Good morning everyone. It’s my pleasure to welcome you in Maxicare’s MAPP – our product briefing for interested agents like you are. With Maxicare, you will find that not only do we offer superior products but we also provide competitive incentives to our intermediary partners. MAPP is actually a pre-requisite to your accreditation. After the training, you will have to take the exam, passing of which will mean that we may proceed with your accreditation as our agent.
MAPP is a whole day product briefing consisting of the following topics: (reads on the slide)
So what do we aim to achieve at the end of the training? At the end of the training, we must have discussed the benefits of having an HMO. This you can also highlight during your selling activity with your prospective clients. Of course in line with the need to have an HMO is choosing Maxicare as the HMO provider hence an introduction of who we are in the market will be needed. Along with the introduction is a detailed discussion of our products and services so that you, as our agent, will gain utmost familiarity and a deep dive knowledge of what we offer. Lastly, we would like to gain your appreciation in partnering with us by presenting our competitive commission scheme and incentives for agents. During the course of the discussion if you have questions, please feel free to raise your hand or raise your concern. And lastly, good luck everyone to your exam!
So why HMO? Why do you need to have an HMO? The need for HMO arises not only because people are getting sickly and illnesses proliferate on a day to day, but also because of what an individual goes through in times of sickness.
In times of sickness, an individual will feel absolute pain. Physical pain is given brought about by the illness, now let me tell you another kind of PAIN a person may suffer from during this time. PAYABLES – you are a luck one if you can pay outright for the consultation or your hospitalization. But lets face it, healthcare is never a priority of Filipinos. Even I, when I had my first paycheck, I did not allocate for my healthcare needs. So in times of sickness, our budget gets all tangled up. Payables become an issue. Either this is your payable to the hospital, or to the bills you have to put aside first – you find yourself having difficulty with your finances. At times, people will even resort to asking for debt. What if the cost of treating your sickness involves a large sum of money? ANXIETY – then this comes in. Increased anxiety. When we are badly indebted, when there are other bills past due and we cannot pay because of our treatment, when there are people making singil already, your anxiety will most likely increase. Of course there are a hundred and one impact on you as an individual if you are suffering from anxiety. It impacts your health, it impacts your relationship with other people, it impacts your output as an employee... And a lot more. INFERIOR OPTIONS – On the other hand, people who cannot really afford a healthcare resort to inferior options. By this we mean hilot, herbals, non prescribed drugs, etc. NEGLECT – or worst, we simply take for granted that we feel pain, that we are sick.
There were 18 products that were process but most of it no feedback from Sales if the product will pursue. These are products are…. We are still working on IFG under ASO, ….
There were 18 products that were process but most of it no feedback from Sales if the product will pursue. These are products are…. We are still working on IFG under ASO, ….
What does it offer to the market? (Read on the slide) This means that any hospitalization or confinement brought about by any of these diseases or illnesses shall be covered by the card based on the specified limit.
There are 2 plan types available under MyMaxicare Lite – Gold 1 and Gold 2. Both plan types have room entitlement of Regular Private. This means that once confined, the member will be given a Regular Private room in any of Maxicare’s accredited clinic regardless of the cost as it varies from one hospital to another. Inpatient coverage is up to P25,000 for both plan types. This means that Maxicare will cover the confinement of the 6 identified diseases up to a maximum of 25,000 only. Any excess shall be shouldered by the patient. Both plan types have access to Maxicare’s vast network of medical providers spanning for over 1000 nationwide. However, Gold 1 is restricted to access the identified 6 major hospitals. This means that for any of their confinement needs, they may access any other accredited hospitals of Maxicare anytime except the following. These are Asian Hospital in Alabang, Cardinal Santos, Makati Medical Center, St. Lukes Quezon City and Global and the Medical City. Thus, Gold 1 has a lower membership fee of only P1599. Gold 2 which costs P2199 has access to these 6 major hospitals.
Gold 1 and Gold 2 plans provide coverage on the following inpatient or confinement services: (read on the slides) While Maxicare shall provide coverage on all these, it is subject to the P25,000 limit specified on both plan types.
MKTG Agents Training Revised 7.2012
M . A . P . P Maxicare Agent’s Product Presentation
Program OutlineI. The Need for HealthcareII. Benefits of a Healthcare ProgramIII. Maxicare Healthcare Organization: Your #1 Healthcare ProviderIV. Maxicare’s Edge: 1. Our Value Offering 2. Our Diversed ProductsV. Provision and GuidelinesVI. Maxicare’s Extensive Healthcare Program & Seamless AvailmentVII. General ExclusionsVIII. Agent’s Benefits and Incentives
Objectives of the Program Discuss the benefits of having an HMO;Introduce Maxicare as an HMO Company to the agents; Familiarize the agents with Maxicare’s portfolio of products and services; Increase appreciation of partnering with Maxicare as an intermediary;
In times of sickness, there is ayables nxiety nferior options eglect
A trusted HMO will not only take awaythe PAIN caused by sickness, but itprovides EACE OF MIND ayables CONOMIC FREEDOM nxiety CCES TO QUALITY HEALTHCARE nferior options OMPREHENSIVE HEALTH COVERAGE EXCELLENT CARE eglect
and when it comes to healthcare, there can only be one HMO you can trust.
