.
Individual KonsultaMD KonsultaMDUnlimited medical consultation via telephone
Dual KonsultaMDKonsultaMDSame as Individual KonsultaMD, up to 2 people
Group KonsultaMDKonsultaMDSame as Individual KonsultaMD, up to 5 people
Maxicare EReadyMaxicareOne-time emergency related cases; two variants available
Maxicare EReady AdvanceMaxicareOne-time emergency-related coverage, unlimited outpatient consultation; two variants available
MyMaxicare LiteMaxicareOne-time confinement due to 8 covered diseases. Variants: Yellow and Blue
PRIMAMaxicareUnlimited outpatient consultations. Variants – Silver: 0 – 59 years old,
Gold: 60 years old and above,
Health CheckMedicard Philippines, IncUnlimited  check-up for
HealthPlusMedicard Philippines, IncUnlimited  preventive and outpatient care
MediCard SelectMedicard Philippines, IncIndividual 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 
My MediCardMedicard Philippines, Incunlimited consutlations in Medicard-accredited clinics and hospitals nationwide.
RxERMedicard Philippines, Incup to P20k limit for ER care, up to P5k for lab and diagnostic tests, emergency for trauma cases, preventive and outpatient care
Family Smile PackageMetroDentalDental care for four persons
MetroDental White PassMetroDentalOne dental consultation, One oral prophylaxis, One panoramic (full mouth) X-ray 
MetroDental Platinum PassMetroDentalSame as White Pass, One fluoride gel treatment, one temporary filling (per tooth), one simple tooth extraction
MyHealth Basic Metabolic PanelMyHealthClinicAvail for a panel of metabolic lab tests
MyHealth Clinic Annual Health PackageMyHealthClinicAvail for baseline check-up
MyHealth Comprehensive Metabolic PanelMyHealthClinicSame as Basic Metabolic Panel, plus lab test for liver or check health of organs
MyHealth Pregnancy Laboratory PackageMyHealthClinicOne Ob-gyne consultation and lab tests
MyHealth PRIME Check Executive Check-upMyHealthClinicIncludes physical and special exams, and lab tests
MyHealth Top2Bottom Executive Check-UpMyHealthClinicAvail for thorough health exam
Dengue AssistPhilCare18 – 64 years old, up to P30K limit for confinement due to dengue
Dengue RX Plus for AdultsPhilCare21 – 64 years old, same as Dengue Assist
Dengue RX Plus for FamilyPhilCareSame as Dengue Assist for two children and two adults
Dengue RX Plus for KidsPhilCareSame as Dengue Assist for individuals 20 years old or younger.
DigiMed Plus Consult (Single use) PhilCareOne-time video teleconsultation
ER Health Assist 40 for AdultsPhilCareUnlimited 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 AdultsPhilCareSame as ER Health Assist 40 for Adults, benefit up to P60K
ER Health Assist 80 for AdultsPhilCareSame as ER Health Assist 40 for Adults, benefit up to P80K
ER ShieldPhilCareEmergency care for viral and bacterial illnesses and treatment as result of accident injuries, up to P50k
ER Vantage Plus 40 for AdultsPhilCare18 – 64 yeras old, same as ER Shield, up to P40K
ER Vantage Plus 40 for KidsPhilCare6 months – 17 years old, same as ER Shield and up to P40K
ER Vantage Plus 60 for AdultsPhilCareSame as ER Vantage Plus 40 Adults, up to P60K
ER Vantage Plus 60 for KidsPhilCareSame as ER Vantage Plus 40 Kids and up to P60K
ER Vantage Plus 80 for AdultsPhilCareSame as ER Vantage Plus 40 Adults, up to P8
0K
ER Vantage Plus 80 for KidsPhilCareSame as ER Vantage Plus 40 Kids and up to P80K
Health Vantage 40 for AdultsPhilCare18 – 64 years old, same as ER Shield plus hospital confinement, up to P40K
Health Vantage 40 for KidsPhilCare6 months – 17 years old, same as ER Shield plus hospital confinement, up to P40K
Health Vantage 60 for AdultsPhilCareSame as Health Vantage Plus 40 Adults, up to P60K
Health Vantage 60 for KidsPhilCareSame as Health Vantage Plus 40 Kids, up to P60K
Health Vantage 80 for AdultsPhilCareSame as Health Vantage Plus 40 Adults, up to P80K
Health Vantage 80 for KidsPhilCareSame as Health Vantage Plus 40 Kids, up to P80K
PhilCare Agapay 700PhilCare16 – 65 years old, one-time availment of healthcare services up to P40k for viral, bacterial illnesses and injuries sustained from accident
PhilCare Agapay 900PhilCare16 – 65 years old, one-time availment of healthcare services up to P40k for viral, bacterial illnesses and injuries sustained from accident
PhilCare RushPhilCareTravel emergency care, ambulance, outpatient emergency and hospitalzation up to P50k
Single-use DigiMed ConsultPhilCareOne-time teleconsultation
unli-CONSULT for 65+PhilCareUnlimited consultation for 65 years old and older
unli-CONSULT for AdultsPhilCare18 – 64 years old, unlimited consultation
unli-CONSULT for KidsPhilCare1 – 17 years old, unlimited consult
Unli-DigiMed ConsultPhilCareUnlimited digital consultation
VidaCare COREPhilCare60 years older and above, unlimited consultation and lab/diagnostic tests
VidaCare PREMIERPhilCareSame as VidaCare CORE, plus up to P20k emergency care for viral, bacterial illnesses or injuries due to accident
MediCash Dengue InsurancePioneerUp to P10K assistance on diagnosis of dengue
MediCash Leptospirosis InsurancePioneerUp to P10K assistance on diagnosis of Leptospirosis

2. 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.

