WELLS FARGO ENTERPRISE GLOBAL SERVICES,- LCC PHILIPPINES Coverage Period:
February 1, 2016 to January 31, 2017
MAXICARE IS A COMPANY COMMITTED TO CONTINUOUS PROGRESS FOR ITS CLIENTS
More than
1,000 Accredited
Hospitals & Clinics nationwide All Maxicare centers are online with the Head Office Continuously growing in number
More than
43,000
doctors and specialists nationwide At minimum, our doctors are Internal Medicine Specialists.
These are Maxicare-owned healthcare facilities / clinics that have its own staff of customer service representatives and primary care physicians, who administer healthcare assistance to Maxicare members only.
Exclusive to Maxicare Members Only Easy access to Internal Medicine Specialists Unlimited number of FREE consultations Strategically located in/near major hospitals
3rd Floor, Tower 1 Makati Medical Center
Ground Floor Medical Arts Bldg., Medical City, Ortigas Avenue, Pasig City
10th Floor Chinese General Hospital Medical Arts Building, Sta Cruz Manila
Lower Ground Floor, Asian Hospital Lower Civic Drive, Alabang, Muntinlupa
15th Floor, North Tower St. Lukes, Quezon City
Room 325, Medical Arts Building St. Lukes, Fort Bonifacio, Global City
Unit 933 Centuria Medical Makati, Century City, Kalayaan Ave. cor. Salamanca St. Brgy. Poblacion Makati City
MyHealth clinics are Maxicare affiliated/accredited clinics located at selected malls in Metro Manila, making them easily accessible. Availability beyond 5PM and during weekends*
FREE consultation with a Maxicare physician Access to state-of-the-art medical facilities
Easy access because they can be found in malls *Clinic hours are subject to mall hours (highlight)
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SM North EDSA 2nd Level, North EDSA, Quezon City
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EDSA Shangri-La Level 1, Shangri-La Plaza Shaw Blvd., Mandaluyong City
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Festival Supermall Level 2, Festival Supermall Filinvest, Alabang
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Robinsons Cybergate, Cebu 3rd Level, Robinsons Cybergate Fuente Osmena, Cebu City
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G/F Filomena Building Amorsolo Street Legaspi Village, Makati City
MAKATI MEDICAL CENTER
THE MEDICAL CITY
8th floor, Makati Medical Center
12th floor, Doctors Building Ortigas Avenue, Pasig City
Roving Personnel or Liaison Officers assist Maxicare members who are confined by thoroughly explaining their coverage and informing them of the documents they need to submit before discharge.
is a portal on the website dedicated for Maxicare members. The member gateway aims to provide full access from one’s basic information to online LOA requests.*
*Members must register first using their card number in the Member Gateway.
This provides the members with the basic information about their healthcare coverage such as: Effective date Expiry date
Plan Description Benefit Limit Room and Board Entitlement Access to Hospitals
AVAILMENT SUMMARY
Members may track the summary of their availment through this portal. Availment may be filtered per date or availment type. This is also a way to help the members manage their usage.
is a facility under Member Gateway, which allows the members to request their Letter Of Authorization (LOA) online. Advantages of the ONLINE LOA facility: Members may facilitate LOA request anytime and anywhere Convenient and saves the member a great amount of time from queuing
Coverage of the HealthCare Program
Regular employees aged 65 years old and below Dependents of regular employees STATUS STATUS OF OF EMPLOYEE EMPLOYEE
Married Single Single Parent
ALLOWED ALLOWED DEPENDENT/S DEPENDENT/S
AGE RQMT AGE REQT OF DEPENDENT OF DEPENDENT/S
Spouse and
Up to 65 years old
Children (eldest to youngest)
15 days old up to 21 years old
Parents
Up to 65 years old
Domestic Partner
Up to 65 years old
Child/ren (eldest to youngest) and/or Parents
15 days old up to 21 years old; Up to 65 years old
Domestic Partner
Up to 65 years old
*Must follow Hierarchy
PROVISION FOR DOMESTIC PARTNER • •
• • •
•
Cover for Team Member’s domestic partner, regardless of gender HMO premium will be collected based on the number of months being covered. The monthly deduction is the same as existing dependents. Maximum Benefit Limit for 2016 will remain in full for Domestic Partners enrolled in August. Standard hierarchy rules shall apply Both the Team Member and Domestic Partner must be of legal age, but be no more than 65 years of age and have no legal impediment to marry; have not contracted marriage in the Philippines or elsewhere; are not related by blood whether legitimate or illegitimate, up to fourth degree. Both the Team Member and Domestic Partner have shared a single, intimate, committed relationship of mutual caring for at least 12 months; intend to remain as each other’s sole domestic partner indefinitely.