With 25 years of excellent healthcare service, Leading HMO
Our Roster of ClientsEMBASSY AND AIRLINE INDUSTRY AUTOMOTIVE INDUSTRY
Our Roster of ClientsPETROLEUM INDUSTRYINSURANCE INDUSTRY
Our Roster of ClientsBANKING AND FINANCE INDUSTRY
Our Roster of Clients MANUFACTURING INDUSTRYBUSINESS PROCESS OUTSOURCE INDUSTRY
Our Roster of ClientsAnd a few more known brands and clients we serve....
Our Value Offering • Vast Network of Provider1 • Maxicare Intelligent Card2 • Primary Care Centers and MyHealth Clinics3 • Extensive Customer Care4 • Maxicare Web Portal5 • Lifestyle Partners6 • Comprehensive Healthcare Program7
Vast Network of Providers More than 1000 Accredited Hospitals and Clinics nationwide 65% are tertiary hospitals All Maxicare centers are onlinewith Head Office Continuously growing in number
Vast Network of ProvidersMore than 30,000 Accredited Doctors nationwide At a minimum, our doctors should be an Internal Medicine Specialist.
Maxicare Intelligent Card Real-time validation of membership during availments Swipe facility using more than 1300 POS units nationwide Immediate activation & de-activation of memberships within 24 hours Cards need not be replaced on a yearly basis
Maxicare Intelligent CardMaxicare Reimbursement Card (MRC) Withdraw the funds in any ATMs Purchase any item using the card’s balance in any of the Bancnet accredited shops
Primary Care Centers & MyHealth Clinics Primary Care Center (PCC) is a healthcare facility which has its staff of Customer Service Representatives and Primary Care Physicians (who are either Internal Medicine Specialists or Pediatricians). ADVANTAGES: Exclusive to Maxicare Members Only Easy access to Internal Medicine Specialists Unlimited number of FREE consultations*Majority are strategically & conveniently located@ major hospitals
Primary Care CentersFilomena BuildingG/F Filomena BuildingAmorsolo StreetLegaspi Village, Makati CityMonday to Friday: 7AM – 6PMSaturday: 7AM - 4PM *(Quality lab exams @ the least possible cost)
Primary Care CentersMakati Medical Center1st Floor Tower One, Makati MedicalCenter, Amorsolo St. Makati CityMonday to Friday: 7AM – 7PMSaturday: 8AM - 4PM
Primary Care Centers Quezon City15/F Room 1501, North Tower, Cathedral Heights, QCMonday to Friday: 7AM – 6PMSaturday: 7AM - 4PM Global CityRoom 325 Medical Arts Building, Rizal Drive Cor. 15thAve. & 32nd Ave. Fort Bonifacio Global City
Primary Care CentersMGR04, Ground floor, Medical ArtsTower 1, The New Medical CityOrtigas Ave., Pasig CityMonday to Friday: 7AM – 6PMSaturday: 7AM - 4PM
Primary Care CentersChinese General Hospital10th Floor Medical Arts and ParkingBuilding, Sta Cruz, ManilaMonday to Friday: 8am-5pmSaturday: 8am-4pm.
Primary Care CentersAsian Hospital & Medical CenterLower ground floor, Asian Hospitaland Medical Center, 2205 Civic Drive,FCC, Alabang, MuntinlupaMonday to Friday: 8am-5pmSaturday: 7am-5pm.
MyHealth ClinicsSM City North Edsa Festival Supermall2nd Level Building F, SM City A-3 Level 2 Style Boulevard,North Edsa, North Avenue, Festival Supermall, FilinvestQuezon City Corporate City Tel #: 441-4106 Tel #: 850-4855 7AM to 9PM 7AM to 8PM Edsa Shangri La Unit 146, Level 1, Shangrila Plaza EDSA corner Shaw Blvd., Mandaluyong City Tel #: 570-4325 7AM to 8PM
Extensive Customer CareMaxicare 24/7 Customer Care
Extensive Customer CareMaxicare Helpdesk Clinica Manila 2nd Floor, Unit 202 Building A SM Megamall Complex Don Julia Vargas Avenue, Mandaluyong City Monday to Saturday Tel. No: (0632)661-7777 local 102
Extensive Customer CareMary MediatrixMedical Center2nd Floor, H.B. Calleja BuildingMary Mediatrix Medical CenterJ.P. Laurel Highway, Lipa City, BatangasMonday to SaturdayTel. No: (043)784-9999 local 1152
Extensive Customer CareCalamba MedicalCenterGround floor , Central Registration,Crossing, Calamba,CityMonday to Saturday
Extensive Customer CareMANILA DOCTORSHOSPITALRoom 220, Manila Doctors HospitalMonday to SaturdayTel. No: (02)524-3011 local 4510
Extensive Customer Care Maxicare Satellite OfficesBAGUIO BAGUIO PAMPANGA PAMPANGA HEAD OFFICE --Makati HEAD OFFICE MakatiBATANGAS BATANGAS CEBU CEBU BACOLOD BACOLOD ILOILO ILOILO DAVAO DAVAO DUMAGUETE DUMAGUETE CAGAYAN DE ORO CAGAYAN DE ORO GENERAL SANTOS GENERAL SANTOS
Extensive Customer CareEmail Support firstname.lastname@example.org Members can send their inquiries and concerns through Email.
