Hmo Ppt Part 1 and 2

8/17/2019 Hmo Ppt Part 1 and 2

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The Union proposes that the Company

provides hospitalization and medicalcoverage to all Union member based on the

card holder type HMO system. On a yearly,

basis the Company shall review the Medicalcoverage plan towards improving the same,

subject to cost consideration.

The Union proposes Medicard as the

employees HMO.


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Why Medicard

•MediCard is a pioneer in the HMO industryestablished in 1987.

It is also one of the six foundingmembers of the Association of Health MaintenanceOrganizations of the Philippines, Inc. (AHMOPI.

•MediCard is the only HMO bein! run and operated

by doctors.

•MediCardis the only HMO awarded with the I"O 9##1$%##8 Certi&cation in the Philippines and in Asia.

•MediCard is the lar!est HMO in the Philippines interms of membership base totaling to more than !!,!!!,a "ery signi#cant factor to support claims.


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policy* in contrast to clinicbased and desi!natedhospital* enables members to a"ail of hospitalization andout$patient ser"ices in any of our %,!!! accreditedhospitals&clinics bac'ed$up by o"er (!,!!! doctors )specialists nationwide that is )ost con+enient andaccessible to them. +eading the list are Asian Hospitaland Medical enter, Ma'ati Medical enter, -t. +u'esMedical enter, /he Medical ity and ardinal -antos

Medical enter.

•MediCard has a team of ,elltrained liaison o-cerswho assist members during con#nement and before

discharge.•MediCard has)er!ency Assistance and /esponse"er+ice (A/" Hotlinesa+ailable %0 hrs. a day* 23days a year.•"a+in!s on administrati"e time and costs compared tothe insurance&self$administered type of medical co"erage.


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•4O MO/ 56IO" 6OCM45A5IO4P/OC6/". It is almost trouble$free.•-ince our professional fees are based on HMO$industry

standards, it will ta'e longer for members to maximizethe limitations of their bene#ts. 2nli'e other HMOs, ourmaximum limit for the dreaded disease is on a perillness per year basis and not on an aggregate, lifetime

or entire membership limit.

•MediCard is 'nown for the 3uality ser"ices we ha"ebeen extending to our clients for the past years as pro"enby our rene,al persistency rate o 88. -ome of our

more than 4,5!! corporate clientele are 4(&6 ustomerPhilippines, Inc., itiban', 7.A., 8MA 7etwor' 8roup ofompanies, /oyota Motor Phils., Phil. 9aily In3uirer,Philippine -tar 9aily, +andban' of the Phils., etc.


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Hospitali:ation Con&ne)ent ;ene&t<

Members in need of hospitalization can alwayscount on the con"enience and expertise ofMediard. :ith its "ast medical pro"ider networ',

one can feel at ease 'nowing that ones health isready to be ta'en cared of anytime, anywhere.


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;ene&t/e)ar=s

(All li)its sub>ect to PC

7o deposit upon admission o"ered

;oom and board According to type of plan enrollment

2se of operating theatre and ;eco"ery ;oom within 99+

including screening&processing? except gamma globulin

within 99+

I2 con#nements within 99+

hemotherapy, ;adiotherapy ) 9ialysis %! sessions within 99+,whiche"er comes #rst

Admission 'it including wee bag o"ered

All other items directly related to the management ofthe case

within 99+

Bisitation of Mediard liaison oCcer o"ered


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;.Outpatient Care "er+ices<

8etting your needed out$patient medical ser"icesshouldnt be a hassle. /hat is why Mediardpro"ides its members with the complete range ofout$patient healthcare ser"ices$$a one$stop shopfor 3uality out$patient care. :ith one of the mostexpansi"e networ' of hospitals and clinics,

doctors and dentists, members are assured oftrouble$free access to medical ser"ices, whene"erand where"er you may need it.


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;ene&t/e)ar=s


;egular consultations ) treatmentwithin 99+D

except prescribed medicines

;eferral to specialists within 99+D except prescribed medicines

/reatment of minor inEuries and surgery not re3uiring

con#nementwithin 99+

except screening? up to P%,!!!

onsultations for hronic 9ermatoses >except Psoriasis? o"ered

onsultations for -cabies o"ered


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;ene&t/e)ar=s


M;I & M;A 2p to P ,!!!

