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Selecting A Sound HMO Often every 3 years, companies begin to feel the itch for a new HMO for

their employees. Such is the average life-span of a companyHMO relationship, confirms Norman Amora, Assistant Vice President for Sales & Marketing of leading HMO IntelliCare. But it need not be that way. IntelliCare's relationships with a lot of its clients prove it. The need to look for a new one is usually triggered by laxity or the sudden successive failures of HMOs to deliver on their promises. Sometimes, it happens when top management actually experiences the failure of the HMO. This habit of shifting every 3 years or so can put a tremendous stress on companies, their employees, most especially who benefit from the health plans. If only there were a set of criteria on which companies can immediately appraise a line up of HMOs when they shop for one, the constant shifting may happen a lot less. But companies do it differently. They have their own set of criteria and may vary depending on what their needs are or financial capabilities are. So what should a company look for in an HMO? IntelliCare has been in the industry for years and has observed the behavior of companies when it comes to looking for an HMO. Amora says, This practice of looking into the price of an HMO's offer is of course, all sound and logical. Sometimes though, companies tend to prioritize their wants rather than their needs, which is evident in their choice of a lower priced HMO with more benefits, overlooking the fact that this scheme will be more costly in the long run. If companies stick to their terms of reference (TOR), they can do away with benefits to lessen the cost of their health care benefit. But high cost of their incumbent HMOs is just one of the reasons why companies look for other HMOs. Other issues include contract implementation and interpretation when members do not understand what are covered and how to use the card, the bad service of the HMO, and its providers like the absence or quality of doctors among other things which even regular patients, not just HMO cardholders, complain about as well. When clients experience such things, that is the time that they look for another HMO. It does not have to reach this point. As its outstanding client retention rate of above 90% should prove, IntelliCare is now in a very good position to share with many what the ideal set of criteria is. Benefit package Companies usually look for wide coverage of the benefit package first. What company would not? They are looking after the welfare of the employees after all. Any benefit package must include the basics, such as access to clinics and tertiary hospitals for consultation with the common medical specializations and in time of confinement or in-patient. The basics are after all the most commonly utilized service of the HMO. The benefit package must be tailor fitted into the company's needs. There are cases when some benefits, though incorporated at the time of bidding or choosing an HMO are never used by the cardholder. "To be able to tailor fit the health care package, the HR has to be involved with the so called health consultant of the provider," Amora says. Caution must be set though when appraising the benefit package.

The benefit package though should be fair and must be in the most feasible of terms. It must be within the budget set. Any demands that go beyond the realistic terms will without a doubt affect the services of the HMO and its affiliates. Since most companies have a budget set for this service, companies cannot just rely on data given to them without studying the terms of reference or the benefit package given by the previous HMO. Network An HMOs strength should be measured in terms of its network. This includes the hospitals, clinics, other facilities and affiliates or expert resources such as doctors and specialists. How far can an HMO go? Do they have affiliates in far flung areas outside of Manila? Or at least in key cities that cardholders need not be compelled to come to Manila when they avail of the services? A lot of the beneficiaries and extension cardholders reside outside of Manila. They are the families of the principal holders who are based in Manila. To be of proper service to these, the HMO's reach must go as far as at least the key cities of the provinces where they reside. Also, the affiliate doctors should be complete at least on the level of the basic medical specializations in each facility. IntelliCare for one has the numbers to show its strength. With over 9,000 affiliate doctors, 350 accredited hospitals, over 200 clinics, some of which are owned by the company and some are accredited independent facilities. Add to these its dominance in the number of Patient Relations Officers (PROs) spread out in the country. All these manpower are distributed in a manner that fits the locale. Financial capability Financial capability is a crucial factor in the selection because its capacity to deliver the services depends highly on it. If your prospective HMO impresses you with a benefit package with a below-industry price tag, you might want to think twice. Such a practice spreads them too thinly and the result can be disastrous. In the last ten years there were a handful of HMOs that closed shop because of wrong pricing. These companies were keen on penetrating the market by offering low prices. In the end, their capacity to deliver because of the financial instability that resulted from the risky pricing scheme, suffered. The closure put a negative effect on the HMO and people started questioning just how feasible this kind of service is on the long run. The concern was so serious because not only were money being wasted, they affected greatly the cardholders. To look into the financial capability of an HMO, one can begin with looking into its roster of clients. Do they include big corporations that put a premium on quality service or are not willing to risk their investment on a company that they see is bound to fail? Pricing/Premiums This is usually the first on the list of most companies. Again, it is fair because most companies already have a budget set for a health plan for its employees. Some are even carved in stone. But when considering the price, one has to assess carefully before being impressed by low costs and big promises. Fair pricing are the key words. As long as the package is fairly priced, all stakeholders, including the providers, the hospitals, the general administrative expenses of the HMO and all medical claims will be appeased. Their fees will be paid accordingly and will eventually redound to good service. As a fairly priced HMO, you will not shortchange the client and all of your stakeholders will not lose. And most importantly, Service After sales service What happens after the promises are made? You then expect them to be delivered. The product is sensitive because it deals with human life so an HMO can only aim for excellent service, nothing less. Unfortunately, service is only appreciated only when a crucial case is attended to or criticized when a glitch happens. Hardly is service appreciated when it is fairly delivered outside of an unfortunate medical incident.

