What you should know about HMOs

For a vast majority of Filipinos, falling sick is unacceptable. The demands of daily life are often too rigid and unyielding to allow for any unexpected breaks, especially if someone is the breadwinner in their family. The financial costs of a bad accident, an unfortunate injury, or an unexpected diagnosis can set a family back and derail their lives completely.

This is, among many reasons, why health insurance is so important to daily life. Fortunately, many employers in the Philippines are partnered with renowned health maintenance organizations (HMOs) to give their employees the security they need to avoid the worst scenarios.

HMOs are a type of insurance provider that works with a network of physicians to give the subscribers under its coverage basic and supplemental health and medical care in times of need. Typically, the network or organization provides such health insurance coverage for a monthly or annual fee charged to one’s employer, and covers the fundamental services needed by individuals to maintain their health and well-being such as in-patient and out-patient care, basic surgeries, and other ancillary services like laboratory testing and medication.

While HMOs may not provide the extensive and comprehensive coverage given by private health insurance, they also come at a cheaper cost. By limiting the coverage to medical aid provided by the primary care physicians, clinical facilities, and specialists within their network, HMOs can allow for lower, more affordable premiums. This also comes to the health care providers’ benefit, as such contracts give them a steady stream of patients to look after.

HMO subscribers pay a monthly or annual premium to access medical services in the organization’s network of providers. Many companies in the Philippines are partnered with HMOs and automatically provide their employees with all the included benefits without any additional work on their part.

The catch to such convenience is that HMO subscribers are also limited to receiving health care from specific contracted medical providers under their particular network. The insured employee can only get medical care and services from doctors under the HMO network or else pay out of his own pocket. However, there are some companies that offer out-of-network medical care coverage, including services like emergency care and dialysis.

Additionally, HMO coverage could require the insured to live or work in their particular plan’s area of network in order to be eligible for coverage. This is a non-issue for Filipinos working within Metro Manila, but could be something worth considering when one is moving to the provinces.

What also bears noting is that many HMO plans also work with PhilHealth, giving Filipinos much more out of their health insurance. As the health insurance provider run by the government, PhilHealth seeks to offer all Filipino citizens an affordable and progressive insurance program that extends financial assistance to all citizens seeking medical help, whether employed or unemployed. This means that it comes first before any health insurance plan. For instance, in times of hospitalization, PhilHeath will partially cover one’s medical bills from anywhere to 15% and 30% by default, while the remaining balance could be paid by HMOs or private health insurance provider.

PhilHealth membership is compulsory for all Filipino employees and typically half of the monthly contribution is covered by the employer while the other half is deducted from the employees’ salary. The amount of financial assistance it extends to its members will vary according to the disease, and knowing more about particular illnesses and the associated coverage plan could save a lot of trouble down the road.

The major downside to HMO plans is that they are not as comprehensive and extensive as private health insurance, which may offer much better financial assistance in times of critical illness. Premiums at these organizations are priced much higher than HMOs and are usually fully paid by the insured, but these come with facilities that are typically at par with international standards and policies that may extend even outside the country. Many private insurers also offer lifelong coverage, as opposed to the limited coverage and duration of HMO plans.

Given enough resources, of course, the best option would be to subscribe to both an HMO plan and private health insurance, as this will ensure that any health and medical needs could be paid for if the need arises. If that is too much, and all you want is basic health coverage to protect you from any common illnesses and emergencies, then an HMO will be enough. — Bjorn Biel M. Beltran