Extensive Customer CareMaxicare’s Facebook Fanpage www.facebook.com/maxicarehealthcarecorp Members can like us on facebook and send inquires and concerns via chat.
Maxicare Web Portal Maxicare MEMBER GATEWAY is a portal on the Maxicare’s website which will now provide members unparalleled visibility and information regarding their account with Maxicare. Members will now have full access from one’s basic account information to availment details.
Ineligible Professions Acrobats/ Stuntment AFP Personnel Electrical Linemen Explosive Factory Workers Loggers Mines/ Quarry Workers Night Club and bar workers Oil Rig Workers Pensioner/ retirees*Complete list of the ineligible professions are found in your manual.
*Restricted Professions Seamen Medical Practitioners Actor/Actresses Politicians Unemployed Personal Drivers Application is subject for approval
Enrollment GuidelinesPhilhealth StatusRequired - filing of PHIC of member/patient is mandatoryUnemployed Enrollees Annual mode is recommended to avoid account from lapsing. For other modal factors, conditions are: 1. Provide PAYOR 2. For Lapsation: First Offense - REINSTATEMENT Second Offense - REAPPLICATION
Enrollment GuidelinesPayor/ Non-member Guardian All dependents aged from 2 to 17 years old need to have a payor. Relationship of the payor should be established by submitting a birth certificate of the member or a written request.Dependents’ Plan It must be the same plan as the Principal or one plan lower.
Enrollment GuidelinesINDIVIDUAL MEMBERSHIP: Application Form Medical Requirements for 50 years old and above Photocopy of Alien Certification of Residency if foreign nationality FAMILY MEMBERSHIP : Application Form Medical Requirements for 50 years old and above Photocopy of Alien Certification of Residency if foreign nationality Copy of Marriage Certificate Copy of Birth Certificate*Incomplete requirements will not be accepted.
Enrollment ProcessStep 1:Fill out the IFG Application Form
Enrollment ProcessStep 2:Submit all necessary documentsfor processing.TAT : 3 – 5 working days for Clean Application)TAT: 5 - 7 working days for apps with medicalrequirements, BMI concern and previous member
Enrollment ProcessStep 3:Pay at any of these channels:• Maxicare Head Office, 3rd Floor• Banco de Oro branches• Equicom Savings Bank branchesStatement of Account Billing Schedule:For New Business : 1-2 days upon approvalFor Renewal : 45 days before renewal date
Enrollment ProcessStep 5:Receive your Maxicare ID cardas proof of membershipCard will be sent within 10working days after receipt ofpayment
Cut – Off Dates PAYMENT or EFFECTIVE DATE O.R. DATE11th to 25th of the month 1st of the following month26th to 30/31st of the month 16th of the following month1st to the 10th of the month 16th of the current month
Payment Provisions CONDITIONS FOR REINSTATEMENT -Penalty fee of PhP 500 -Advance Payment for the next period -30-day non-coverage upon 45-day Reinstatement Period paymentDuring the reinstatement period, Maxicare Healthcare coverage will be suspended
Nationwide Access- Access to all accredited facilities and providers all over the country.
Luzon Access Access to all facilities and providers within Luzon except NCR. Visayas Access Access to all accredited facilities and providers within Visayas except Luzon, NCR and Mindanao. Mindanao Access Access to all accredited facilities and providers within Mindanao except Luzon, NCR and Visayas.
Ineligible Industries Groups where other than a single employer-employee relationship exists; Groups which involve special hazards; Groups which include more than 10% of the group residing outside the Philippines; Political Groups; Nuclear/Chemical/Natural Gas plants Education (except Pre-schools only) Construction Companies; Oil Production; *These industries will automatically be not accepted under Maxicare Plus; for Corporate, it will be subject for approval.
