MAXICARE BENEFITS AND COVERAGE EALTHCARE BENEFITS A.
OUT-PATIENT OUT-PATIE NT (OP) CARE Consultations during regular clinic 1 hours, except prescribed medicines
2 3
4 5
6
7
8
9
Pre and Post Natal consultations
COVERAGE/LIMIT
Subject to MBL Subject to MBL
Eye, ear, nose and throat (EENT) treatment prescribed by an Accredited Subject to MBL Physician/Specialist Treatment for minor injuries such as lacerations, mild burns, sprains and Subject to MBL the like Dressings, conventional casts (plaster Subject to MBL of Paris) and sutures. X-Ray, laboratory examinations, routine, diagnostic and therapeutic procedures prescribed by an Accredited Physician/Specialist, Subject to MBL provided however that the cost of diagnostic and therapeutic procedures covered shall be limited to a specific amount. Minor surgery not requiring confinement prescribed by an Subject to MBL Accredited Physician /Specialist Eye laser therapy only for retinal tear, retinal hole, retinal detachment and glaucoma prescribed by an Up to Php 10,000 /eye Accredited Physician/Specialist. Eye /member /year correction such as Lasik, PRK and the like are not covered. Electrocauterization of skin lesions such as plantar warts, flat warts, Up to Php 1,000 /member periungual warts, filiform warts and /year molluscum contagiosum, in any part of the body, except genital warts and
condyloma acuminata, prescribed by an Accredited Physician/Specialist. Sclerotherapy for varicose veins (except medicines and for cosmetic 10 purposes) as prescribed by an Accredited Physician, to be availed through accredited vascular surgeons. Allergy Testing/ allergy screening and other related examinations 11 prescribed by an Accredited Physician
Up to Php 5,000 /leg /member /year
Up to Php 2,500 /member /year
Covered as charged up to Php 10,000/ member/ year Speech therapy (for stroke patients (reimbursement basis). 12 only) Note: Consultations shall be part of the limit and treated as sessions Up to Php 600 /member 13 Tuberculin test /year B.
IN-PATIENT (IP) CARE
1
2
3
4 5
Room and Board Accommodation Use of operating room, Intensive Care Unit (ICU), isolation room (if prescribed by Attending Accredited Physician) and recovery room. Professional fees in accordance with Maxicare Schedule of Rates. a. Attending Physicians b. Surgeons c. Anesthesiologists d. Cardio-pulmonary clearance before surgery and cardiac monitoring during surgery. Standard Nursing Services Medicines for in-patient use
Subject to the Member’s Room and Board limit Subject to MBL
Subject to MBL
Subject to MBL Subject to MBL
Blood products transfusions and 6 intravenous fluids, including blood screening and cross matching. X-Ray, laboratory examinations, 7 routine, diagnostic and therapeutic procedures incidental to confinement Dressings, conventional casts (plaster 8 of Paris) and sutures 9 Anesthesia and its administration 10 Oxygen and its administration 11
Standard Admission kit All other items directly related in the medical management of the patient, 12 as deemed medically necessary by the Attending Accredited Physician
Subject to MBL
Subject to MBL Subject to MBL Subject to MBL Subject to MBL Subject to MBL Subject to MBL
C.
ROUTINE PROCEDURES (whether OP or IP) 100% of Actual Cost 1 Blood Chemistries subject to MBL 100% of Actual Cost 2 Chest X-Ray subject to MBL 100% of Actual Cost 3 Complete Blood Count (CBC) subject to MBL 100% of Actual Cost 4 Fecalysis subject to MBL 100% of Actual Cost 5 Urinalysis subject to MBL
D.
