Maxicare HMO Program (1)

7/23/2019 Maxicare HMO Program (1)

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PROVINCIAL MAXICARE PLUS HEALTHCARE PROGRAM

HEALTHCARE BENEFITS MAXICARE

A. OUT-PATIENT CARE

1 Consultations during regular clinic hours, except prescribedmedicines

Subject to MBL

2 Pre and Post Natal consultations Subject to MBL

3 Eye, ear, nose and throat (EENT) treatment prescribed by anAccredited Physician/Specialist Subject to MBL

4 Treatment for minor injuries such as lacerations, mild burns, sprainsand the like

Subject to MBL

5 Dressings, conventional casts (plaster of Paris) and sutures. Subject to MBL

6 X-Ray, laboratory examinations, routine, diagnostic and therapeuticprocedures prescribed by an Accredited Physician/Specialist,provided however that the cost of diagnostic and therapeuticprocedures covered shall be limited to a specific amount.

Subject to MBL

7 Minor surgery not requiring confinement prescribed by an AccreditedPhysician / Specialist

Subject to MBL

8 Eye laser therapy only for retinal tear, retinal hole, retinaldetachment and glaucoma prescribed by an AccreditedPhysician/Specialist. Eye correction such as Lasik, PRK and the likeare not covered.

Up to Php 10,000 /eye /member /year

9 Cauterization of skin lesions such as plantar warts, flat warts,periungual warts, filiform warts and molluscum contagiosum, in any

part of the body, except genital warts and condyloma acuminata,prescribed by an Accredited Physician/Specialist

Up to Php 1,000 /member /year

10 Sclerotherapy for varicose veins (except medicines and for cosmeticpurposes) as prescribed by an Accredited Physician, to be availedthrough accredited vascular surgeons.

Up to Php 5,000 /leg /member /year

11 Allergy Testing/ allergy screening and other related examinationsprescribed by an Accredited Physician

Up to Php 2,500 /member /year

12

Speech therapy (for stroke patients only)

Covered as charged up to Php 10,000/ member/ year(reimbursement basis)

Note: Consultations shall be part of the limit and treatedas sessions

13 Tuberculin test Up to Php 600 /member /year

B. IN-PATIENT CARE

1 Room and Board Accommodation Subject to the Member's Room and Board limit

2 Use of operating room, Intensive Care Unit (ICU), isolation room (ifprescribed by attending Accredited Physician) and recovery room.

Subject to MBL

3 Professional fees in accordance with Maxicare Schedule of Rates. Subject to MBL

a. Attending Physicians

b. Surgeons

c. Anesthesiologistsd. Cardio-pulmonary clearance before surgery and cardiacmonitoring during surgery.

4 Standard Nursing Services Subject to MBL

5 Medicines for in-patient use Subject to MBL

6 Blood products transfusions and intravenous fluids, including bloodscreening and cross matching.

Subject to MBL

7 X-Ray, laboratory examinations, routine, diagnostic tests andtherapeutic procedures incidental to confinement

Subject to MBL

8 Dressings, conventional casts (plaster of Paris) and sutures Subject to MBL9 Anesthesia and its administration Subject to MBL

10 Oxygen and its administration Subject to MBL

11 Standard Admission kit Subject to MBL

12 All other items directly related in the medical management of thepatient, as deemed medically necessary by the attending AccreditedPhysician

Subject to MBL

C. ROUTINE PROCEDURES (whether IP or OP)

1 Blood Chemistries 100% of Actual Cost subject to MBL

2 Chest X-Ray 100% of Actual Cost subject to MBL

3 Complete Blood Count (CBC) 100% of Actual Cost subject to MBL


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3 Schedule of Losses for AD&D Coverage

a. life 100% of amount of insurance

b. entire sight of both eyes 100% of amount of insurance

c. both hands or both feet 100% of amount of insurance

d. one hand and one foot 100% of amount of insurance

e. either hand or foot and sight of one eye 100% of amount of insurance

f. Arm at or above elbow 70% of amount of insurance

g. Leg at or above knee 60% of amount of insurance

h. One hand at or above wrist 50% of amount of insurance

i. One foot at or above the ankle 50% of amount of insurance

j. Hearing of both ears 50% of amount of insurance

k. Sight of one eye 50% of amount of insurance

l. Four fingers and thumb of one hand 50% of amount of insurance

4 Eligible Members

Employees18 to 65 years of age (who are all regular, full time and

actively at work)