Ineligible Industries Underground Mine workers & workers using explosives; Drinking places except restaurants; Logging/Forestry Government Institution Pharmaceutical Groups (Manufacturing/Distributing) Medical Groups NGOs and Cooperatives (except employees of the organization) *Account would still be asked to submit: 1. Answered questionnaire 2. Audited Financial Report 3. Masterlist with job classification
Ineligible Industries Group of Firemen (Note: Minimum of 500 lives); Manufacturers of Ammunition or explosives; Full Time Athletes; Drillers (oil/water/gas); Sauna, Turkish baths, massage parlors or similar enterprises; Private households; Media (newspaper, TV & Radio Broadcast); Law Firm Education (except Pre-Schools only)
Dependent’s Participation Requirements Escalation clause significant decrease of initial count to actual number of enrollees failure to comply to the 75% participation requirement Participation Requirement* Applicable Rates 60% - 74.9% + 15% to standard rates 50% - 59.9% + 35% to standard rates 40% - 49.9% + 55% to standard rates 30% - 39.9% + 65% to standard rates 20% - 29.9% + 75% to standard rates Below 20% Under Individual Program or +100% to standard rates
Franchise Process Accounts with 5-19 heads; Agents must use template proposal with published rates. Accounts with 20- 50 heads Email request of proposal to Account Office.( TURN AROUND TIME : 1 DAY)
Franchise Process Accounts with 51-99 headsSubmit the following: 1. Franchise Form 2. Prospective Corporate Account Form(Same franchising requirements apply to Corporate Accounts.)( FRANCHISE APPROVAL TAT: 1 DAY)
Franchise Process INITIAL FRANCHISE VALIDITY - 60 calendar days from date of franchise approval FRANCHISE EXTENSION FRESH ACCOUNTS - up to 120 days COMPETITOR ACCOUNTS - effective date of HMO coverage*same franchising validity applies to Corporate Accounts.
Account’s Categories by SizeGROUP 5 to 19 principals (under Maxicareplus)SMALL CORPORATE 20 to 99 members (under Maxicareplus)MEDIUM CORPORATE 100 to 499 members (under Corporate)LARGE CORPORATE 500 to 999 members (under Corporate)JUMBO CORPORATE 1,000 to 4,999 (under Corporate)SUPER JUMBO CORPORATE 5,000 and up (under Corporate)
Benefits Limits MAXIMUM BENEFIT LIMIT ANNUAL BENEFIT LIMIT (MBL) (ABL)• Maximum amount that a member • Maximum accumulated amount can avail of per illness or injury that a member can avail of for all during the coverage year; types of illnesses during the coverage year.• Does not include ACU • Includes ACU’s, consultations and routine procedures. • Only applicable for Corporate Plans
Funding ArrangementsFull Risk (Premium- based) • Requires for the payment of membership fees.Administrative Services Only (ASO) • Requires an account to set up and maintain a fund [revolving fund] • Is replenished to a certain minimum level [threshold limit]
Funding ArrangementsAdministrative Services Only (ASO) • Requires minimum number of enrollees = 200 • Revolving Fund (equivalent to 3 months claims) • Threshold Limit (equivalent to 1 month claims) • Standard Network Access Fee (NAF) = 450 • Standard Processing Fee (PF) = 100 • Standard Claims Handling Fee (CHF) = 13.5%
Contract Type Full HMO – In-patient – Out-patient – Preventive care – Annual Check-Up – Emergency care Above benefits are all subject to certain exclusions, limitations and conditions.
Contract Type Unbundled In-patient (IP)– Standard IP benefits under the Full HMO product– OP surgery– OP radiotherapy– OP chemotherapy– OP dialysis– Preventive care (except Passive and Active Vaccines)– Emergency treatment that leads/doesn’t lead to confinement
Contract Type Unbundled Out-patient (OP)– Standard OP benefits under the Full HMO product except: OP surgery OP radiotherapy OP chemotherapy OP dialysis– Preventive care– OP emergency
Unbundled Products Requires at least 100 members Standard unbundled products will only be : (a) Unbundled Inpatient (b) Unbundled Out-Patient Combination of these is subject to approval of Chief Actuary.
The Maxicare Eready Card The first Maxicare Emergency Prepaid Card; Provides a one – time coverage for illnesses or injuries during emergency cases or conditions at a very low price; Open for both Maxicare members and non- members aged 15 days old to 65 years old*;Up to 2 enrollment is allowed per person per year with (3) months interval from the 1 stenrolment.
