Illness gets you when you least expect it. Consequently, very few people are well-prepared for any kind of disease while most don’t have health insurance. This is especially true in the Philippines. However, if you are one of the lucky few who do have it, whether as an employment benefit or self-insured, here are a few things you need to know before (God forbid) you will ever need to make a claim from your HMO (Health Maintenance Organization):
1. Review List of Principal and Dependents
Make sure all names and birthdates are accurate and complete. Until someone gets sick and needs health care, things like a one letter or number error could go undetected. And fixing these things when an incident has occurred could be inconvenient.
Don’t be like me…I only spotted Hodgegirl’s wrong birth year during her first hospitalization.
Usually, dependents are your spouse, minor children, and parents (up to a certain age).
2. Your Maximum Cover
Different companies and plans have different maximum covers. Once your charges exceed this, the excess will be billed to you. Therefore, there is no such thing as FREE! Just because your HMO will cover your hospital bill now doesn’t mean you don’t watch what goes into it especially if it’s only the beginning of the year and you’re already approaching the limit.
3. Cover for Diagnostic and Imaging Tests
An x-ray is one thing but MRI, CT, PET/CT scans are a different story. These are the ones that you would need to be covered should you need one. For example, in major Metro Manila hospitals, here are some (approximate) prices:
▪Chest MRI with contrast – Php15,000 ($340)
▪ full body CT scan with contrast – Php39,000 ($876)
▪ PET/CT scan full body with contrast (as of this writing, only available in St. Luke’s Global City) – Php75,000 ($1,685)
▪ Echocardiogram – Php6,615 ($149).
Of course, you may never need any of these but it always pays (pardon the pun) to be aware.
4. Co-pay and Deductible Policies
Some plans may have a deductible (very much like car insurance policies) where you pay for medical bills until the amount is reached, after which your HMO starts covering your expenses. Other plans, however, have no deductible but requires a co-pay from the insured. The most common scheme is the 80-20 where the HMO covers 80% while you shoulder 20% of the bill. Again, it helps to check if their is a co-payment ceiling. Once you reach this for the year, your insurance will cover 100%.
5. Check the Fine Print
If you have a copy of your Schedule of Benefits (and you should), read the fine print for what may not be covered or have limited cover. One important thing to note is that if it’s not written under NOT covered, then it’s still open to discussion and may still be covered following your doctor’s advice or referral.
Our policy clearly states that each family member gets one of each diagnostic test (Echocardiogram, X-ray, MRI, PET scan, etc) per year. Upon her doctor’s request, however, Hodgegirl has had an additional 2 PET scans, 3 Echocardiograms, and 2 Chest x-rays that have all been approved by our HMO.
6. Payment Policy
Find out if the policy is for you to pay up front and file for reimbursement or if your HMO will settle your bill directly. Sometimes, only affiliated providers are covered and you don’t need to advance any payment. This kind of info is especially important once you start racking up your bills because reimbursement takes filing, some chasing, and lots of time to process.
7. Higher Claims = Higher Premiums
Of course, no one wants to get sick but the moment you or any of your dependents do and your claims are high, expect your next premium to also be higher. And if you are part of a group plan, your employer could be charged more premium the following year. What could you do? Nothing. If the premium comes from your own pocket, bite the bullet and be thankful that you didn’t have to pay for treatments yourself. If it’s paid by an employer, be even more thankful for the benefit.
The funny (or sad) thing about insurance is that when you least need it, you can easily get it but when you do ALREADY need it, it’s either you can’t get it at all or you get it for an exorbitant amount.
So, if you are among the luckily insured, congratulations. Except for your annual physical exam, I hope you will never have any real use for it!