Service is a complete package of offerings even in times when availment isn't even there yet. It starts from the orientation seminar given by the HMO up to the availment of actual services. Service is after all, hard to define especially if you do not yet have an experience with the HMO. IntelliCare, for its part, tries to manage the orientation not only when they gather the employees in a forum for some frequently asked questions (FAQs) and introduction into the services. Everything should be given in the orientation from the interpretation of the contract, to procedures, to the network of providers and other such matters. If the employee needs further information, they can always refer to the customer representative. For big companies where an HMO needs to manage well the information, they can put out a help desk for a period of time, like what IntelliCare does. They have the manuals, collaterals, a website, newsletter and even medical bulletin emails to complete the orientation process. So they should be there long after the actual seminar is conducted. Like IntelliCare, an HMO must have an entire account management team to attend to a client's needs from as simple as consulting on the services even before the need arises. Seeking testimonials or existing client feedback is also one way of knowing how an HMO will perform. IntelliCare even suggests to its clients to call their existing clients and accredited hospitals for feedback. It's the only way to sell an intangible such as service. IntelliCare's clients witness the kind of service given to them when a Patient Relations Officer (PRO) attends to them in their time of need. They know that their service is outstanding because of their above 90% client retention rate, a figure that is unheard of in an industry that averages at 3 years per client. When you carefully review your company's needs, this set of criteria will surely appear a sound way to choose an HMO. It's almost a sure formula to avoid that 3 year itch.

HMO BENEFIT PROGRAM Corporate Accounts Who is Eligible to Enroll?

Single Proprietor / Partnership / Corporation duly registered with DTI or SEC to conduct business in the Philippines. Minimum of 10 regular employees.

MEMBERSHIP ELIGIBILITY 1. 2. Principal members at least eighteen (18) to sixty-five (65) years old. Dependents: a. Married principals must enroll their spouse first, aged sixty-five (65) and below, followed by the eldest to the youngest child at thirty (30) days old to twenty-one (21) years old; b. Single/unmarried members, must be acknowledged natural children first, parents aged sixty-five (65) and below, then the siblings, eldest brother/sister to the youngest child at least fifteen (15) days old to twenty-one (21) years old; What are the benefits in enrolling under the HMO Program?

A.

IntelliCare members have the privilege to avail of the following services at any accredited Hospitals and Clinics Nationwide. ANNUAL PHYSICAL EXAM Complete blood count Physical Examination Urinalysis Fecalysis Chest x-ray Electrocardiogram (For members age thirty-five (35) years and above, or if indicated) Pap smear (For female members age thirty-five (35) years and above, or if prescribed)

B.

PREVENTIVE CARE Periodic medical check-up Management of health problems Counseling on health habits (family planning, diet prescriptions) Record keeping of medical history Routine Immunization (except cost of vaccines)

C.

OUT-PATIENT Medical consultation during regular clinic hours, excluding prescribed medicines; Emergency room care; Referral to accredited specialist/s; Eye, Ear, Nose, and Throat consultations; Treatment of minor injuries and/or illnesses Laboratory tests, x-rays, and other diagnostic exams prescribed by the IntelliCare physician; Minor surgery not requiring confinement; Speech and physical therapy Pre-natal and post-natal consultations.