/ scan 2p to P ,!!!

2ltrasound 2p to P ,!!!

-erum chemistry panels >eg. hem 45, -pec M, etc.? 2p to P ,!!!

Angiography >e.g. oronary, cerebral, retinal, pulmonary,8I, etc.?

2p to P ,!!!

Pulmonary perfusion scan 2p to P ,!!!

/ests in"ol"ing use of 7uclear /echnologies >e.g.;adionuclide -can&Bentriculography, /hallium stresstesting, Pyrosphosphate-cintigraphy, Myocardial Perfusion-canning, etc.?

2p to P ,!!!

Flectromyography, 7er"e onduction Belocity -tudies 2p to P ,!!!

4($Hour Holter Monitoring, 4$9 Fcho and 9oppler 2p to P ,!!!

/readmill -tress /est 2p to P ,!!!

Myelogram 2p to P ,!!!

9iagnostic Fndoscopy >including one of "ideo? 2p to P ,!!!

9iagnostic Arthroscopy 2p to P ,!!!

9iagnostic Hysteroscopy 2p to P ,!!!

Plasma&2rinary ortisol, Plasma Aldosterone,Adrenocortical=unction, etc.

2p to P ,!!!

Mammography and -onomammogram 2p to P ,!!!

one densitometry scan >9exascan? 2p to P ,!!!

Immunologic -tudiesG Anti$nuclear antibody >A7A?, $;eacti"e protein, +upus cell exam

2p to P ,!!!

8enetic studies 2 to P !!!

Co)ple? 6ia!nosticProcedure<


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Pre+enti+e Healthcare "er+ices

;ene&t /e)ar=s

Annual Physical Fxamination >APF? to include o"ered

omplete lood ount 2nder APF

2rinalysis 2nder APF

=ecalysis >stool exam? 2nder APF

hest


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6.)er!ency Care "er+ices

In Accredited HospitalsIt may happen when you least expect it. /hat is why Mediard has ta'en steps in

pro"iding its members not only a comprehensi"e emergency medical care program,

but also access to swift emergency medical help for the inEured and the sic'. -o whenan emergency does stri'e, you are assured that Mediard will be there to pro"ide youor your lo"ed ones prompt medical assistance.

;ene&t/e)ar=s


9octors ser"ices within 99+

Medicines used during treatment or forimmediate relief

within 99+

Oxygen and intra"enous @uids within 99+

9ressings, plaster casts and sutures within 99+

+aboratory, x$ray and other diagnosticexaminations within 99+D directly related to the emergency management ofthe patient


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;ene&t /e)ar=s

Appro"ed Hospital ills

!J based on Mediard ;elati"e Balue >M;B? up to P5!,!!!

9octors Professional =ees

In 4onAccredited Hospitals

=or emergency medical ser"ices in non$participatinghospitals and clinics, members must ad"ance paymentand later #le reimbursement from Mediard.;eimbursement shall be based on the table belowG


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Me)ber's @inancial Assistance(@or )ployees only

;ene&t /e)ar=s

7atural 9eath P %!,!!!

Accidental 9eath P 4!,!!!

+oss of both hands&both feetD +oss ofsight

P %!,!!!

+oss of one hand, one foot or one eye P ,!!!


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;ene&t/e)ar=s


:or'$related i llness&accidents >except those in exclusion? 2p to 99+ for Fmployees only

2npro"o'ed Assault 2p to 99+

ongenital Illnesses 2p to P,!!! for Fmployees only

-lipped 9isc, -coliosis, -pondylosis, -pinal -tenosis 2p to P,!!! for Fmployees only

Hyper"entilation syndrome =irst F; a"ailment up to P,!!! for Fmployees only

APF PromoAPF Pac'age for members 5 years old and abo"e shall include =asting lood -ugar >=-? and /otalholesterol if a"ailed during on$site APF conducted by 2ro Industrial linic or at Mediard linicsonly. /his o1er is "alid from May %, 4!%( to April 5!,4!%.