NameCompanyDetails
OptimumCare ProgramCareHealthPlus Systems InternationalBuild up healthcare plan with a five year saving period
Quantum GoldCareHealthPlus Systems InternationalHelathcare coverage for 7 years and pay for only five years
QuantumCare ProgramCareHealthPlus Systems InternationalFive-year renewal HMO plan
ValuePlus ProgramCareHealthPlus Systems InternationalThree-year renewal HMO plan
Enhanced Core 10Caritas Health Shield, Inc.5 year renewal, 10 years plan
ENHANCED CORE 6Caritas Health Shield, Inc.5 year renewal, 6 years plan
KIDDIE HEALTH PLANCaritas Health Shield, Inc.Healthcare plan for kids
Ultimate Kaiser Health Builder PlanKaiser lnternational Healthgroup, IncComes in four variants: K50, K75, K100, and K125; long-term health care
Short Term Health CareKaiser lnternational Healthgroup, IncComes in variants of H500, H800, H1200, H1900, H2600 and H160, H2800, H3200, H4200
MyMaxicareMaxicareHMO plan for individuals, comes in four variants
Health Assure Plus ClassicMetroCare Heallh Systems, Inc.Plans depend on room and board type, as well as the annual benefit limit
Health Assure Plus PrestigeMetroCare Heallh Systems, Inc.Same as Health Assure Plus Classic, with major hospitals
Blue RoyalePacific Cross Health Care. IncUSD 2 million ABL, travel abroad coverage for less than 90 days, comes in three variants
LifestylePacific Cross Health Care. IncIssue age 21 – 35 y.o. 250K ABL per illness per lifetime, renewable until age 40
AIA MED-ASSISTPhilam LifeCo-pay of 10%, benefit up to P4million
Global Health AccessPhilippine AXA Life100 million ABL, plan can be taken advantage within and outside the country

3. 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.

NameCompanyDetails
Care and Share ProgramCareHealthPlus Systems InternationalOutpatient, dental care
Emergency Medical ExpenseEastwest Healthcare, IncFor one time emergency care
Health Emergency Pampamilya Program (HELPP)Eastwest Healthcare, IncEmergency care plus hospital daily allowance while confined
INFINITY HEALTH ADVANTAGE (Individuals / Family)Eastwest Healthcare, IncComprehensive HMO program
Short Term Health CareKaiser International Healthgroup, IncVariants: Health 600, Health 800 and then Health 1200, Health 1600
MyMaxicareMaxicareOffered for individuals and families, four variants available
Individual and FamilyMedicard Philippines, IncHospital confinement. Variants: 50k, 60k, 100k, and 120k ABK
KabayanMedicard Philippines, Incfor OFWs, White Plan (60K), Blue Plan (100K), and Purple Plan (150k)
VIPMedicard Philippines, IncGlobal Healthcare assistance for travelling 150km or more for less than 90 days
Health Assure Plus ClassicMetroCare Health Systems, Inc.Plans depend on room and board type, as well as the annual benefit limit
Health Assure Plus PrestigeMetroCare Health Systems, Inc.Same as Health Assure Plus Classic, plus access to major hospitals
Select PlusPacific Cross Health Care. IncABL of P1.5 million reimbursement
Select Plus with AccessPacific Cross Health Care. IncABL of 1.5 million with no cash outlay
Select StandardPacific Cross Health Care. IncUp to P1.5 million reimbursement for each disability per lifetime
Select Standard with AccessPacific Cross Health Care. IncUp to 1.5 million per disability per lifetime with no cash outlay

4. 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.

NameCompanyDetails
Plan 1MKaiser lnternational Healthgroup, Inc61 years old and above, 1m annual benefit limit
Plan 250kKaiser lnternational Healthgroup, Inc250k annual benefit limit
Plan 500kKaiser lnternational Healthgroup, Inc500k annual benefit limit
Blue Royale PremierPacific Cross Health Care. Inc66 and above
PremierPacific Cross Health Care. Inc66 years old and above, reimbursement, 10% co-pay

5. 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.

NameCompanyDetails
GreatValue ProgramCareHealthPlus Systems InternationalRenewable healthcare plan available for Group/Corporate
ROYAL HEALTH ADVANTAGEEastwest Healthcare, Inc5 to 99 members
Exceptional Care for GroupFortune Medicare, IncAt least 20 enrollees
Group Account for small groupFortune Medicare, IncMinimum of 10 enrollees
SME Fit PlanIntellicare20 to 50 enrollees (including depdnents) 
Short Term Healthcare mini-group, group, SMEKaiser International Healthgroup, IncGroup Rates 50 – 99 members, variants: H500, H800, H1200, H1900, H2600 and H160, H2800, H3200, H4200
Short-term healthcare Corporate Kaiser lnternational Healthgroup, IncGroup 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, H4200Kaiser lnternational Healthgroup, IncGroup rates 10-49
Maxicare BusinessEssentialMaxicare3 employees, 99 enrollees
Maxicare PlusMaxicare10 principals, 99 enrollees
Maxicare Starter PlanMaxicareAt 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 BasedOptimum Medical & Health CareAt least 10 employees
Third Party AdministrationOptimum Medical & Health CareBased on corporate needs
BC Flexi AccessPacific Cross Health Care. Incat least 20 employees

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.

  • Coverage
  • Exclusion
  • Issue age
  • Cover age
  • Dependents
  • Mode of availment
  • Premium

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.

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.

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.

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.

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.

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.

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 status money-wise. 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 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 that provides you may the see the tables of the HMO plans above. You may want to visit the website of the companies to inquire. 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

  • 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 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)

3. Fill out the application forms in good faith.

Once you have narrow down your choices and decided on one plan, prepare the initial premium payment. Several 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.

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 result.

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.

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