The Maxicare Eready Card PLAN TYPES Plan 788: Plan 988:Without access to 6 Major Hospitals With access to 6 Major Hospitals 1.Asian Hospital 2.Cardinal Santos Medical Center 3.Makati Medical Center 4.St. Luke’s Quezon City 5.St. Luke’s Global 6.The Medical City
The Maxicare Eready Card Coverage for Maxicare standard ER benefit (exclusion conditions shall apply) Coverage is limited to one (1) time availment only per membership card per year; Access to Maxicare accredited hospitals nationwide up to P15,000 for the first 24 hours; Life AD&D (Accidental Death and Dismemberment) up to P25,000 with Double Indemnity Feature; 20% discount from Metro Dental Services. (www.metrodental.com.ph) 15% discount from My Health Services. (www.myhealth.ph)
It is the first prepaid Inpatient Benefit Card specifically designed to provide aone-time coverage on the following confirmed coverable diseases - Dengue Malaria Cholera Typhoid and Paratyphoid Gastroenteritis Pneumonia
PLAN ROOM AND LIMIT NETWORK MEMBERSHIP TYPE BOARD ACCESS FEEGold 1 Regular Private Php 25,000 Without Access to Php 1,599 6 Major HospitalsGold 2 Regular Private Php 25,000 With Access to 6 Php 2,199 Major Hospitals6 MAJOR HOSPITALS: Asian Hospital Cardinal Santos Medical Center Makati Medical Center St. Luke’s Medical Center Quezon City St. Luke’s Medical Center Taguig The Medical City
Room and Board Accommodation Use of Operating Room, Intensive Care Unit (ICU), Isolation Room (ifprescribed by the Attending Accredited Physician) and Recovery Room Professional Fees of Accredited Attending Physicians in accordance withMaxicare Schedule of Rates Standard Nursing Services Medicines while in confinement Blood products, transfusions and intravenous fluids, including blood andscreening and cross matching for member only as recipient
Preventive Care Individual Outpatient Care Inpatient Care Family Emergency CareBenefit Enhancers Optional Riders Maxicareplus Life Insurance and AD&D Maternity Care Dental Care Corporate Cancer InsuranceBenefits
Plan Types and Maximum Benefit R&B Entitlement Plan Room & Board Annual Check Up Limit Platinum / 150,000 / Large Private Executive (OP)Platinum Plus 200,000 Gold Regular Private 75,000 Semi-executive (OP) Silver Semi-Private 60,000 Routine Bronze Ward 50,000 Routine For Corporate Product lines, limits of each plan type may be customized.
Annual Check -up Physical Examination Urinalysis Fecalysis Chest X-ray Complete Blood Count ECG for members 35 yrs old and above Pap Smear for female members 35 YO & aboveNote: Extensive Coverage varies per plan type.
Outpatient CareConsists of coverage for regular consultations/ check ups.
Step 4:Secure laboratory slip if there is aneed to undergo any laboratoryprocedureLaboratory procedure amounting to more thanP1000.00 will need a Head Office approval.
Step 6:Secure your test results from thecoordinator of the clinic/hospital
STEP 2 STEP 3 If required to STEP 1 PM goes to the Medilink POS PM presents his LOE, undergo Plan Member (PM) terminal and swipes the card Maxicare card & 1 valid laboratory exam, goes to Maxicare for membership verification ID to Plan Coordinator secure Laboratory accredited facilities (LOE) and consultation takes Slip from the place; Coordinator *LOE is only valid on the day it was swipedSTEP 5 STEP 4 For laboratory tests at P1000 below,For tests not available at the clinic, PM may no need to secure confirmation fromproceed to Maxicare accredited hospitals. Maxicare; otherwise Hospital will getMembers should go back to the doctors at confirmation from Maxicare if cost isthe clinic/primary care center for follow-up. more than P1000
Inpatient CareConsists of coverage for hospitalization expenses.
