Purple cow 2011 (medical hmo)


Published on

Published in: Health & Medicine, Business
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Purple cow 2011 (medical hmo)

  1. 1. Purple Cow 2011 Benefits TERMS & CONDITIONS 8. Separate Dependent utilization to reduce cost 8. 100% Congenital Conditions coverage +Same rates for Dependents in 2011 +Principals 18yo-65yo; Dependents 30dy-21yo / 18yo-65yo 10. Special Procedures = 30%/100% of MBL 9. Benefits on top of Philhealth 7. 100% Pre-Existing Conditions coverage 10. 1 st year Virgin promo rate, if applicable 5. Minimum group size = 10 5. Private patient for reimbursement (HMO rate) Medical HMO benefits are covered on top of Life and Personal Accident benefits 9. Buy now, pay later 7. Pooled Employee utilization to spread risk 6. Minimum mode of payment = monthly 4. No individual applications required 3. No utilization report required 2. No franchising required 1. Instant rates, regardless of size 6. Access to Big 5 Hospitals and Healthway 4. HMO patient for no-cash-out 3. MBL per disability, per year 2. Combined inpatient & outpatient limits 1. HMO buffet of benefits: IP/OP/ER ASIANLIFE (21,519 MD / 352 hospitals / 358 clinics) MEDICAL HMO (nationwide)
  2. 2. Purple Cow 2011 Benefits 18. Accidental injuries All Dreaded & Non-Dreaded PEC are covered 100% to MBL 19. Diseases of the immune system 18. Collagen / connective tissue diseases 17. Hypertension, coronary artery disease / myocardial ischemia, cerebrovascular accident and other chronic cardiac diseases 16. Malignancies of the blood and bone marrow 15. Chronic musculo-skeletal malignancies 14. Moderately to far advanced tuberculosis 13. Seizure disorders 12. Endocrine illnesses 11. Polyps, ulcers, liver cirrhosis and other chronic gastrointestinal diseases 10. Chronic conditions of the genitourinary system 9. Calculus cholecystitis / cholelithiasis and/or urolithiasis 8. Chronic neurologic conditions 7. Sinus condition requiring surgery 6. Pathological abnormalities of nasal septum and turbinate 5. Diseased tonsils requiring surgery, cataracts & other opthalmo-otolaryngologic conditions 4. Hemorrhoids and other chronic colonic and ano-rectal illnesses 3. Chronic gynecologic conditions 2. Benign cyst / tumor and malignant conditions 1. Asthma, pleural effusion or other chronic airway obstruction conditions PRE-EXISTING CONDITIONS (Non-Dreaded) 19. Second and third degree burns 20. Surgical procedures requiring application / use of prosthesis for immediate treatment 17. Illnesses / injuries necessitating the use of isolation room / ICU or other IC facilities 6. Chronic hepatobiliary diseases 21. PEC (except congenital ones) subject to the provision on ‘PEC’ in this Agreement [waived] 16. Pathological / accidental fractures 15. Chronic musculo-skeletal diseases 14. Chronic opthalmo-otolaryngologic diseases 13. Antibiotic / chemotherapy-resistant diseases / bactemia / septicemia 7. Neuro-surgical / neurological conditions 8. Chronic pulmonary diseases 12. Endocrine abnormalities 2. Benign / malignant new growths 1. Blood dyscrasias 3. Chronic cardiac / cardio-vascular diseases 5. Diseases of the immune system 9. Chronic genito-urinary diseases 10. Chronic gynecological conditions 11. Chronic gastrointestinal conditions 4. Collagen / connective diseases PRE-EXISTING CONDITIONS (Dreaded) MEDICAL HMO…
  3. 3. Purple Cow 2011 Benefits SPECIAL PROCEDURES – 100% of MBL 4. Sclerotherapy 4. Laser therapy (excludes use for correcting vision) 14. C-reactive protein (rheumatic & complications) 13. Anti-nuclear anti-body (ANA) 10. Pulmonary perfusion scan 7. Other new modalities of treatment for conditions with established etiologies and used as alternatives to conventional or traditional procedures 11. Endoscopy 8. Thallium scintigraphy 5. Physical & speech therapy 12. Bone densitometry scan 16. Sleep therapy 9. CT scan / MRI 7. Nuclear technologies 6. Angiography 3. Radiation oncology / therapeutic radiology 2. Chemotherapy 15. Lupus cell exam 1. Dialysis 6. Cost of artificial limbs, joint prosthesis and heart valve prosthesis 3. Laparoscopic procedures For the above special procedures, the remaining 70% of your Maximum Benefit Limit per disability per year can be used for conventional treatment of the same condition (unlike other HMO’s which exclude conventional treatment after a special procedure, and limit special procedures to 1x/year). 5. Nuclear / radioactive isotope scans 2. Arthroscopic procedures 1. Lithotripsy SPECIAL PROCEDURES – 30% of MBL MEDICAL HMO…
  4. 4. Purple Cow 2011 Benefits 17. Organ transplant-expense relating to organ donation of the donating party/parties 7. Dental-related cases except those that may be provided by the Dental Benefits and to the extent that are necessary for the repair or alleviation of damage caused solely by accidental injury sustained (and not caused by the plan member) 6. Non-recommended confinement, convalescent / domiciliary / custodial care, rest cures 18. Executive check-ups, unless explicitly provided in the master policy, and/or confinements purely for diagnostic purposes, as well as non-recommended confinements 8. Circumcision, cosmetic / aesthetic procedures except re-constructive surgery to treat functional defects due to a covered disease and/or accidental injury 22. Medical / surgical procedures and/or diagnostic tests that are experimental in nature and/or not generally accepted by the medical profession such as, but not limited to, iridology, chiropractic services, and acupuncture 12. Illnesses / injuries resulting from the plan member’s active participation in hazardous activities such as, but not limited to, bungee jumping, hang-gliding, scuba