PROVISION FOR DOMESTIC PARTNER • • •
Both have resided together in the same residence for at least 12 months. Both are mentally competent to consent or contract. Must be able to provide all of the following required documentation: A joint Affidavit of Domestic Partnership certifying that all criteria are met Barangay Certification of Co-Habitation stating that Team Member and Domestic Partner live in the same address including the duration of their residence therein Certified copy/ Statistics Office (NSO) copy of birth certificate Certified copy/NSO copy of No Marriage
•
Team Members are encouraged to share program guidelines with their domestic partner before enrolling them to ensure they fully understand and meet all eligibility requirements.
PLAN TYPE EMPLOYEE of CLASSIFICATIO EMPLOYEE/ N DEPENDENTS Employees Hired before March 1, 2013 Employees Hired after March 1, 2013
PLAN TYPE MAXIMUM OF BENEFIT EMPLOYEE/ LIMIT DEPENDENTS MAXIMUM
PLATINUM
GOLD
ROOM AND &BOARD ROOM BOARD ACCOMODATION
ACCOMODATION
BENEFIT LIMIT P250,000
Open Private
P180,000
Small Private
MBL or Maximum Benefit Limit - per illness/injury/member/year *no access to Healthway clinics
Periodic Monitoring of Health Problems Health Education & Counseling on diet and exercise Family Planning Counseling Wellness Programs
* May be availed during the regular consultations.
Physical Examination Urinalysis Fecalysis Chest X-ray
Complete Blood Count FBS and Cholesterol ECG for members 30 yrs. old and above
Pap Smear for female members 35 yrs. old & above
COVERAGE
LIST
Regular Consultations (except prescribed Medicines)
Up to MBL
Eye Laser Therapy (including cataract removal except cost of lens; Lasik/PRK treatment not covered
Up to P10,000 per member/year
Pre and Post Natal Consultations
Up to MBL
Ears, Nose, Throat Treatment Treatment of minor injuries Minor surgeries not requiring confinement X-ray, Laboratory exams, Routine and other diagnostic Procedures
Up to MBL
COVERAGE
LIST
Sclerotherapy – removal of Varicose veins
Up to MBL
Cauterization of Warts (except genital warts)
P1,000 per member per year
Speech Therapy (outright coverage; for stroke patients only)
Up to MBL
Tuberculin Test
P600 per member per year
Therapeutic Procedure (IV Chemotherapy, Dialysis, etc.)