DIAGNOSTIC PROCEDURES (whether OP or IP) 100% of Actual Cost 1 12-Lead Electrocardiogram (ECG) subject to MBL 24-hour Electroencephalogram (EEG) 100% of Actual Cost 2 Monitoring subject to MBL 100% of Actual Cost 3 24-hour Holter Monitoring subject to MBL 100% of Actual Cost 4 Adrenocortical Function subject to MBL
5
Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam
6
Arterial Blood Gas
7
Arthroscopic Procedures, Orthopedic Arthroscopy
8
Audiograms and Tympanograms
9
Bone Densitometry Scan (Dexascan)
10
Bone Mineral Density Studies
11
Cardiac Stress Tests (Thallium and Dipyridamole Stress Tests)
12
Computed Tomography (CT) Scans
100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL
13 Diagnostic Radiographs: a. Biliary tract: Cholecystogram and Cholangiogram b. Chest, ribs, sternum and clavicle c. Digestive: Plain film of the abdomen, Barium Enema, Upper Gastrointestinal (GI) Series, Lower GI Series, Small Bowel series d. Face (including sinuses), Head and Neck e. Urinary: Kidney, Ureter and Bladder (KUB) Pyelograms and Cystograms f. X-ray of the extremities and pelvis g. X-ray of the spine (cervical, thoracic, lumbo-sacral) 14 Diagnostic Ultrasounds: a. 2D-Echo with Doppler
100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL
b. Abdomen c. Duplex Scan d. Digestive and Urinary Systems e. Ultrasound of the Lungs Electroencephalogram (EEG) Monitoring Electromyelography and Nerve 16 Conduction Studies 15
17
Endoscopic Procedures
18
Fluorescein Angiography
19
Impedance Plethysmography
20
Magnetic Resonance Angiography (MRA)
21
Magnetic Resonance Imaging (MRI)
22
Mammogram and Sonomammogram
23 Myelogram 24
Nuclear Radioactive Isotope Scan
25
Pap's Smear
26
Perfusion Scan
27
Plasma Urinary Cortisol, Plasma Aldosterone
28
Polysomnograms (Sleep Recording)
29
Pulmonary Function Tests
30 Radioisotope Scans and Function
100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL
Studies:
a. Cardiac b. Gastrointestinal c. Liver d. Parathyroid Bone, Pulmonary (Perfusion/ Ventilation Lung Scans) e. Renal f. Thyroid Scans g. Total Body Scans
E.
31
Radionuclide Ventriculography
32
Surface Electromyography (SEMG)
33
Thallium Scintigraphy
34
Treadmill Stress Test (TMST)
100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL
THERAPEUTIC PROCEDURES
1
Arthrocentesis
2
Dialysis
3
Intravenous Chemotherapy
4
Phlebotomy
5
Physical therapy / Occupational therapy excluding subspecialties such as cardiac rehabilitation, pulmonary rehabilitation and the like.
Up to six (6) sessions subject to MBL for OP; Up to MBL for IP Up to MBL shared limit for OP and IP Up to MBL shared limit for OP and IP Up to six (6) sessions subject to MBL for OP; Up to MBL for IP Shared limit of up to twelve (12) sessions/member/year subject to MBL for OP;
6
Thoracentesis
7
Therapeutic Radiology:
a. Brachytherapy b. Cobalt c. Linear Accelerator Therapy d. Radioactive Cesium e. Radioactive Iodine
F.
8
Continuous Positive Airway Pressure (CPAP) titration for sleep study
9
Oral chemotherapy
Up to MBL for IP Note: Therapy of one (1) body area shall be considered as one (1) session Up to six (6) sessions subject to MBL for OP; Up to MBL for IP Up to MBL shared limit for OP and IP Up to MBL shared limit for OP and IP Up to MBL shared limit for OP and IP Up to MBL shared limit for OP and IP Up to MBL shared limit for OP and IP Up to Php 60,000 shared limit for OP and IP Up to Php 60,000 shared limit for OP and IP
PREVENTIVE CARE
1 2 3 4
Passive and active vaccines for treatment of tetanus and animal bites Periodic monitoring of health problems Health-education and counseling on diets or exercise Health habits and Family Planning counseling
Up to Php18,000 /member /year Covered Covered Covered
ADDITIONAL PROCEDURES AND MODALITIES (shared limit for OP and IP; Professional Fees, Hospital Bills and other G. incidental expenses relative to the procedure shall form part of the limit)
1
Angiography (gastrointestinal, brain, retinal and peripheral vascular)
2
Coronary Angiogram and/or Angioplasty/Coronary Artery Bypass Graft
3
Cryosurgery
4
Gamma Knife Surgery