Pre$employment ser"ices

P (!!.!! per head for pre$employment physical examinations >paid up front? at designatedMediard owned clinics.If the applicant is hired and enrolled under Mediard, this will ser"e as his annual physicalexamination and Mediard shall refund the said amount bac' to the company.

=ree consultations at Mediard owned clinics

=ree consultations at Mediard owned clinics from the following primary physicians and specialistsG

%. 8eneral -urgeon4. Obstetrician 8ynecologist5. Pediatrician(. =amily Medicines

. 8eneral PractitionerK. 8eneral Internist

Abo"e consults will not be charged to the members Maximum ene#t +imit

Members can also a"ail of the free consultations e"en for conditions which are classi#ed undergeneral exclusions or pre$existing conditions which are not co"ered.

On top of this, members can a"ail of discounts on laboratory examinations up to 4!J for caseswhich are not co"ered.

7O/FG Fxcept for /PA

;xF;

0ou may also want to extend the bene#ts of ha"ing a Mediard plan to your employees dependents. /hrough ;xF;, MediardLs latest emergency product, they get a specialized healthcare maintenance

ser"ice that co"ers emergency, pre"enti"e and outpatient care for one year for P%,.!!. est ofall, thereLs no age$limit, no medical exam re3uired, and no hierarchy to be followed.

Applying is simple too. Nust #ll out the application form, pay for the corresponding amount and getyour card in an instant.

-alient bene#ts which you may a"ail in any of our Mediard$owned clinics includeG

• 2nlimited chec'$ups with primary care physicians, Pediatricians, Medical Internists and O8ynecologists

• =lat rate of P5!.!! for specialists• One =;FF Oral Prophylaxis• 9ental consults with dentists• 5!J discount on dental procedures• 5!J discount on diagnostics and tests• One$time basic G , 2rinalysis, -tool Fxam, hest


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Other ;ene&ts

;ene&t /e)ar=s

4(&6 all enter -er"ice&Access /run'lineG (%$!!D /oll =reeG %$!!$%$!!%

/ext Mediard

A uni3ue addition to complement Mediard ser"ices is an -M- ser"ice formembers to access the database of Mediards accredited networ' ofhospitals and doctors. /ext Mediard is accessed by simply sending the'eyword Mediard to access numbers !!$(%%( for -martsubscribers and !%6$%4K( for 8lobe and -un subscribers.

BaccinesAccess to the special discounted prices on "accines through the Mediard$8laxo-mithline >8-? adult "accination campaign>In@uenza, Hepa A ) ,

/yphoid, etc.?.


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ree?istin! Conditions Co+era!e

Me)ber Co+era!e

Members

ear o )e)bership A)ount o Co+era!e

%st year 2p to P ,!!! per illness per member per year

4nd year

2p to P ,!!! per illness per member per yearpro"ided that the pathogenesis or onset of suchillness, inEury or ad"erse medical conditionstarted prior to or during the contestabilityperiodD otherwise, up to 99+.


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9readed diseases are potentially or actually life$threatening conditions or illnesses which may re3uire prolonged orrepeated hospitalization or intensi"e care management. Mediard shall pay for hospitalization ser"ices up to the

maximum limit subEect to the pre$existing conditions co"erage.

/he following are considered dreaded diseaseG

a. erebro"ascular Accident >stro'e?b. entral ner"ous system lesions >Poliomyelitis&Meningitis&Fncephalitis&7eurosurgical conditions?

c. ardio"ascular 9isease>oronary&Bal"ular&Hypertensi"e Heart 9isease&ardiomyopathy?d. hronic Obstructi"e Pulmonary 9isease >hronic ronchitis&Fmphysema?, ;estricti"e lung diseasee. +i"er Parenchymal 9isease irrhosis, Hepatitis >except type A?, 7ew growthQ

f. hronic idney&2rological disease >2rolithiasis, Obstructi"e 2ropathies, etc.?g. hronic 8astrointestinal /ract 9isease re3uiring bowel resection and&or anastomosish. ollagen diseases >;heumatoid Arthritis, -ystemic +upus Frythematosus?i. 9iabetes Mellitus and its complications