D.

IN-PATIENT CONFINEMENT No deposit upon admission Room and Board benefits specified in Schedule per category; Use of operating room and recovery room facilities; Standard admission kit (e.g. ID bracelet, thermometer, etc.); Professional services of all attending accredited specialists, anesthesiologists; Anesthesia and medications; Blood transfusions and intravenous fluids; Laboratory tests, x-rays, and other diagnostic examinations; Administered medicines; Dressings, plaster casts, sutures and other items directly related to the medical management of the patient; ICU confinement/ dialysis; CT scan and ultrasound (except for maternity cases); Ambulance service Assistance in administrative requirements through the liaison officer; and All other hospital charges deemed necessary by IntelliCare Accredited Physician in the treatment of the patient.

E.

EMERGENCY CARE

E-1. IN ACCREDITED HOSPITALS Doctors services Medicines used Oxygen and intravenous fluids Dressings, casts and sutures Laboratory, x-ray and other diagnostic examinations directly related to the emergency management of the patient

E-2. IN NON-ACCREDITED HOSPITALS

IntelliCare agrees to reimburse up to eighty percent (80%) of the total hospital bills including professional fees using IntelliCare Relative Values Scale (RVS) but not to exceed Php30,000.00.

E-3. IN FOREIGN COUNTRIES

Confinement in foreign territory shall be treated as if the member had been confined in an nonaccredited hospital facility using IntelliCare Relative Values Scale (RVS) but not to exceed Php30,000.00.

E-3. IN AREAS WITHOUT ACCREDITED HOSPITALS

IntelliCare agrees to reimburse up to one hundred percent (100%) of the total hospital bills including professional fees using IntelliCare Relative Values Scale (RVS) but not to exceed Php30,000.00.

F.

Financial Assistance including AD&D (For principals only)

al death

of sight of one eye G. H.

PHP 10,000.00 20,000.00 10,000.00 10,000.00 10,000.00 10,000.00 10,000.00 10,000.00 5,000.00 5,000.00

Dental Services (OPTIONAL BENEFIT) Dental Examination; Annual oral prophylaxis; Oral health education through chairside instruction; Orthodontic consultation (braces and malposition of teeth); Pre-natal check of teeth and gums; Temporo Mandibular Joint (TMJ) consultation (clicking of jaws); Conduct activities on dental health education (e.g. regarding AIDS); Emergency dental treatment for the relief of pain; Gum treatment for cases like inflammation or bleeding; Temporary fillings; Simple extraction of unsavable tooth; Recementation of fixed bridges, crowns, jackets, inlays/outlays. How can we get a quotation and enroll in the HMO Corporate Program?

Request for proposals will personally be handled by the Business Development Officers of IntelliCare. They are trained to assist, handle and answer any of your concerns regarding the program. Please call (02) 789-4000 and have yourself connected to the Sales and Marketing Department. You can also direct your inquiries to our email address: marketing@info.intellicare.net.ph

1. How do I know which doctors are affiliated and with IntelliCare? You may check the list of IntelliCare affiliated doctors and their schedule with the IntelliCare Hospital Coordinator. You may also call our Customer Service Specialists through telephone numbers 789-4000 or 902-3400 for the list of accredited facilities and additional inquiries or visit our website: www.intellicare.com.ph.

2. Can I get a copy of the IntelliCares list of affiliated doctors? IntelliCare continually updates its list of affiliated doctors, thus it is advisable for you to check and verify their schedules with the IntelliCare Hospital Coordinator or call IntelliCare Customer Service for details.

3. Are IntelliCare Hospital Coordinators/Assistant Coordinators available 24 hours a day? What should I do if they are unavailable? IntelliCare has two to three (2-3) Hospital Coordinators per hospital and will accommodate members for outpatient and non-emergency consultations during their specified clinic hours. For other hospitals that have no Coordinators but have an HMO or Industrial office, you may secure IntelliCare Referral Forms from the said office. For medical emergencies, you may proceed directly to the emergency room of the hospital for immediate treatment. However, assessment of whether the case is emergency or not will depend on the Emergency Room physician.