Step 2:Call Maxicare Hotline at least 24hours before the admission
Step 3:Proceed to the Admitting Sectionof the hospital on theconfinement day to secure theLOE
Step 4:File your PhilHealth on or beforedischarge
Step 5:Present your Maxicare card andsign the hospital bill beforedischarge
Step 6:Settle charges not coverable by Maxicare
Secure Admitting Slip Call Maxicare Hotline al least 24 On Confinement day, go from a Maxicare hours before admission for to the Admitting Section Accredited Physician assistance in securing the entitled POS Terminal to secure room assignment and other the LOE verification MAXICARE will issue LOA, member proceeds with confinementSettle charges not coverable File Philhealth on or by Maxicare at the Billing Present Maxicare Card before discharge Section once the discharge order is issued by the and sign the Attending Doctor hospital bills Secure Follow up before dischargePrescription from the attending Physician
Emergency Care Doctor’s Services Emergency room fees Medicines used for immediate relief and during treatment Oxygen, I.V. fluids, whole blood, and human blood products Dressings, casts, and sutures X-ray, laboratory, and diagnostic exams
Emergency Care Passive & active vaccines for treatment of tetanus, animal bites & snake bites Ambulance Services up to MBL if within the network, and up to Php2,500/member/case if outside the network
Availment Procedure for Emergency CoverageStep 1:Procced to the Emergency Roomof Maxicare accredited hospital
Step 2:Present your Maxicare card formembership verification
Step 6:Present your Maxicare card andsign the hospital bill beforedischarge
Step 7:Settle charges not coverable byMaxicare
Emergency Availment in a Non-AccreditedAvailment in Non-accredited hospital within the Philippines FacilityMaxicare shall reimburse 80% of the Hospital Bills and Professional Fees, based onMaxicare standard rates up to 30,000 per case for the 1 st 24hrsOutside the PhilippinesMaxicare shall reimburse 80% of the Hospital Bills and Professional Fees, based onMaxicare standard rates up to 30,000 per case for the 1 st 24hrsAreas without affiliated hospitals within the PhilippinesMaxicare shall reimburse 100% of the Hospital Bills and Professional Fees, based onMaxicare Standard Rates up to MBL
Member Emergency Room of nearest Present Maxicare Card at the Accredited Hospital/Clinic Emergency Section If for Confinement Avail of treatment at the Emergency Room File Philhealth on or Settle charges not covered by before discharge Avail of entitled room plan and Maxicare at the Billing Section notify MAXICARE within 24once the Discharge Order is issued hours for proper assistance by the Attending Doctor
Claims Reimbursement Procedure Check ReimbursementAll claims must be submitted to the Maxicare Head Office within 30 days from date of discharge fromthe hospital. The following are the required documents for reimbursement: Claim Reimbursement Form (CFR); Original Receipts of all Hospital Bills & Professional Fee of the Doctor; Original Charge Slips (with itemized breakdown of charges); Clinical Abstract, Admitting History and Medical Certificate; Histopath/Surgical Report (if surgical operation was done); Police Report in case of accident and medico legal cases:•Processing of claims will be 30 calendar days upon receipt of the complete documents•Checks payable to the principal will be issued by Maxicare once the reimbursement is approved
Claims Reimbursement Procedure Maxicare Reimbursement CardAll claims must be submitted to the Maxicare Head Office within 30 days from date of dischargefrom the hospital. The following are the required documents for reimbursement: Claim Reimbursement Form for MRC (with filled out SMS number and email); Original Receipts of all Hospital Bills & Professional Fee of the Doctor; Original Charge Slips (with itemized breakdown of charges); Clinical Abstract, Admitting History and Medical Certificate; Histopath/Surgical Report (if surgical operation was done); Police Report in case of accident and medico legal cases:Processing of Claims will be 7-15 days from receipt of complete documents.Approved reimbursement shall be credited to your Maxicare Card.
Claims Reimbursement Procedure Maxicare Reimbursement Card Once your reimbursement has been approved:Your card will be activated to cashcard and you will receivenotification thru SMS of your PIN Member may withdraw the OR member may use the amountand approved reimbursement amount to Equicom ATMs or to purchase from any of theamount. Bancnet, Expressnet or Megalink Bancnet accredited merchants ATMs*Your SMS number must becorrectly reflected in the ClaimsReimbursement Form.
Injuries arising / resulting from; War or any combat-related activities while in military service
Injuries arising / resulting from; Self infliction as a result of functional disorders of the mind, alcoholism and drug addiction or abuse
Member’s own misconduct which may be a cause of;Gross Negligence;Vicious or immoral habits;Direct of Indirect participation in the commission of a crime whether consummated or not; Violation of a law or ordinance;Unnecessary exposure to imminent danger or hazard to health
Beautification Purposes: Cosmetic surgery, reconstructive surgery to treat a functional defect due to accidental injury within the initial confinement Oral surgery following accidental injury to teeth for purposes of beautification Weight reduction programs, surgical operation or procedure for treatment of obesity, including gastric stapling or balloon procedures and liposuctions.
Government funded healthcare entitlements All other government funded health- care entitlements as provided for by law. Infectious diseases (according to the local epidemiologic patterns) that may arise in times of epidemic (i.e. Avian Flu, Meningococcemia, etc.) as declared by the Department of Health
Personal Medical RequirementsRoutine physical examinations requiredfor obtaining or continuing employment,requirement in school, insurance orgovernment licensing
Involvement in the Hazardous Sport Treatment of injuries/illnesses the direct and immediate cause of which is the engagement and participation of the Member in any (a) hazardous sport or activity i.e. scuba diving, mountain climbing, parachuting et. al. ,
Any Additional or Extra ChargesAdditional charges resulting from roomupgrading, or additional personal comfortitems not included in the room & boardaccommodation ( T.V., telephone, etc.)
Any Additional or Extra Charges Corrective appliances, artificial aids, prosthetic appliances Take home medicine Services obtained from Non- Accredited Physicians and Hospitals or other provider of care, except under emergency care.
Any Additional or Extra ChargesPurchase or lease of durable medicalequipment, oxygen dispensingequipment, and oxygen except duringcovered in-patient care.