E. Malignancies and lood 9yscrasias >ancer, +eu'emia, Idiopathic /hrombocytopenic Purpura?

'. InEuries from accidents or assaults, frustrated homicide or frustrated murderl. omplications of an apparent ordinary illness including MO9- and -I;- >e.g. sepsis due to pneumonia, typhoid

ileitis, cerebral malaria, etc.?m. -ingle or multiple organ dysfunction and failure >MO9- and MO=?n. onditions that may re3uire dialysiso. hronic pain syndrome >greater than six wee's?p. Any illness other than the abo"e which would re3uire Intensi"e are 2nit con#nement3. Ft cetera

6readed 6isease


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Mediard Accredited Hospitals in /anauan


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Me)ber5ype

li!ibility

PrincipalMember

At least 18 years old up to age 2# and

e)ployed by the co)pany.

e)bership li!ibility


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h i i i h Bl l b


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Why is it i)portant that Blare's e)ployees beco+ered ,ith an HMO Plan

A study commissioned by the Department of Science and Technology-

National Research Council of the Philippines (DOST-NRCP) last yearshowed that business process outsourcing (BPO) workers are generally happy

with their high-paying jobs, but think of leaving them in the immediate future

due to health and social concerns.

Researchers Nimfa Ogena and Soccoro Rodrigue conducted an onlinesurvey covering a total of !"# BPO workers from etro anila, !ebu, "avao

#u$on. %f the &' respondents, * percent were from etro anila, +* percent

from !ebu, * percent from "avao and * #u$on.

ven if they/re happy on average, there are many who are planning to leave

their jobs within the ne0t *+ months,1 %gena stated in e0plaining the results of

the study titled $%ealth and Social Policy &ssues of BPO 'orers in thePhilippines &s %appiness at 'or *ttaina+le,

2hey/re happy but they have issues,1 she added.

ajority of the respondents were employed in call centers and the rest were

into non-.oice ser.ices such as back office, software development,medical transcri tion and en ineerin .

Ch ll i ;PO l i


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Challen!es acin! ;PO e)ployees inPhilippines

Hittin! ;usiness "tandardsIt is "ery common in an industry or any institution to set abusiness goal. eing in line with the PO employees

nowadays, it is your goal to meet up the re3uirements thatthe company as' you to perform. It cant be denied that thiscan add up the pressure in absorbing and adEusting thetraditional practices in a call center.

Copin! ,ith Health Issues /here are two common health conditions that normally exist whenwor'ing in a PO industry. It would either be a hypertension which'nown as High blood pressure or the hypotension that used to gi"e youa lower blood pressure. An agent should be wise enough in ta'ing care

of her body, by ta'ing "itamins and supplements.

Artilce by Armando artolome, A-R7 news Posted at 9ec %5 4!%(


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What Are the Differences Between HMOs and PPOs?

health )aintenance or!ani:ation, or HMO, only co"ers subscribersLmedical expenses when they "isit health pro"iders that are part of the HMOLsnetwor'.

Preerred pro+ider or!ani:ations, or PPOs, gi"e their subscribers greaterfreedom to "isit out$of$networ' doctors and hospitals but are more li'ely toconsistently co"er expenses when subscribers "isit the PPOLs preferred, in$networ' doctors and hospitals.

PPO networ's are often much larger than HMO networ's, so it is more li'elythat a specialist pro"ider a patient wants to see will be part of a PPO networ'.

HMO plans are generally cheaper than PPO plans.


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HMO ersus PPO

It is i)portant to =no, the diEerence bet,een HMO and PPO.

HMO is an or!ani:ation o healthcare pro+iders (e.!. doctors and

hospitals that ha+e contracted ,ith an insurance co)pany to oEertheir ser+ices at a &?ed price. HMO plans are nor)ally Fuite restricti+e and ,ith lots o rules. ou,ill be as=ed to select a pri)ary care physician* ,ho handles allaspects o your healthcare.