4. If I am in an accredited hospital and want to use the services of my personal doctor who is not accredited, can I have the medical services reimbursed? Consultation, treatment and referral for diagnostic procedures and/or confinement coming from a non-accredited doctor is non-reimbursable. For you to enjoy the benefits of your health plan, you must avail of your benefits in an IntelliCare accredited hospital or clinic and have your case managed by an IntelliCare affiliated doctor , except during emergency cases.

5. Can I have my personal doctor/dentist accredited by IntelliCare? You may write a request for accreditation to IntelliCares Account Management Department or coordinate with your HR Representative to facilitate your request. The doctor/dentist will be asked to submit necessary requirements to IntelliCare and will be evaluated by the companys Medical Relations Department if qualified to be part of IntelliCare's network.

The doctor may be affiliated only if he/she passes IntelliCares evaluation AND he/she agrees to the payment terms and conditions of our contract. We will give you status update through our Account Officer if your request has been approved or not.

6. During confinement, if I want to occupy a room category higher than what is stated in my plan, may I do so? Yes, you may occupy a room category higher than what is entitled to you. However, during voluntary upgrading (when you choose to occupy a higher room category even if your allowed room is available), you will pay all incremental charges. Due to socialized pricing in hospitals, the higher the room occupied - the higher the cost of services. This includes room rate, professional fees, medicines, medical supplies, hospital procedures and the like. The same charges may also apply if you are admitted in a hospital that does not provide or does not allow confinement of non-private patients in the room category corresponding to your plan. The IntelliCare Patient Relations Officer shall explain and remind you to pay these charges prior to hospital discharge.

7. What if, during the time of my admission, all the rooms under my room category are occupied what will I do? In this case, you may choose one of the following options:

Occupy a lower room category and pay no incremental charges. Occupy an available room one category higher than what is entitled and pay only the room and board excess. You must transfer to your designated room category once the room becomes available, otherwise you will pay all incremental charges from day one (1) of confinement You may transfer to another accredited hospital if it is a non-emergency case.

Note: Provision on involuntary upgrading of room category may vary according to the plan of the member.

8. What if my illness/condition developed certain complications will these illnesses have a separate Maximum Benefit Limit? Any and all illnesses proven to be related or is a complication of a certain illness shall share the same Maximum Benefit Limit.

9. Who is responsible for the filing of my Philhealth forms with the hospital? What happens if I fail to file? It is the members responsibility to file the Philhealth forms. If you fail to file upon hospital discharge, you will pay the amount corresponding to your Philhealth benefit and apply for reimbursement directly from the Philhealth Office afterwards. You may coordinate with your companys HR Representative during your confinement period to secure a signed Philhealth Claim Form 1, Philhealth contributions and Member's Data Record (MDR) as well as a Philhealth Claim Form 2 to be signed by your attending physician prior to hospital discharge. IntelliCare Patient Relation Officers (PROs) will provide assistance in reminding you to submit the said forms. They, however, will not be directly responsible for the actual filing.

In the case of a non-Philhealth member, member must pay the Philhealth portion of the hospital bill prior to hospital discharge

10. Do I get 100% reimbursement for my emergency confinement in a non-accredited hospital? If you were treated in a non-accredited hospital for a medical emergency, IntelliCare will reimburse your medical expenses based on the Relative Value Scale (RVS) or rates IntelliCare has agreed upon with its accredited providers. Th e amount will not be exactly the same as the amount that you spent in the non-accredited facility. The same computation applies to emergency confinement cases in non-service areas or foreign countries (please refer to your Emergency Care benefits for the percentage and maximum amount of reimbursement).

11. What is the turn-around time for the submission and processing of reimbursement? Submission of the duly accomplished IntelliCare Reimbursement form and required attachments is within 30 days from the date of hospital discharge or treatment. IntelliCare will process the request within 30 days upon receipt of the complete documents.

12. What should I do if I am asked to pay for medical services which I know are covered? You should call IntelliCares Customer Service through telephone numbers 789-4000 or 902-3400 for assistance and verification of the service being charged.

13. What if the hospital has a cash basis policy for some of the procedures even if they are recommended or performed by an IntelliCare-affiliated physician? You may pay for the cost of the procedure first then file for reimbursement later on. Reimbursement shall be based on the Relative Value Scale (RVS) or pre-agreed rates for laboratory and diagnostic examinations (i.e. CT scan, MRI, etc.). If you do not want to shell out the amount being asked for, you may transfer to another IntelliCare-accredited facility that has no cash basis only policy. You may call IntelliCare Customer Service for assistance.