Other Non- Insurable Condition• Custodial, domiciliary and convalescent care.• Long-term rehabilitation and Psychiatric care.• Dental and Maternity cases• Circumcision, sex transformation, diagnosis and treatment of fertility or infertility, artificial insemination, sterilization or reversal of such.
Other Non- Insurable Conditions• All expenses incurred in the process of organ donation and transplantation, unless the Member thereof is the recipient of such donation or transplantation.• All physical deformities prior to enrolment• Experimental medical procedures, acupuncture• Hepatitis B screening and all diagnostic examinations for Members who have pre-existing Hepatitis B.
Travel Package up to Php 25,000 HBA/ Independent Agent for IF and Maxicareplus Php 3.5M minimum production Cut – off Period : November Regardless of contract date of Accreditation
Free 1 year HMO Coverage HBA/ Independent Agent for IF and Maxicareplus Php 3.5M minimum production Cut – off Period : November Regardless of contract date of Accreditation* Silver Plan; Semi – Private, up to Php 60,000 MBL ( may be upgraded)
Race to 5 on 25 Php 25,000 cash incentive for a minimum of Php 5,000,000 TCV * 20 % paid TCV
Recruitment Incentive and Referral FeeReceive the following cash incentive for everysuccessful referral of agents: Php 2,500 – AUH PHP 1,500 – AUM Php 500 – HBA &AIA *referred agent/s must have at least achieved 10% of their annual quota.
Chairman’s ChallengeTop Three agents with the highest numberof sales based on TCV will receive the following; 1st Place - PLAQUE - Php 40,000 2nd Place - PLAQUE - Php 20,000 3rd place - PLAQUE - Php 10,000
A prospective client asks, “What is the nature of business of Maxicare?” The correct answer would be:a. Non- life insuranceb. Life insurancec. Healthcare Maintenance Organizationd. Health insurance
A member calls you to report that her son’s Maxicare Intelligent Card has been lost. What website would you recommend to process the ID replacement?a. Maxicare Member Gatewayb. Maxicare Portalc. Maxicare Linkd. Maxicare Get Away
Which of the following best describes Maxicare’s Primary Care Centers?a. These are Maxicare owned healthcare facilities that offer unlimited free consultations to Maxicare cardholders and provide medical services and laboratory procedures at a least possible cost.b. Maxicare’s affiliated clinics which offer consultations to all patient both members and non – members.c. Tertiary hospitals that offers in – patient and outpatient services.d. None of these
A client asks you, “What number shall I call for my general inquiries about eligibility and benefits? The correct answer would be:a. 582-1900b. 582-1990c. 582-9000d. 582-1999
A client asks you; “When was Maxicare founded?”, Your response would be;a. 1985b. 1990c. 1987d. 1984
You are about to present Maxicare’s products to aclient. He/she is interested to a product with only 1enrollee. What is the best Maxicare product for the client? a. Family b. Group c. Individual d. Maxicare Plus
A client with 1 enrollee asked you,” What is the age eligibility for an Individual Plan?” The correct answer would be;a. 2 – 60 years oldb. 1 month old – 70 years oldc. 2 years old and upd. 2 years old, renewable up to 65 years old
A client who wants to avail an Individual andFamily plan ask ,”How many prophylaxes are allowed per member per year?” The correct answer would be; a. 1 c. 2 b. 3 d. 5
Rule of Hierarchy refers to;a.non-selection of dependents to be enrolled for a Maxicareplanb.selection of dependents to be enrolled for Maxicare planc.pre - selection of dependents to be enrolled for Maxicare plan.d.None of these.
You are discussing platinum plan for Family and individual program when a client asked you;“How much is the coverage for Acquired Dreaded and Non Dreaded condition on the first year of membership under Platinum Plus?” Your answer would be; a.Php 20,000 b. Up to MBL c. Php 15,000 d. Up to ABL
SituationNick, a company manager called you to inquire about Maxicare Plus.
Nick asked; “What is the minimum number of theprincipal enrollees in order for the company to beaccepted in a Maxicare Plus program?” Your answerwould be;a. 5 b. 99 c. 50 d. 10
Nick asked you about the different modes of payment for Maxicare Plus. Which of the following modal payment is applicable to Maxicare Plus?a. Per payout cut-offb. Annual mode of paymentc. Monthly mode of paymentd. Weekly mode of payment
Nick’s company is located in Mindanao and they would like that their medical network access be in that region only. What Maxicare Plus variant will you offer?a.Maxicare Plus Provicial – Mindanao accessb.Maxicare Plus Nationwide accessc. Maxicare Plus Luzon – Accessd.Maxicare Plus – Visayas Access
A client asks you; “When will the coverage for acquired dreaded condition commence?”a.Right after the effectively of the contract.b.On the 2nd year of a continuous contract.c.On the 3rd year of a continuous contractd.It will never be covered
The following belongs to the ineligible group/industries under a Maxicare Plus program except:a. Law Firmb. Full Time Athletesc. Construction Companiesd. Religious Group/Sector
SituationRalph an HR manager of a multi- national company with 2000 employee.