PPOs also ha+e contractual relationships ,ith insurance co)panies.6iEerence is that they are )ore loosely or!ani:ed and are not asrestricti+e as HMOs. With a PPO* you can choose to see ,hiche+er doctor you li=e* but ithe doctor is not in the net,or=* you ,ill ha+e to pay )ore outo

poc=et. ou don't need a reerral to see a specialist

PPOs are a popular choice for sole proprietors or owners of very smallcompanies , since they require employees to pay a larger percentageof their own health care costs..


25/31httpsG&&www.humana.com&indi"idual$and$family&products$and$ser"ices&medical$plans&hmo$"s$ppo

HMO +s PPO 5able


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5ypical costs o )edical care


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5ypical costs o )edical care

Gidney proble)s S Medical costs in the Philippines for treating 'idneyproblems is extremely expensi"e. According to the national 'idney and

transport institute, 'idney diseases are the 6th biggest cause of death in thePhilippines. 9ialysis which is usually a re3uired treatment for 'idney problemscan cost 5!!! S (!!! pesos per session and can be re3uired 5 times perwee' for years. /his means someone undergoing dialysis could be spendingo"er (!,!!! pesos per month Eust on the dialysis procedure. /his type ofmedical cost is Eust too high for many =ilipinos. /he actual 'idney operationcan cost from % S 4 millions pesos.

Heart disease S out of %! =ilipinos according to the 7-A die fromcardio"ascular causes and up to 4%J of the deaths in a particular year arecaused by heart disease. Its a serious problem, e"en more so when youconsider the a"erage cost of heart surgeries and treatments range from4!!,!!! pesos to %. million pesos for your total medical bill.

Cancer S the most common cancer in the Philippines is breast cancer with %=ilipinos a day who die from the disease. /reatment costs can "ary dependingon the cancer and stage but can often cost more than 4 million pesos once

you include the expensi"e medicines and doctors fees. /his puts tremendousstress on families who will su1er both emotionally, seeing their lo"ed ones

Aileen 7g for Money Monster health Insurance

Health proble)s and stress in Inor)ation 5echnolo!y and ;usiness


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Health proble)s and stress in Inor)ation 5echnolo!y and ;usinessProcess Outsourcin! e)ployees

In an article by the " 4ational ibrary o Medicine 4ational Instituteo Health. it discussed the health problems that employees in I/ and POindustries are prone to.

Twherein sleep disorders were obser"ed among 5J as compared with

industry a"erage >I/ enabled -er"ices? of 5.J.>%%? urn out stresssyndrome which included chronic fatigue, insomnia, and altered biologicalrhythm was also commonly obser"ed among them.T

A detailed 3uestionnaire of around 1### I5 and ;PO e)ployees includingtheir personal details, stress score by Holmes and ;ahe to assess the le"el of

stress and master health chec'up pro#le were ta'en and the results wereanalysed. Around KJ had musculoskeletal symptoms. 22% had newlydiagnosed hypertension,10% had diabetes, 36% had dyslipidemia, 5% haddepression, an!iety and insomnia, 0% had obesity. "he stress score washigher in employees who de#eloped diabetes, hypertension and depression.Farly diagnosis of stress induced health problems can be made out by stress

scores, intense lifestyle modi#cation, diet ad"ice along with psychologicalcounsellin would reduce the incidence of health roblems in I/ sector and


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In an Ori!inal /esearch conducted by 6i+ya. P* MP5Physiotherapist*o the 6epart)ent o /espiratory Medicine*

M. ". /a)aiah Medical Colle!e*;an!alore* Garnata=a* India in his Paper entitled Cardio+ascular/esponse to erbal Co))unication A "tudy in ;usiness ProcessOutsourcin! )ployees

6i+ya tested 13# ;PO e)ployees beore and ater their shit.

Outco)e Measure)ents$

5he cardio+ascular para)eters such as Heart rate*blood pressureand rate o percei+ed e?ertion ,ere measured before and after

shifts. 5he heart rate and blood pressure ,ere )easured usin!6i!ital electronic )onitor and rate o percei+ed e?ertion ,as)easured ;or! ratin! o percei+ed e?ertion scale


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Hmo Ppt Part 1 and 2

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Transcript of Hmo Ppt Part 1 and 2