Beruflich Dokumente
Kultur Dokumente
ELIGIBILITY
Both Single and Married Officers employees are entitled to enroll both of their parents or either parent to the
program.
No addition and deletion of enrolled dependents within the coverage period.
A.
AGE
B.
For Single Employees, they shall enroll their qualified dependent/s to Gold 1 or Silver 1 Plans only
For Married Employees, they shall enroll their qualified dependent/s to Gold 2 or Silver 2 Plans only
Shall the employee wish to enroll both parents, they have to be enrolled to one /same plan only.
No upgrading or downgrading of plan within the coverage period
Only dependents of newly hired employees maybe enrolled in the middle of the coverage within 30
days from date of hire.
III.
: up to 65 years old
: up to 65 years old
PLAN TYPE
II.
Mother
Father
Member Type
Parent/s of
Single Employees
Parent/s of
Married Employees
Parent/s of
Single Employees
Parent/s of
Married Employees
Maximum
Benefit Limit
ACU
100,000.
Regular Private
100,000.
Routine (Clinic)
100,000.
Semi-Private
100,000.
PROVIDER ACCESS
Nationwide access to all accredited hospitals/clinics including nine (8) major hospitals. The following are the Nine (8)
Major Hospitals:
1.
Asian Hospital & Medical Center
2.
Cardinal Santos Medical Center
3.
Makati Medical Center
4.
St. Luke's Medical Center - Quezon City
5.
The Medical City
6.
Cebu Doctors Hospital
7.
Chong Hua Hospital
8.
Davao Doctors Hospital
Moreover, Members shall have no access to Healthway Medical Clinics and St. Lukes Medical Center Global City.
IV. BENEFIT
The benefits covered which should be availed at the HMO Accredited hospitals / clinics through the Maxicare
Coordinator, are as follows:
OUT-PATIENT CARE
IN-PATIENT CARE
ANNUAL CHECK-UP
PREVENTIVE CARE
EMERGENCY CARE
DENTAL CARE
HEALTHCARE BENEFITS
A.
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
10
11
12
13
Tuberculin test
B.
a. Attending Physicians
b. Surgeons
c. Anesthesiologists
Subject to MBL
Subject to MBL
10
11
Subject to MBL
Subject to MBL
Subject to MBL
12
Subject to MBL
13
Subject to MBL
14
Subject to MBL
15
Subject to MBL
16
Subject to MBL
C.
ROUTINE PROCEDURES
Whether OP or IP
Blood Chemistries
Chest X-Ray
Fecalysis
Urinalysis
D.
DIAGNOSTIC PROCEDURES
Whether OP or IP
Adrenocortical Function
10
11
12
Diagnostic Radiographs:
13
14
15
16
17
18
19
Diagnostic Ultrasounds:
20
21
b. Abdomen
22
c. Duplex Scan
23
24
25
26
27
Endoscopic Procedures
28
Fluorescein Angiography
29
Impedance Plethysmography
30
31
32
33
Myelogram
34
35
Pap's Smear
36
Perfusion Scan
37
38
39
a. Cardiac
41
b. Gastrointestinal
42
c. Liver
43
44
e. Renal
45
f. Thyroid Scans
46
47
Radionuclide Ventriculography
48
49
Thallium Scintigraphy
50
E.
THERAPEUTIC PROCEDURES
Arthrocentesis
Dialysis
Intravenous Chemotherapy
Phlebotomy
Thoracentesis
Oral chemotherapy
Therapeutic Radiology:
a. Brachytherapy
10
b. Cobalt
11
12
d. Radioactive Cesium
13
e. Radioactive Iodine
F.
PREVENTIVE CARE
Health-education
exercise
G.
1
2
and
counseling
Not Covered
Up to Php18,000 /member /year
Covered
on
diets
or
Covered
Covered
Cryosurgery
Hysteroscopically-guided D&C
Laparoscopy
Lithotripsy
10
11
Conventional Hemorrhoidectomy
12
Scalpel Hemorrhoidectomy
13
Stapled Hemorrhoidectomy
14
Mammotome
15
16
Esophageal Manometry
17
18
19
20
CT Pulmonary Angiography
21
Photodynamic Therapy
22
23
EMERGENCY CARE
In Accredited Hospitals
a. Doctors services
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
In Non-Accredited Hospitals
5
6
Subject to MBL
Subject to MBL
up to 24 hours
Reimbursable up to 80% of hospital bills & professional fees
based on Maxicare rates incurred during the first 24 hrs. of
treatment up to Php 30,000 /availment/member /year
Reimbursable up to 100% of actual cost up to Php 30,000
/availment /member /year
100% based on Maxicare rates up to MBL
Subject to MBL
Reimbursable up to Php 2,500 per conduction
Note: The ambulance service provided herein shall be available regardless of the location within the Philippines.
7
I.
PRE-EXISTING CONDITIONS
Dreaded Conditions
Non-Dreaded Conditions
J.
