PhilCare ..A Health Maintenance Organization or HMO is a pre-paid health care Philippines

PhilhealthCare, Inc., is one of the Philippines' top 1,000 corporations, is a healthcare service provider which offers clients access to quality and affordable healthcare services for their preventive and curative needs through its wide range of product lines.

A Health Maintenance Organization or HMO is a pre-paid health care delivery system that finances and delivers a package of comprehensive health services such as out-patient consultations and treatments.

Benefits:

IN-PATIENT (Hospital Confinement) SERVICES

1. Services of a Physician including surgical services

2. Room and Board according to the type of room accommodation and subject to the maximum rate of Daily Room and Board as stated in the Member's Benefit Classification.

3. General Nursing Service

4. Use of operating room and recovery room

5. Anesthesia and its administration

6. Drug and medication during confinement

7. Confinement in Intensive Care Unit up to the maximum limit

8. Other services deemed medically necessary such as but not limited to:

                 a. Oxygen and its administration

                 b. Dressings, plaster casts and other medical supplies

                 c. Laboratory tests and other necessary diagnostic services

                 d. Transfusion of blood and other blood elements, except the cost of blood screening

                 e. Dialysis, chemotherapy and similar treatment procedures up to the maximum limit

9. Assistance in the administrative requirements through a Liaison Officer in affiliated hospitals in Metro Manila and key cities nationwide

OUT-PATIENT SERVICES

1. Annual Physical Examination (APE)

                 a. Taking of Medical History;

                 b. Physical Examination;

                 c. Chest X-ray;

                 d. Routine Urinalysis;

                 e. Routine Stool Examination;

                 f. Complete Blood Count (CBC)

                 g. Electrocardiogram (ECG) for Members 35 years old and above

                 h. Pap smear for female Members 35 years old and above

2. Preventive Health Care

                 a. Administration of vaccine (cost of vaccines, allergens and determinations of susceptibility are not included)

                 b. Advice on diet, exercise and other healthful habits

                 c. Periodic monitoring of health problems

                 d. Family planning counseling

3. Out-patient Services such as but not limited to:

                 a. Consultation, including specialist evaluation

                 b. First aid treatment of injury or illness

                 c. Emergency medicine for immediate relief of symptoms

                 d. Necessary x-rays , laboratory examinations and other diagnostic examinations

                 e. Eye, Ear, Nose and Throat (EENT) care

                 f. Pre-natal and post-natal consultations at PhilCare owned Clinics

                 g. Transfusion of blood and other blood elements, except the cost of blood screening

                 h. Dialysis, chemotherapy and similar treatment procedures up to the maximum plan limit if medically indicated

EMERGENCY CARE SERVICES

1. No charge on the following emergency care services rendered at PhilCare Affiliated Hospitals :

                 a. Doctor's services

                 b. Medicines, blood transfusions, intravenous fluids, oxygen, dressings, sutures and plaster casts
                     (except fiberglass casts)

                 c. X-ray, laboratory and other diagnostic examinations

                 d. Treatment of laceration, pains and other minor injuries

                 e. Medicines for the immediate relief of symptoms and during treatment

2. Reimbursement of expenses in cases of emergency confinement in a non-affiliated hospital inside or outside the territorial limits of the Philippines up to 100% of the amount that would have been paid by PhilCare had the Member been under the care of an affiliated doctor in an affiliated hospital or medical center or Php15,000 whichever is lesser.

LATEST MODALITIES OF TREATMENT

Coverage for the latest modalities of treatment based on the limits set forth below or subject to the maximum plan limit whichever is lesser:

All new modalities of treatment and/or diagnosis for which there are no comparable conventional or traditional equivalent or counterparts will have a maximum limit of Php5,000.00.

The availment of Laparoscopic Cholecystectomy, Lithotripsy, Transurethral Microwave Therapy of Prostate, Percutaneous Ultrasonic Nephrolithotomy, Ureterolithotripsy or Cryosurgery procedure is limited only to once per contract year. When a Member chooses the new modalities of treatment enumerated above, PHILCARE will no longer be liable for the cost of further traditional modes of treatment/diagnostics for the same illness or its complications should they be necessary. If a Member refuses to follow the recommended treatment or procedure and the PHILCARE Physician or Affiliated Physician believes that no professionally acceptable alternative exists, then PHILCARE shall no longer be responsible to provide care for the condition under treatment.

Php 10,000 GROUP LIFE for natural death

Php 100,000 GROUP 24-HOUR PLUS AD&D COVERAGE

SERVICE ASSURANCE MECHANISMS

- 24-Hour Customer Service Call Center
Manned by nurses to handle medical questions and service inquiries

- Hospital Liaison Officers
Nurses that look into member's concerns during confinement

- Physician Coordinators
General Practitioners are assigned to each affiliated hospital and oversee patients overall medical care

- Membership Relations Department & Group Servicing Officer
Handles various concerns and play a pro-active role in ensuring customer satisfaction


QUALITY ASSURANCE MECHANISMS
- Clinical practice guidelines
- Evidence-based medicine
- Clinic service surveys
- In-patient service evaluation
- Immediate feedback to providers and members on any medical servicing concerns
- Monitoring of utilization metrics
- Wellness programs


UTILIZATION MANAGEMENT AND COST CONTAINMENT MECHANISMS
- Pre-admission or pre-utilization certification
- Concurrent review of health services rendered to a confined patient
- Post-review of in-patient utilization
- Peer review of physician's practice patterns and outcomes