Dependents of Married employees legal spouse whose insurance age is 18 to 65 years old

children whose insurance age is 15 days but not over21 years old, unemployed and fully dependent on the

principal

Dependents of Single Employees parents whose insurance age is 18 to 65 years old

siblings who are 15 days but not more than 21 yearsold, unemployed and fully dependent on the principal

Dependents of Single Parent Employees

children who are 15 days but not more than 21 yearsold, or parents whose insurance age is 18 to 65 years

oldsiblings who are 15 days but not more than 21 yearsold. (Children and siblings must be unemployed and

fully dependent on the principal)5 Payment of any insurance benefit shall not be made for any loss resulting from or caused directly or indirectly, wholly or

partially by:a. bodily or mental infirmity or disease of any kind, or infection other than infection occuring simultaneously with and inconsequence of an accidental cut or wound; or

b. suicide or attempted suicide while sane or insane, or self-inflicted injuries; or

c. committing or trying to commit any crime, felony or other illegal act; or

d. murder or provoked assault; or

e. poison, carbon monoxide or drug overdose; or

f. war (declared or undeclared), insurrection, civil commotion or hostile action of armed forces, riots, rebellion; org. entering, operating or servicing ascending or descending from or with any aerial or submarice device or conveyance exceptwhile the Member is riding as a passenger in an aircraft operated by a commercial passenger airline or a scheduled airservice over on established route.

L. CONDITIONS WITH SPECIFIC LIMITATIONS

1 Work Related Conditions based on conditions covered by ECC Up to MBL (Principals only)

2Motor Vehicular Accidents

Covered subject to MBL and Exclusions andLimitations Provisions

3 Provoked and Unprovoked Assault, including domestic violence,whether initiated by the Member or by a known or unknown thirdparty

Up to MBL

4 Scoliosis, including necessary procedures, except physical therapysessions, whether congenital, pre-existing, developmental oracquired

up to Php 20,000 /member /year (shared limit for OPand IP)

5 Congenital Conditions except physical therapy sessions anddevelopmental disorders

up to Php 20,000 /member /year (shared limit for OPand IP)

Congenital Hernia Covered up to MBL

6 Chronic Dermatoses Consultations only

7 Scabies Consultations and treatments

8 Exclusion #25 Covered up to MBL

9 Hepatitis B Covered up to MBL (if acquired)


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EXCLUSIONS AND LIMITATIONS PROVISIONS

Notwithstanding any provisions to the contrary, the following shall not be covered except otherwise specified in Maxicare Benefits

1 Services obtained for non-emergency conditions from Physicians and Hospitals in any of the following circumstances

a. non-Accredited Physicians in non-Accredited Hospitals

b. non-Accredited Physicians in Accredited Hospitals

c. Accredited Physicians in non-Accredited Hospitals or other non accredited healthcare facility.

2 Additional hospital charges and physician's professional fees resulting from:

a. room-upgrading beyond Member's allowable time during emergency care

b. extension of hospital stay despite release of discharge order from Member's attending physician

c. fees of the assistant surgeons / resident doctors who assisteed the Attending Physician in the process of rendering the abovementioned services shall not be chargeable to the Member and/or Maxicare except for hospitals that do not have resident physicians toassist during surgeries subject to the prior approval of Maxicared. use or extra bed, TV, electric fan, DVD/VCD, and other similar items unless such appliances and items are necessarily and ordinarilymedical services brought about by obtaining a room accommodation higher than the Member's Room and Board Accommodation limit

e. extra food

f. toilet articles like face towel, soap, toothbrush and the like

g. difference in room and board, the incremental rate differences for professional fees, diagnostic and laboratory examinations, andother ancillary medical services brought about by obtaining a room accommodation higher than the Member's Room and Board

Accommodation limit;

h. services of a private or a special nurse;

i. all other items not medically necessary in the medical management of the patient.