5
Hysteroscopic Myoma Resection
6
Hysteroscopically-guided D&C
7
Laparoscopy
8
Lithotripsy
9
Percutaneous Ultrasonic Nephrolithotomy
10
Stereotactic Brain Biopsy
11
Conventional Hemorrhoidectomy
12
Scalpel Hemorrhoidectomy
13
Stapled Hemorrhoidectomy
14
Mammotome
15
4D Ultrasound except for maternityrelated cases
16
Esophageal Manometry
17
Intensified Modulated Radiotheraphy
18
Botox which is not cosmetic in nature nor for beautification purpose
100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL (shared limit) 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL 100% of Actual Cost subject to MBL Up to Php 5,000 /member /year Up to Php 5,000 /member /year Up to Php 5,000 /member /year Up to Php 5,000 /member /year Up to Php 5,000 /member /year Up to Php 5,000 /member /year
19
Positron Emission Tomography (PET) Scan
20
CT Pulmonary Angiography
21
Photodynamic Therapy
Other medically necessary modalities not mentioned above and those for 22 which there are no comparable, conventional or traditional counterparts Transurethral Microwave Therapy of 23 Prostate
Up to Php 5,000 /member /year Up to Php 5,000 /member /year Up to Php 5,000 /member /year Up to Php 5,000 /procedure/member /year Up to Php 25,000 /member /year
H. EMERGENCY CARE
1
In Accredited Hospitals a. Doctor’s services b. Emergency Room Fees c. Medicines used for immediate relief during treatment d. Oxygen, Intravenous fluids and blood products e. Dressings, conventional casts (plaster of Paris) and sutures f. X-Rays, laboratory and diagnostic examinations, and other medical services related to the emergency treatment of the patient g. Room Upgrade in case of room unavailability
2
In Non-Accredited Hospitals
Subject to MBL Subject to MBL Subject to MBL Subject to MBL 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
3
Outside the Philippines
4
Areas without Accredited Hospital
5
6
7
I.
J.
Reimbursable up to 100% of actual cost up to Php 30,000 /availment /member /year 100% based on Maxicare rates up to MBL
Ambulance Service (Accredited Hospital/Clinic to Accredited Up to MBL Hospital/Clinic) Ambulance Service (Non-Accredited Reimbursable up to Php Hospital/Clinic to Accredited 2,500 per conduction Hospital/Clinic) Note: The ambulance service provided herein shall be available regardless of the location within the Philippines. Covered for the first 24 hrs. from the time of bite Initial treatment of Animal bites subject to MBL
PRE-EXISTING CONDITIONS
1
Dreaded Conditions
Covered
2
Non-Dreaded Conditions
Covered
ANNUAL CHECK-UP (ACU) The following Routine ACU program shall be conducted at a designated Maxicare Accredited Clinic once a year: 1 Physical Examination Covered 2 Complete Blood Count Covered 3 Urinalysis Covered 4 Fecalysis Covered 5 Chest X-Ray Covered For members 35 years old 6 Electrocardiogram (ECG) and above For female members 35 Pap’s Smear 7 years old and above
K. EXECUTIVE CHECK-UP (ECU)
The following ECU program shall be conducted at Makati Medical Center (MMC) or The Medical City (TMC) once a year: 1 Executive Check-up (IP) Not Covered 2 Executive Check-up (OP) Not Covered 3 Semi-Executive Check-up (OP) Not Covered L.
M .
PRE-EMPLOYMENT Pre-employment examination is covered in lieu of ACU. Reimbursable up to Php 400 per head once the employee is regularized. DENTAL CARE Dental Provider: Annual Dental examination and 1 consultation Emergency Out-patient Dental 2 Treatment - to be availed at accredited dental clinics only 3 Oral prophylaxis
4
Simple tooth extractions Restorative and Prosthodontic 5 treatment planning 6 Temporary Fillings Desensitization of hypersensitive 7 teeth 8 Simple adjustment of dentures 9 Recementation of loose crowns Dental Nutrition and Dietary 10 Counseling 11 Dental Health Education 12
Pre-natal check of teeth and gums
Temporo Mandibular Joint Consultation Gum Treatment for cases like 14 inflammation or bleeding 13
Maxicare Dental Hub
Covered Covered Covered - Once a year Covered Covered Unlimited, as needed Up to 2 teeth Covered Covered Covered Covered Covered Covered Covered
15
N.