Covered for the first 24 hrs. from the time of bite subject to
MBL
Congenital Hernia
Chronic Dermatoses
Scabies
Exclusion #25
Up to MBL
Subject to MBL and exclusions and limitations
Up to MBL
Up to MBL
Consultations only
Consultations and treatments
Up to MBL (if acquired) and subject to Dreaded Preexisting provision (if Pre-existing)
10
11
Hepatitis B Screening
K.
ANNUAL CHECK-UP
The following Routine ACU program shall be conducted at a designated Maxicare Accredited Clinic once a year:
1
Physical Examination
Covered
Covered
Urinalysis
Covered
Fecalysis
Covered
Chest X-ray
Covered
Electrocardiogram (ECG)
Pap's Smear
L. DENTAL CARE
Dental Provider
Covered
Covered
Oral Prophylaxis)
Covered
Covered
Temporary fillings.
Unlimited
Covered
Covered
10
Covered
11
Covered
12
Permanent fillings
13
Covered
14
Covered
15
Covered
16
Covered
17
Covered
V.
Plan Type
Member Type
Gold 1
Gold 2
Semi-Annual
Quarterly
P 37,939.
P 20,487.
P 10,623.
45,435.
24,535.
12,722.
Silver 1
30,714.
16,586.
8,600.
Silver 2
36,764.
19,852.
10,294.
Note:
ANNUAL
Total premium shall be paid by the principal member on an annual basis. Premium of all enrolled
members shall be paid in full on or before November 11, 2014
Payments can be made via cash, cheque or credit card directly to Maxicare Healthcare Corporation,
3/F Maxicare Tower, 203 Salcedo St. Legaspi Village, Makati City
Cash and cheque payments can be made through BPI Payment Facility with Reference#:
BPI0000001000 (Payment Slip must be attached as proof of payment with name of dependent)
Proof of payment such as the Official Receipt or Machine Validated Deposit Slip must be attached to
the application form. Kindly indicate member/s name and contact numbers to the deposit slip.
B.
SEMI-ANNUAL
First-Half Premium
Total First half premium shall be paid by the member on or before November 11, 2014
Payments can be made via cash, cheque or credit card directly to Maxicare Healthcare Corporation,
3/F Maxicare Tower, 203 Salcedo St. Legaspi Village, Makati City
Cash and cheque payments can be made through BPI Payment Facility with Reference #:
BPI0000001000 (Payment Slip must be attached as proof of payment with name of dependent)
Proof of payment such as the Official Receipt or Machine Validated Deposit Slip must be attached to
the application form. Kindly indicate member/s name and contact numbers to the deposit slip.
No Payment, No Processing of application.
Second-Half Premium
Total second half premium (balance) shall be paid on or before January 15 , 2015
Payment can be made via auto debit to credit card or post-dated cheque (PDC) only.
Post-dated cheques shall be payable to Maxicare Healthcare Corporation. This should be submitted
together with the initial payment and completed application form
For credit card payments, any unsuccessful deduction due to insufficient limit, card suspension and
cancellation, or any other reasons that may cause disapproval of the transaction, Maxicare shall
automatically suspend its healthcare services. Suspension an only lifted upon payment of the total
amount due and corresponding penalty fee, if any. Credit card deduction form shall be submitted
together with the initial payment and completed application form.
C.
QUARTERLY
First-Quarter Premium
Total First Quarter premium shall be paid by the member on or before November 11, 2014
Payments can be made via cash, cheque or credit card directly to Maxicare Healthcare Corporation,
3/F Maxicare Tower, 203 Salcedo St. Legaspi Village, Makati City
Cash and cheque payments can be made through BPI Payment Facility with Reference#:
BPI0000001000 (Payment Slip must be attached as proof of payment with name of dependent)
No Payment, No Processing of application.
Payment can be made via auto debit to credit card or post-dated cheque (PDC) only.
Payment due date is the 15th day of the month before the new quarter
o
January 15, 2015
o
April 15, 2015
o
July 15, 2015
Post-dated cheques shall be payable to Maxicare Healthcare Corporation. This should be submitted
together with the initial payment and completed application form
For credit card payments, any unsuccessful deduction due to insufficient limit, card suspension and
cancellation, or any other reasons that may cause disapproval of the transaction, Maxicare shall
automatically suspend its healthcare services. Suspension an only lifted upon payment of the total
amount due and corresponding penalty fee, if any. Credit card deduction form shall be submitted
together with the initial payment and completed application form.
** Premiums for parent dependents of newly promoted employee to be enrolled in the middle of the coverage shall be subject to
Pro-rated premiums.
PARTICIPATION REQUIREMENT: Minimum Headcount requirement is 40 enrollees only.
VII. EXCLUSIONS
Notwithstanding any provisions to the contrary, the following shall not be covered except otherwise specified in List of
Benefits
Services obtained for non-emergency conditions from Physicians and Hospitals in any of the following
circumstances:
1
B. Psychiatric and/or psychological illnesses and conditions including neurotic and psychotic behavior disorders;
anxiety disorders.
Treatment for injury and its complications resulting from self-inflicted injuries including infections as a result of
tattoos, piercing of the ear or in any body part, whether self-inflicted or done by a third party or attempted
suicide or self-destruction, whether sane or insane.