Up to MBL
Physical/Occupational Therapy (Shared Limit)
Up to 25 sessions/member/year subject to MBL (Note: Therapy of one (1) body area shall be considered as one (1) session)
Room and Board accommodation (based on your plan type and entitlement) Use of Recovery Room and Intensive Care Unit (ICU) Professional Fee of attending doctors & nursing services
Drugs and medicines for use in the Hospital Whole blood/human blood products & IV fluids transfusion Anesthesia, oxygen and its administration Standard hospital admission kit Dressings, casts, sutures, and other supplies/services directly related to the medical management of the patient
Doctor’s services Emergency room fees Medicines used for immediate relief and during treatment Initial treatment of animal bites up to MBL (For the first 24 hours from the time of bite) Passive and active vaccines for animal bites up to MBL Ambulance services up to MBL if within the network, reimbursable up to P2,500 if outside the network
Coverage for room upgrade – first 24 hours
Emergency Care (FOR Coverage NON-AFFILIATED) Availment in Non-accredited hospital within the Philippines -Maxicare shall reimburse 100% of the hospital bills and professional fees, based on Maxicare standard rates up to MBL/availment/member/year for the first 24 hours
-If patient is not medically stable after 24 hours, reimbursement shall be allowed
Outside the Philippines
Maxicare shall reimburse 100% of the hospital bills and professional fees, based on Maxicare standard rates up to MBL/availment/member/year
Areas without affiliated hospitals within the Philippines
Maxicare shall reimburse 100% of the hospital bills and professional fees, based on Maxicare standard rates up to MBL
CLAIMS & REIMBURSEMENT PROCEDURE
All claims must be submitted to the Wells Fargo HR Team within 30 days from date of discharge from 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 paid via check and shall be delivered and endorsed to the Wells Fargo HR Team
COVERAGE COVERAGE Pre-existing dreaded and non dreaded conditions
LIST
LIMIT
Work related cases based on conditions set by ECC (Employee Compensation Commission)- for principals only
Motor or Vehicular Accident (subject to exclusions and limitations)
Up to MBL
Provoked / Non Provoked Assault Consultation for Chronic Dermatoses Coverage for Scoliosis (whether pre-existing, acquired, congenital & developmental) Congenital Conditions except physical therapy sessions and developmental disorders (shared limit for OP and IP)
Principals: Up to MBL; Dependents: Up to P20,000
Prosthetic device
Up to P40,000
Slipped Disc and Spondylosis
UP to MBL
Sleep Study related to Organic Illness (if diagnosis is covered)
Up to MBL
Group Life Accident Death and Dismemberment
Up to P10,000
MATERNITY BENEFIT MATERNITY BENEFIT Maternity Benefit
• For female employees (married or single) and spouse of LIMIT COVERAGE LIST COVERAGE male employees only • LOA facilitated if availed at accredited hospitals; reimbursement basis if availed at non-accredited hospitals Coverage:
Limit
Caesarean
P25,000.00
Normal
P20,000.00
Miscarriage
P15,000.00
Home Delivery
P7,500.00
*All laboratory procedures directly related to maternity shall not be covered
Oral Prophylaxis – twice a year Simple tooth extractions
Temporary fillings – covered as needed Permanent fillings – 2 teeth Emergency dental treatment Comprehensive restorative & prosthodontic treatment planning
Desensitization of hypersensitive teeth – 2 teeth Simple adjustment of dentures Re-cementation of loose crowns – inlays or onlays Dental Nutrition and dietary Counseling
Palliative treatment for simple mouth sores & blisters Open incision and drainage Pre-natal check of teeth and gums TMJ consultation Gum treatment for cases like inflammation & bleeding
Member sets an appointment by calling (02) 582-1900
DENTAL HUB NETWORK with access to Accredited Dental Facilities nationwide
Members can also call directly to any accredited dental clinic.
Injuries arising from war or any combat-related activities while in military service Self inflicted injuries Injuries from misconduct or gross negligence Medical emergencies from beautification procedures Chronic Dermatoses (Psoriasis, Skin Asthma)except consultations Government funded healthcare benefits Personal medical requirements Involvement in hazardous sports Non insurable conditions Additional charges
Additional charges resulting from room upgrading, or additional personal comfort items not included in the room & board accommodation ( T.V., telephone, etc.) Corrective appliances, artificial aids, prosthetic appliances Take home medicines Services obtained from Non-accredited Physicians and hospitals or other provider of care, except under emergency care. Purchase or lease of durable medical equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care.
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. 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 screening and all diagnostic examinations for Members who have pre-existing Hepatitis B.
You are cared for by the leader.
Thank You!