Permanent Fillings
2 teeth per year
GROUP LIFE INSURANCE WITH ACCIDENTAL DEATH AND DISABLEMENT (AD&D) BENEFITS The Philippine American 1 Life & General Insurance Insurance Provider Company 2 up to Php 25,000 /member Death (Amount of Insurance) Corporate Personal Accidental Death & Dismemberment 3 (AD&D) A. Schedule of Losses for AD&D Coverage 100% of amount of i.) Loss of Life insurance ii.) Accidental Death, Dismemberment & Disablement or Loss of Use of Limbs 100% of amount of Both Hands insurance 100% of amount of Both Feet insurance 100% of amount of One hand and One foot insurance 50% of amount of One hand insurance 60% of amount of Arm between elbow and wrist insurance 70% of amount of Arm at or above elbow insurance 60% of amount of Leg below knee insurance 70% of amount of Leg at or above knee insurance iii.) Loss of sight 100% of amount of Both eyes insurance 50% of amount of One eye insurance iv.) Loss of speech 100% of amount of
insurance v.) Loss of hearing Both ears One ear
100% of amount of insurance 50% of amount of insurance
vi.) Accidental Dismemberment or Loss of Use of Fingers All of one hand
50% of amount of insurance
vii.) Accident Permanent Total Disability Benefit Monthly cash benefit to an Insured member who has been totally and permanently disabled for 6 months due to accidental causes.
3% of the amount of insurance (less any amount paid or payable) starting on the 7th month up to 32 months, and 4% of the amount of insurance on the 33rd month.
viii.) Murder and Homicide Injury due to murder or any attempt thereof Injury due to homicide or any attempt thereof not occasioned by provocation of Insured member ix.) Flying Coverage Pays a benefit if the Insured member suffers an injury while a passenger boarding or alighting from a certified passenger aircraft provided by a commercial airline on any regular, scheduled or non-scheduled, special or chartered flight and operated by a properly certified pilot flying between duly established and maintained airports over an established passenger route.
100% of amount of insurance (but not exceeding 250,000) 100% of amount of insurance
4
5
6
B. Renewal Bonus Increases the original amount of insurance for Accident Insurance (up to the first P250,000) of the Insured by 5% each year for the first five (5) consecutive years, starting on the second year. Terminal Illness Benefit A lump sum benefit of 50% of the applicable aamount of insurance inforce up to a maximum of P250,000 if the Insured member is medically diagnosed as terminally ill with a life expectancy of twelve (12) months or less. Exclusions Any loss or expense caused by or resulting from the following will not be paid: i.) Suicide during the first year ii.) War, Invasion or Act of Foreign Enemy iii.) Service in the Armed Forces of any country or international authority whether in peace or war. General Guidelines A. Eligibility Age Spouse/Par Children/ Benefits Principals ent Sibling 18-69 years 14 days – Life 18-69 years old old 26 years old 18-65 years 14 days – AD&D 18-65 years old old 26 years old B. Eligible Dependents Legal spouse who are actively performing the i.) Dependents of Married daily normal chores of life employees Children who are single,
unemployed and fully dependent on the principal for support Parents who are actively performing the daily normal chores of life ii.) Dependents of Single Siblings who are single, Employees unemployed and fully dependent on the principal for support Parents who are actively performing the daily normal chores of life iii.) Dependents of Single Parent Children who are single, Employees unemployed and fully dependent on the principal for support C. The No Evidence Limit (NEL) is Php250,000 For any amount of insurance in excess of NEL, proof of good health must be submitted (i.e. accomplished Health Statement, Medical exam). O. CONDITIONS WITH SPECIFIC LIMITATIONS Work Related Conditions based on Up to MBL (For 1 conditions covered by ECC Principals only) Subject to MBL and 2 Motor Vehicular Accidents exclusions and limitations Provoked and Unprovoked Assault, including domestic violence, whether 3 Up to MBL initiated by the Member or by a known or unknown third party Up to Php 20,000 /member /year (shared Scoliosis including necessary limit for OP and IP) procedures, except physical therapy 4 sessions, whether congenital, pre Note: Physical Therapy existing, developmental or acquired sessions shall form part of the Physical therapy /Occupational therapy
limits. Up to Php 20,000 /member /year (shared limit for OP and IP) 5
Congenital Conditions except physical therapy sessions and developmental disorders
6
Congenital Hernia Chronic Dermatoses
7
Scabies
8
Exclusion #25
9
Hepatitis B except vaccines and screening
Note: Physical Therapy sessions shall form part of the Physical therapy /Occupational therapy limits. Up to MBL Consultations only Consultations and treatments Up to MBL Up to MBL (if acquired)