14. Why do I need to pay for the professional fees of accredited Neurologists? The professional fees of Neurologists at the moment are on a cash basis policy for all HMO members. This policy is in accordance with the guidelines set by the Society of Neurologist of the Philippines. You may pay for the cost of professional fees first then file for reimbursement based on IntelliCares Relative Value Scale (RVS). For any recommended procedures, IntelliCare will cover the member immediately according to the plan benefit.

15. What if there is no IntelliCare doctor available in any accredited hospital for the field of specialization I need or I am referred to? IntelliCare will exert all its effort to negotiate for the IntelliCare rate to be charged once the member is referred to a non-affiliated specialist. If the physician does not agree to the rate, you will be asked to pay the cost of their professional fee first then file for reimbursement based on the IntelliCare Relative Value Scale (RVS) .

16. What if I get into a vehicular accident will IntelliCare cover the cost of my medical expenses? In this case, you need to submit a police report and other pertinent documents for any injuries sustained in vehicular accidents and other medico-legal cases (i.e. shooting, stabbing, mauling, etc.) subject for evaluation. IntelliCare will not cover injuries resulting from causes under the general exclusions and limitations.

17. If I resign from my company, can I still use my IntelliCare Card? The members healthcare benefit is co-terminus with his/her stay with the company. You should surrender your card prior to resignation as this is a requirement of the clearance process. Use of the card after separation from the company is an illegal transaction and the member will be billed for any medical availment incurred after resignation/separation from the company.

18. If I lose my card, what should I do? You should notify your HR Representative or IntelliCare Customer Service within 24 hours upon discovery of the loss. You need to submit an Affidavit of Loss and will be charged Php 100.00 for the replacement of the card. If you need medical care while your new card is still being processed, you may contact IntelliCares Customer Service for endorsement to the medical facility where the procedure or consultation/treatment will be conducted.

19. What should I do if I want to give feedback or report any concerns? You may e-mail IntelliCare at intelli_act@intellicare.com.ph or make an incident report and submit it to your HR Representative. For urgent matters, you may call IntelliCares Customer Service for immediate assistance. Please give all pertinent information for IntelliCare to be able to address the concern/s as quickly as possible.

I admit I still miss working in the office. But not because of the work itself but just because of the benefits that I get if you are employed. If you are employed, everything is fixed, you are offered this and that. You will signed a job offer containing everything that you need. if you agree, sign it, if you dont, you have the right to say no. One thing that you need to consider before signing a job offer is the compensation and incentives. Dont just focus on the fixed salary. Instead consider the other benefits you can get as part of your long term goal in that company. Other company in the Philippines has everything they can offer you, money, insurance , retirement plan, car loans etc. Like when I was still working in Apac, they have this insurance for their employees. Our hmo in that company is handled by intellicare. Based from what I heard, Intellicare is one of the best and largest healthcare insurance company. With regards to hmo and ppo benefits, intellicare does handle it well. They have all the healthcare plans that is suitable for your needs.

Intellicare handled our hmo benefits. We have our office visit benefit, inpatient, outpatient and they also handle our dental benefit. In those three benefits, there was only one that I used, it was the dental benefit. I cannot forget that day, I really had a severe toothache back then but still my boss wanted me to come to work because it was a critical workday. I had no money that time to visit a dentist but only my intellicare healthcard. It was amazing because there was a dentist near us that accepts intellicare. It became very useful because it covered all the dental services I needed that day; cleaning and pasta. Yes, the dentist didnt charge me at all. Thanks to intellicare. I also had my colleague who was food poison and needed to go inpatient in the hospital. And the amazing thing there is that the intellicare handles all the his hospital bills. Having an insurance as benefits when you are employed is really important. This should be your priority aside from the basic salary the company will offer you. Think in long term, because at the end of the day, you are the person that will work for the company 8 hours a days and 5 days in a week, so it is imperative for the company to have you covered as their employee. This Intellicare healthcare does have a great service. But I can only have this back if I go back to being employed unless I decided to buy a ppo plan from them. Rating: 9

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