Health Insurance photo

Health Insurance: Choosing an HMO. What You Need To Know

By Willie Ong, MD, (Internist and Cardiologist)

Let’s talk about health insurance. Do you need to avail the services of a health maintenance organization or HMO? Can an HMO cover for your expenses when you get sick? The answer is not as simple as you think. Here’s what you need to know about getting medical insurance in the future.

Q. What should I look for in a good medical insurance policy?

a. Check the coverage – Read the fine print. What diseases are covered by your insurance and what are not? Some HMOs do not cover pregnancy costs, heart disease, high blood pressure, congenital problems, or anything that is deemed PRE-EXISTING before you signed the dotted line.

This is a tricky point because it could be argued that most diseases are genetic, and therefore pre-existing and not covered. Another issue is determining whether the disease is work-related or not.

You have to ask also if your dependents (parents and kids) are covered and to what extent.

b. Look at their track record – Ask your friends who have had experience with a particular HMO. Are they good payers? Are they very strict with their rules? Do they have good doctors? In addition, do patients have a choice which doctors to go to?

c. Determine accessibility – Choose HMOs that are widely accessible and are connected to many hospitals, especially a hospital near your home. Are their clinics located inside the hospital or within shopping malls? During a medical emergency, you need to be near a hospital accredited by your HMO.

Q. Do I need medical insurance?

Unless you’re a multimillionaire, I believe that health insurance can serve as a security blanket for your emergency medical needs. Nowadays, we know the problem with healthcare with the astronomical costs of laboratories, medicines and other hospital fees.

Adding to the expense are the professional fees of your doctors. Having an HMO somehow limits the fee of the doctor. Doctors usually get paid around 200-500 pesos only per consult.

And depending on the limits of your coverage (say P100,000), you can at least be assured of some initial medical care, while you’re still scrambling for money. Most patients don’t have money stashed away for their health bills.

Q. Isn’t my PhilHealth coverage enough?

PhilHealth can be an added source of funds to pay for your hospitalization bills. PhilHealth usually reimburses around P20,000 per hospitalization depending on the illness. However, you have to realize that sometimes P20,000 covers the expense of only a day’s stay in a private hospital.

Also, PhilHealth does not usually cover for your outpatient expenses and your maintenance medicines (yet). Because of this, PhilHealth only covers a small percentage of your total bill. The rest you have to pay on your own.  

My advice is to use your HMO and PhilHealth card together so you can lower further the costs of your medical expenses. Remember that patients need to present their HMO card before being admitted to a hospital, otherwise you might have to pay on your own. Also, you need to have your PhilHealth forms signed by your doctor (ask this from the nurse-in-charge) before you are discharged from the hospital. Otherwise, your privileges might get forfeited.

Q. Should companies avail of medical insurance for their employees?

Several studies show that companies who pay for the medical insurance of their employees gain better productivity and lesser expenses in the future. If the company does not take care of its employees, then there will be more absences and sick leaves. Also, when the employee gets sick, he or she will loan money from the company. And being uninsured, the employee’s hospitalization costs can become very expensive.

Giving free health seminars and providing exercise areas also makes the employees more productive and contented.

Q. What more should I know about HMOs?

Let’s get this straight. Signing for an HMO or PhilHealth does not guarantee that you will live longer. It doesn’t mean you have a license to smoke, drink and eat whatever your heart desires. All it means is that if you get sick, the health insurance will pay for a certain amount of your medical expense.

It’s always best to acquire healthy habits and plan for your health needs while you’re still young. HMOs may pay for a bout of pneumonia or an appendectomy, but they may not be enough to cover for catastrophic disease like strokes, heart attacks and long-term diseases.

Another option is to just use your insurance as a safety net, because nothing is stopping you from going to your doctor of choice at your own expense. In some ways, having a good doctor can save you money. He or she can give you expert care and tips on how to save on your medical expense.

Final advice: For very rich patients, you may do well even without getting medical insurance. For poor patients, I don’t think they can afford to pay the premium of their HMO. All of us are better off signing with PhilHealth to at least be assured of some medical care in the future. Stay well and good luck.

Related Posts