Health is wealth, especially when medical expenses can single-handedly empty out your savings or put you in debt. A smart safeguard from the financial pitfalls of bearing the brunt of your doctor’s prescription is investing in an health maintenance organization (HMO) plan. By contributing premiums, all your healthcare requirements—from preventive check-ups to the treatment of dreaded diseases—are practically handled with a flick of your HMO membership card.
Edwardo Miguel Guevarra Roldan, an Agency Manager for Fortune Care Philippines, says those who enroll in individual HMO plans are wary of mounting hospitalization costs.
More and more, Filipinos realize how practical it is to have an HMO plan as a fall back in dealing with health concerns.
“Most of the time though, people decide to get a plan when they’re nearing old age,” he says.
The tricky part with HMOs is sticking to your coverage plan. If you seek medical services beyond your subscriber agreement, you will be obliged to pay out of your pocket for it. It’s also a hassle following up claim forms with your HMO provider when you’ve gone out-of-coverage due to an emergency. To top it off, you must remember to settle your premiums by the due date—or else your membership may be stamped as delinquent by the time you need it most.
The challenge then is for you to fully enjoy your HMO benefits while avoiding out-of-coverage charges. Understanding the nitty-gritty of your HMO plan is the key to making the most of it. Here are some pointers to guide you:
Prevent bugs early on
Being bedridden compromises not just your well-being but earning capacity as well. Take advantage of the preventive care procedures under your HMO plan to ensure that you’re in tiptop condition. Submit yourself to periodic—at the very least, annual—medical examination. If your HMO plan permits it, avail of the executive checkup facility; spend at least a day in a private hospital suite as you are given routine medical tests. Don’t hesitate to tackle the electrocardiogram or the mammogram if these tests are recommended to you. When a red flag is raised, bear in mind that diseases are best cured when discovered at their early stages. Commit to a healthy lifestyle as it is the best way to take care of yourself.
Connect to the network
You deserve medical attention from no less than the leading healthcare institutions. Since HMOs maintain a network of participating doctors and hospitals, consider its directory list as your yardstick when choosing or maintaining a plan. Ask your plan representative how the HMO provider screens its participating medical network. If you’ve been seeing the same doctors (family physician, pediatrician, OB-gyne) for years, ask what HMO they are affiliated with. Also check out if your neighborhood hospital (or mall clinic) is among the accredited institutions. Your two-way cab fare to Hospital B could be more expensive than having an out-of-coverage checkup at the community hospital a block away from your home.
Although HMOs explicitly state exclusions for pre-existing medical conditions (such as hypertension and diabetes), you can ask for them to be waived after a period of time, usually after a year. Pre-existing conditions are any sickness that you may have had developed before enrolling in an HMO plan. Sometimes, these conditions may not be known to you until after you experience their symptoms. It is then only fitting that you choose an HMO plan that will include pre-existing conditions, which may be chronic diseases. Make it clear with your plan representative on when certain pre-existing conditions are covered in your subscriber agreement before you sign up.
Stretch the service
“Every time you go to a clinic or hospital, the participating doctor should be able to attend to your needs or refer you to another specialist,” Palaruan says. Unless you need emergency care though, you are always required to secure a participating doctor’s recommendation first before hospital admission or even just emergency room use. Otherwise, the medical costs might be charged to you in full. To shrug off the wager against you, insist on getting all related tests or treatments when already under HMO-covered care. For example, asking for a blood chemistry test could determine if you have higher than normal cholesterol or sugar levels—which could alert you to a possible heart problem or diabetes.
Take it to the max
Each HMO plan specifies a maximum amount it will shell out for a covered medical service. Your annual allowable expense—which is usually indicated at the back of your health card or described in a separate sheet or booklet—is determined by your premium. Instead of feeling shortchanged when you realize at year-end how you never consumed your HMO benefits, think of ways to maximize your plan. Getting immunizations—flu shots, for one—are a great way to capitalize on your HMO, especially if you have a family plan extending to your children-dependents. Have your HMO’s coordinating doctor refer you to specialist services (say dermatological) if you need one; the professional fees will be paid for by your plan.
Dig in for extras
If you travel within and outside the country a lot, take note if your HMO plan buffers you from emergency or urgent medical situations you may deal with while on the move. Most HMOs will refund part of the medical bills you spent as long as you’re within coverage. Dental, hearing, and vision care, which seem common enough medical concerns, are not covered by some HMO plans. Services for these are considered optional and are bundled with additional charges. If you are a woman planning to have a child, include maternity benefits as an add-on to your plan.
From the 2007 edition of MoneySense, the country’s first and only personal finance magazine. You can read more financial tips and stories at http://www.moneysense.com.ph.
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- Managing Partner at Princeton Business Initiative
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- Agency Manager at Fortune CARE Health Maintenance Organization (HMO)
- Financial Investment Advisor at Rampver Strategic Advisors
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