diving, mountain/wall climbing, and professional sports 19. Take-home medicines, unless optional ‘Reimbursement of Prescribed Medicines’ benefit is provided, and vaccines, except for first doses of either anti-venom, anti-rabies or anti-tetanus used for emergency treatment 2. Services rendered or supplies provided free of charge 14. Self-inflicted injuries including, but not limited to, any form of suicide attempt 1. Expenses that should be taken care of by any government programs such as Philhealth 3. Additional hospital charges and/or professional fees resulting from a plan member taking a room accommodation more than his R&B limit (excesses and/or incremental costs) 16. Acquisition of prosthetic appliances, artificial aids, durable equipment, surgically implanted devices and external prosthetic devices except those that are explicitly covered and enumerated in the ‘Special Procedures or New Modalities of Treatment’ provision of this agreement 5. Sterilization of either sex or reversal of such, artificial insemination, sex change, consultation/confinement regarding fertility 9. Psychiatric disorders, psychosomatic conditions, treatment for any mental or nervous disorders, illness / injury / condition / complication arising from the plan member’s excessive alcohol intake and/or use of regulated/prohibited drugs 20. Medico-legal fees including the cost of Medical Certificates that a plan member may require for any purpose it may serve him or her 10. Illnesses and/or injuries arising from the plan member’s participation in brawls, riots, commission of a crime, violation of ordinances, or the like 21. Congenital disease / deformity that is evident to the plan member at birth and/or can be clinically determined to be congenital [waived] 11. Illnesses / injuries resulting from conditions of war or sustained from combat-related activities 15. Sexually transmitted disease, AIDS, rehabilitative treatment for alcoholism and drug abuse 13. Illnesses / injuries attributable to the plan member’s own misconduct / gross negligence / immoral habits, and willful and unnecessary exposure to danger or health hazards 4. Maternity and maternity-related conditions and/or complications except those benefits that may be provided by the (optional) Maternity benefit EXCLUSIONS MEDICAL HMO…
  5. 5. Purple Cow 2011 Benefits 3. Non-prescription lenses and frames 2. Dental 2. Dental procedures not included in the dental HMO plan 3. Vision EXCLUSIONS ASIANLIFE Rx Medicines, Dental & Vision are covered on top of Medical & Dental HMO benefits +Reimbursement for Prescribed Medicines, Dental & Vision benefits within 15 working days of receipt of all documents. +Reimbursement for Prescribed Medicines covers treatment for any covered sickness or accident. +Reimbursement for Dental covers the same schedule of benefits as the dental HMO, but with your choice of dentist for full reimbursement up to your aggregate limit. +Reimbursement for Vision covers tests for visual acuity and prescription lenses. +The annual aggregate limit for all prescribed medicines, dental and vision benefits together = 1/10 th your MBL. 1. Vitamins, supplements and/or non-BFAD approved medicines, herbal medicines, and other medicines that have no legal BFAD-approved therapeutic claims 1. Prescribed Medicines Optional Reimbursement Plan
  6. 6. 1 ‘Large’ Size Fits All SME : If you are an SME, with 10+ employees, you can join Purple Cow, be part of a bigger group, and be treated like a large company. (Unlike most HMO plans) You can enjoy the same toys as the Big Boys Purple Cow 2011 Why Purple Cow?
  7. 7. 2 Ways to Access Healthcare : you can see an HMO doctor for free, or your own doctor for reimbursement at the HMO rate – each time you avail. (Unlike most HMO plans) You can see your own doctor, cheaper Purple Cow 2011 Why Purple Cow?
  8. 8. 100% Pre-Existing Conditions: you get 100% Pre-Existing Conditions coverage, up to MBL, for cancer, hypertension, diabetes, asthma, etc. (Unlike most HMO plans) You are covered for dreaded & non-dreaded diseases Purple Cow 2011 Why Purple Cow?
  9. 9. 100% Congenital Conditions : you get 100% Congenital Conditions coverage, up to MBL, for mitral valve pro-lapse, rheumatic heart disease, hernia, etc. (Unlike most HMO plans) You are covered for medical conditions since birth Purple Cow 2011 Why Purple Cow?
  10. 10. Benefits on Top of Philhealth : your HMO limits are on top of Philhealth , so you won’t need as much MBL. Your Benefits = Philhealth + MBL, not just MBL. (Unlike most HMO plans) Purple Cow 2011 Why Purple Cow? You get full HMO benefits on top of Philhealth benefits
  11. 11. Medical HMO : you can get inpatient, outpatient and emergency treatment from 21,519 doctors, 352 hospitals, and 358 clinics nationwide. (unlike some HMO plans) You can go to MMC/ SLMC/ CSMC/ AHMC/ TMC/ Healthway Purple Cow 2011 Why Purple Cow?
  12. 12. Optional Reimbursement Plan : you can get reimbursed up to an aggregate limit of 1/10 th your MBL for Prescribed Medicines, Dental & Vision. (Unlike all HMO plans) You can get the best perks of medical insurance as well Purple Cow 2011 Why Purple Cow?
  13. 13. Same Benefits for Dependents : Dependents can get the same benefits, terms and conditions as Employees (as well as the same costs in 2011). (Unlike most, if not all HMO plans) Your Dependents are treated like Employees Purple Cow 2011 Why Purple Cow?
  14. 14. The Design is Right : Purple Cow provides medical necessity, not luxury. Savings from excess R&B/MBL are reallocated to benefits of greater use. (Unlike most HMO plans) R&B/MBL combinations are good up to 99% of the time Purple Cow 2011 Why Purple Cow?