3 Custodial, domiciliary, convalescent and intermediate care.

4 Long-term rehabilitation and psychiatric and/or psychological illnesses and conditions including neurotic and psychotic behaviordisorders; anxiety disorders

5 Treatment for injury and its complications resulting from self-inflicted injuries including infections as a result of tattoos, piercing of theear or in any body part, whether self-inflicted or done by a third party or attempted suicide or self-destruction, whether sane or insane.

6 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.

7 Treatment of any injury received when there is negligence, unauthorized use of prohibited drugs or regulated drugs, alcoholic liquorintake, direct or indirect participation in the commission of a crime whether consummated or not, violation of a law or ordinance orunnecessary exposure to imminent danger, knowingly or unknowingly or hazard to health, by the Member. Maxicare may rely on thePolice or Doctor's report to evaluate such claim.

8 Aesthetic, cosmetic and reconstructive surgery or any consultation or treatment for any beautification purposes except if necessary totreat a functional defect due to accidental injury within the initial confinement.

9 Oral surgery following accidental injury to teeth for purposes of beautification. Dental examinations, extractions, fillings, other dentaltreatment and their complications except to the extent that are medically necessary for repair or alleviation of damage to the Membercaused solely by an accident. 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/ordelivery which affect the conditions of the Member and the unborn child.

11 Circumcision (except for treatment of urological conditions), sex transformation, diagnosis, treatment and procedures related to fertilityor infertility, artificial insemination, sterilization or reversal of such and their complications.

12 Experimental medical procedures and its complications.

13 Acupuncture, chirotherapy and other forms of therapies and its complications.

14 All expenses incurred in the process of organ donation and transplantation if the Member is the donor of such donation ortransplantation, and its complications.

15 Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance/travel or governmentlicensing, health permit and other similar purposes.


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16 Purchase or lease of durable medical equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care.

17 Corrective appliances, 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, intravascularcatheters, vascular stents, bone screws/plates, pins, wires, balloons, orthopedic internal fixator/fixation systems, orthopedic externalfixator/fixation systems, intraocular lens, braces, crutches.

18 Take-home medicine and out-patient medicine except:

a. chemotherapy medicine

b. medicine administered during an emergency treatment

19 Congenital, genetic and hereditary diseases and their complications (except for hernias) affecting functions of individuals.

20 All physical deformities prior to enrollment.

21 Treatment of injuries/illnesses caused directly or indirectly by engaging in any professional sport or hazardous activity such as but notlimited 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 Sexually transmitted diseases, genital warts, AIDS and AIDS related diseases.

25 Valvular heart disease (congenital and/or acquired) including Cardiomyopathies, Chronic Glomerulonephritis, previous craniotomysequelae/hearing impairment/ Neurologic disease and Spinal Stenosis (if pre-existing)/Poliomyelitis/Slipped disc (if pre-existing) andGuillain-Barre Syndrome, Diabetes and its complications (if pre-existing), Complicated Hypertension (e.g. those with history of stroke,myocardial ischemia or infarction and poor kidney function), and all malignant tumors (if pre-existing).

26 Treatment for chronic dermatoses.

27 Infectious diseases (i.e. Avian Flu, Meningococcemia, etc.) that are declared epidemic or pandemic by the Department of Health, WorldHealth Organization or any recognized health authority.

28 Pre-existing Hepatitis B and screening and vaccines for all types of Hepatitis.

29 Animal bite/scratch/lick or snake bite including its complications.

30 Benefits covered by Philhealth and all other government funded healthcare entitlements as provided for by law.

31 Laser procedures/treatments.

32 Speech therapy for developmental and congenital diseases.

33 Weight reduction programs, surgical operation or procedure for treatment of obesity, including gastric stapling or balloon proceduresand liposuction.

34 Routine, diagnostic, therapeutic and other procedures of the same or similar nature not otherwise specified in this Agreement.

35 Cost of vaccines for immunization including its administration.

36 Cost of medico-legal cases.

37 All screening tests.

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/ABL.

Maxicare HMO Program (1)

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