HMO or Health Management Organization is a medical insurance base plan which requires a PCP (Primary Care Physician) referral in order to be covered. Here in the Philippines, it works the same way in most aspects but there are a couple of differences.
When it comes to medical insurance, regardless of what kind of insurance it is, not many Filipinos have personal private health insurance. Most of the Filipinos who have health insurance are those who are working for small businesses up to big multi-national companies. Most of these companies provide HMO medical benefits to its employees.
In the US, a member would have to go to a Primary Care Physician (PCP) to get a referral so that he/she can be seen by a specialist or undergo a medical procedure. Here, the usual scenario is that the member would go to a satellite office of the insurance company. These insurance companies have offices in major private hospitals and they even have their own general practitioners for initial findings. Sometimes, they would require you to be seen by their in-house doctor first so they can refer you to the right specialist.
They will give you the referrals and/or approvals for medical procedures and then you’re free to go. You don’t have to pay anything unless you have used the maximum amount allowed on your plan which is highly unlikely.
I’ve worked for an American health insurance company and the HMO benefits differ a lot. Here, HMOs usually offer 100% coverage and there are no strings attached. No co-pays, no deductibles, 100% coverage but there is a maximum limit allowed depending on the contract. Most of the time, the maximum amount a patient can use would range from 75,000 to 100,000 pesos per year. That’s roughly $1,600 to $2,200 a year. And yes, they even cover pre-existing conditions as soon as you become a member.
On the other hand, benefits for dependents are lower than the principal member most of the time. They usually have a significantly lower maximum amount. Let’s say if the principal member has 150,000 pesos, the dependent can get as low as 50,000 to 75,000 pesos. Also, there may be procedures that are not covered for dependents and pre-existing clauses usually apply to them.
The expenses and cost of living here are quite low compared to the US. 100,000 pesos is quite big and the possible reasons why it can be used up would be long duration inpatient stay, long term treatments, occasional state-of-the-art equipment medical procedures and surgery.
I’ve also seen a few HMO insurance companies here that follow the PCP pattern and they have specific participating doctors in different hospitals. Members also go there to get referrals so they can go ahead and visit a specialist or go for a procedure.
Well, that’s basically how HMO in the Philippines works. Hopefully, it will be more accessible to the greater public. We have Philhealth government insurance for the public though but HMOs offered by private companies usually have better benefits.