Developmental disorders including functional disorders of the mind, such as but not limited to Attention-Deficit
Disorder (ADD)/Attention-Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Bipolar Disorders,
Central Auditory Processing Disorder (CAPD), Cerebral Palsy, Down Syndrome, Neural Tube Defects, and Mental
Retardation.
Treatment of any injury received when there is:
A. Negligence
B. unauthorized use of prohibited drugs or regulated drugs
Aesthetic, cosmetic and reconstructive surgery or any consultation or treatment for any beautification purposes
except if necessary to treat a functional defect due to accidental injury within the initial confinement.
A. Oral surgery following accidental injury to teeth for purposes of beautification.
B. Dental examinations, extractions, fillings, other dental treatment and their complications except to the extent
that are medically necessary for repair or alleviation of damage to the Member caused solely by an accident.
C. Medical care resulting from any dental related conditions.
10
Maternity care and all other conditions (except pre and post natal consultations) related to and/or resulting from
pregnancy and/or delivery which affect the conditions of the Member and the unborn child.
A. Circumcision (except for treatment of urological conditions).
B. Sex transformation
11
12
13
14
All expenses incurred in the process of organ donation and transplantation if the Member is the donor of such
donation or transplantation and its complications.
15
Routine physical examinations required for obtaining or continuing employment, requirement in school,
insurance/travel or government licensing, health permit and other similar purposes.
16
Purchase or lease of durable medical equipment, oxygen dispensing equipment, and oxygen except during
covered in-patient care.
A. Corrective appliances
B. Artificial aids
17
B. Prosthetics and Orthotics such as but not limited to eye glasses and contact lenses, hearing aids, pacemaker,
artificial limbs, valves, knee-tibial insert for total knee arthroplasty, vascular grafts, titanium thread, myringotomy
tube, intravascular catheters, vascular stents, bone screw/plates, pins, wires, balloons, orthopedic internal
fixator/fixation systems, orthopedic external fixator/fixation systems, intraocular lens, braces, crutches.
18
19
Congenital, genetic and hereditary diseases and their complications (except for hernias) affecting functions of
individuals.
20
21
Treatment of injuries/illnesses caused directly or indirectly by engaging in any professional sport or hazardous
activity such as but not limited to scuba diving, surfing, water skiing, mountain climbing, rock climbing,
mountaineering, parachuting, airsoft, drag racing, paintballing, wakeboarding and bungee jumping, except for
activities under company-sponsored sports activities.
22
Injuries resulting from direct participation in riots, strikes, and other civil disturbances.
23
Treatment of injuries or illnesses resulting from war or any combat-related activities while in military service.
24
25
G. Poliomyelitis
H. Slipped disc (if pre-existing)
I. Guillain-Barre Syndrome
J. Diabetes and its complications (if pre-existing)
K. Complicated Hypertension (e.g. those with history of stroke, myocardial ischemia or infarction and poor kidney
function)
L. all malignant tumors (if pre-existing)
26
27
Infectious diseases (i.e. Avian Flu, Meningococcemia, etc.) that are declared epidemic or pandemic by the
Department of Health, World Health Organization or any recognized health authority.
A. Pre-existing Hepatitis B
28
29
30
Benefits covered by Philhealth and all other government funded healthcare entitlements as provided for by law.
31
Laser procedures/treatments.
32
33
B. Surgical operation or procedure for treatment of obesity, including gastric stapling or balloon procedures and
liposuction.
34
Routine, diagnostic, therapeutic and other procedures of the same or similar nature not otherwise specified in this
Agreement.
35
36
37
38
Treatment of work-related injuries of high-risk occupations such as but not limited to construction workers, miners,
loggers and drillers.
39
Cost of the medical services and professional fees in excess of the MBL.
40.
IMPORTANT REMINDERS:
Incomplete Application Form and Credit Card Deduction Forms (for credit card payments) will not be processed
Maxicare Premium cards will be issued to all qualified enrolled dependents 10 working days after the effective date.
All dependents of the same principal member must be enrolled under one plan only.
No additional enrolment and disenrollment within the coverage period except for newly hired officers and newly
promoted staff (to officer)-employees.
Initial membership fees were based on a 10-month coverage period only. Subject to recomputation for annual rates for
the renewal period.
BPI CCRs located at 5/F BPI head Office Bldg. Ayala Avenue Makati City or 7th fl. Maxicare Tower Salcedo
St. Legaspi Village Makati City (for deposit transactions)
For over-the-counter cash and cheque payments or credit card payments please forward the application
forms to 7th fl. Maxicare Tower Salcedo St. Legaspi Village Makati City
For Enrolment Inquiries / benefit Clarifications and Enrolment submission, please contact the following:
o
Emma Flor Dulay emma.dulay@maxicare.com.ph
o
Arianne May De Leon arianne.deleon@maxicare.com.ph
o
Jennifer de Leon jennifer.deleon@maxicare.com.ph
o
Hannah Llorente hannah.llorente@maxicare.com.ph
o
Tel Nos. (02) 9086900 local 1110, 1105 or 1125. Group Email: bpi.enrollment@maxicare.com.ph