He asks you,” What are the standard benefitscoverage for corporate plan?”. Your best answerwould be;a.Inpatient, Outpatient, Emergency ,Preventive, & Annual Checkupb.Inpatient onlyc.Emergency, Outpatient and Preventived.Emergency and Preventive
A client asks if they can still change the benefits under a corporate plan, your answer would be:a.Yes, because corporate account can be customized dependingon the corporation’s needs.b. No, because in order to have a corporate account, the company needs to avail all the health program of Maxicare.c. Both answers are correct.d. None of these.
What are the covered benefits under an OutPatient Unbundled program ;a. Standard out – patient benefit under the full HMO benefit except out – patient benefits that are offered in in-patient unbundled program.b. Out – patient radiotherapy, out – patient dialysis and preventive carec. Out – patient surgery, consultations and Emergency cared. All of the above
Ralph asks; “What are the different availment modes that can be offered in a Corporate Plan?”a. Hospital –based and Clinic based.b. Hospital onlyc. Clinic onlyd. None of these
A client asks you; “What are the different riders for a corporate plan?” The correct answer would be;a.Maternity benefits, dental, cancer benefit and group life insurance.b. Annual physical examination, maternity benefit and group life insurance.c. Cancer benefit, emergency benefit and dental.d. None of these
The client wants to know the price of MaxicareEReady card. The answer would be;•788 and 988 c. 799 and 899•750 and 950 d. 699 and 799
The client asks you; “How much is the maximum emergency coverage of the EReady card?”a. Php 15,000 c. Php 10, 000b. Php 20, 000 d. Php 5, 000
The client asks; “How many times can I use the EReady card?a. Once b. twicec. trice d. unlimited
The client wants to know when the card will be ready for use once registered. Your answer would be;a. After 7 calendar daysb. Within 7 business daysc. After 3 calendar daysd. Within 3 business days
What is the expiration date of Maxicare EReady Card if registered and activated?a.1 year after the activation day.b. 6 months after the purchasec. 1 year after the purchased.6 months after the activation day
A client asks you; “what is the initial availment process for emergency cases.a. Proceed directly to ER and show your Maxicare Card.b. Go to Maxicare’s medical coordinator and secure LOAc. Call Maxicare’s call center and ask for assistance.d. None of these
A Maxicare member asks; “How much will you cover for a consultation to a non - accredited doctor? The correct answer would be;a. 80 percent of the actual costb. Maxicare Ratec. 100 % of the actual costd. Not covered
How many days will Maxicare allow a member to file for a reimbursement claim?a. within 30 calendar days from date of availmentb. 20 calendar days from date of LOA issuancec. within 30 calendar days from date of discharged. 30 calendar days from date of LOE issuance
Within how many days can an IF (individual/family) member file for a reinstatement of policy?a. within 30 calendar days from effective dateb. within 45 calendar days from policy lapsation datec. within 30 calendar days from policy lapsation dated. within 45 calendar days from effective date
What is a pre – existing condition?a. It is a condition or a disease that is present or diagnosed before the enrollment of the member to Maxicare .b. It is a condition or a disease where in there is no cure.c. It a condition or a disease that is present after the enrollmentd. None of the above
A client is asking if a personal nurse will be covered by Maxicare; The correct answer would be;a. Yes, because it is a part of in – patient coverage.b. Yes, because since, you are a customer you can request what you wantc. No, because a private duty nurse has a very expensive rate.d. No, because personal nurse, other additional hospital charges such as telephone and TV, etc.,
A client called you complaining that the medical coordinator told her that take home medicines are not covered by Maxicare. Your best response would be;a. “Please be informed that take home medications are part of the exclusion of the plan.”b. “Only medications used inside the emergency room for treatment and medication administered within confinement will be covered by Maxicare.”c. “That should be covered, wait I’ll call the medical coordinator.”d. Both a and b
A member is inside the Emergency room due to avehicular accident. In order for Maxicare to coverthe medical expenses, what initial document does the member need to secure. A.Medical abstract B.Police report C.Admitting History D.Driver’s License
Maxicare will not cover any medical expenses for a vehicular accident of the member if; a. There is any violation of the law or ordinance b. Cannot present a police report c. The driver is drunk d. All of the above
A member who will undergo a kidney transplant asked you if both the donor and recipient will be covered by Maxicare. Your response would by;a. Yes, it will be covered since the members will be the recipient of the organ.b. Yes, it will be covered, as long as the purpose of the donation is not for organ selling or buying,c. No, because, all expenses incurred in the process of organ donation and transplantation if the Member is the donor of such donation or transplantation is part of the exclusion.d. Both A and B