2022 - Product Manual

Version: Q2 2022
Maxicare Healthcare Corporation
PRODUCT
MANUAL
This manual belongs to:
Disclaimer:
MAXICARE HEALTHCARE CORPORATION has made every effort to ensure that this User’s Manual is
accurate; MAXICARE disclaims liability for any inaccuracies or omissions that may have occurred.
Information in this Product Manual is subject to change without notice and does not represent a
commitment on the part of MAXICARE. MAXICARE assumes no responsibility for any inaccuracies that
may be contained in this Product Manual. MAXICARE makes no commitment to update or keep current
the information in this Product Manual, and reserves the right to make improvements to this Product
Manual and/or to the products described in this Product Manual, at any time without notice. If you find
information in this manual that is incorrect, misleading, or incomplete, we would appreciate your
comments and suggestions
HCB1
CHAPTER 1
HMO stands for Health Maintenance Organization.
It is an organization that provides or arranges managed care for individuals or employers at a fixed
fee/premium or prepaid contract.
An HMO covers health care rendered by those doctors and other professionals who have agreed by
contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a
steady stream of customers. *
Functions of an HMO
CHAPTER 2
COMPANY PROFILE
Maxicare Healthcare Corporation, one of the pioneer health maintenance organizations in the Philippines
was established in 1987 by an esteemed group of doctors and businessmen with a vision for a better
healthcare delivery system in the country.
Since its founding, Maxicare has always focused on providing peace of mind to all of its members.
Through its extensive medical provider network nationwide, responsive customer care unit, stress-free
availment process, personalized assistance, and comprehensive wellness campaigns, Maxicare members
are assured of no less than the best for their healthcare needs.
Maxicare believes in providing its members comprehensive health programs with unsurpassed levels of
customer service, quality, and cost-effectiveness. With service excellence and stability combined – the
country’s prestigious medical institutions as the foundation of our service delivery and distinguished
medical consultants and esteemed businessmen as major shareholders – Maxicare remains the
healthcare company of choice by the top employers of the country.
1. TRUSTED
Our Mission
To help people achieve peace of mind through quality health care.
Our Vision
To be the leading health maintenance organization preferred by customers
because of Superior Service.
Company Milestones
• In 1987, a group of Doctors from Makati Medical Center and a few

Businessmen established Maxicare with a vision for a better healthcare for
the country
• In 2003, the official name of the company was changed to MAXICARE

HEALTHCARE CORPORATION.
• In 2004, the company reached its 1 billion sales.
• In 2005, Maxicare launched its Intelligent Cards.
• From 2005 to the present, the company has added medical facilities
such as PCCs and transferred to its new office, Maxicare Tower.
Visionaries
Roberto K. Macasaet, M.D. - Founder and Chairman Emeritus
Roberto M. Macasaet, Jr. - Chairman of the Board
Antonio L. Go - Vice Chairman
Christian Argos - President and CEO
ADVISERS TO THE BOARD
John L. Gokongwei - Owner of JG Summit, Cebu Pacific, Universal Robina and etc.
Atty. Nilo T. Divina - Founder of the largest Thomasian Law Firm, Divina-Uy Law Firm
Elizabeth H. Lee - First female president of CAMPI
Ramon Sy - Former Chairman of UCPB (United Coconut Planters Bank

2. RELIABLE
A Global Standard
Maxicare is a company-wide ISO 9001:2015 certified
✔ Unparalleled service delivery aimed at meeting customer requirements
✔ Improved efficiency in the day to day operations
✔ Increased customer satisfaction by integrating it as part of our corporate culture
✔ Defined processes operating on an ISO guideline
3. CONVENIENT
I. Vast Network of Providers Nationwide
Our Company Statistics now reaches the following:
▪ MEMBERSHIP POPULATION: More than 1,600,000 nationwide

▪ AFFILIATED DOCTORS AND SPECIALIST: more than 71,000 (per affiliation) Top Caliber Doctors
(Consultants, Fellows, and Diplomats) with a minimum requirement of Internal Medicine
Specialist. More than 18,000 doctors per warm body headcount.
▪ AFFILIATED HOSPITALS AND CLINICS: More than 2,000 nationwide (65% are tertiary hospitals)
▪ AFFILIATED DENTAL PROVIDERS: More than 3, 800 nationwide
Now, as a proud member of Equicom Group which includes Equicom Savings Bank Inc., ALGO Leasing and
Finance Inc., Equitable Computer Services Inc., and Equicom Information Technology Inc. to name a few,
we are more than ready to be of service to you
II. Access to Primary Care Clinc (PCCs)
Maxicare Primary Care Clinic (PCCs) are Maxicare owned clinics that have a staff of Customer
Service Representatives and Primary Care Physicians offering extensive healthcare services and additional
medical networks for Maxicare members.
The following are the locations of Maxicare’s PCCs:
1. Maxicare PCC Double Dragon Meridan Park

G/F Tower 2, Double Dragon Meridian Park, Diosdado Macapagal Ave. cor EDSA Extension, Pasay City
Email Address: pcc.doubledragonmp@maxicare.com.ph
Clinic Hours: 06:00 AM - 10:00 PM from Monday to Sunday
Tel. Nos: 79086967, local 6966 and 6967
2. Maxicare PCC Iloilo

Unit 4, Three Techno Place, Megaworld Blvd, Mandurriao, Iloilo City, Iloilo
Email Address: pcc.iloilo@maxicare.com.ph
Tel. Nos: (033) 3239254
3. Maxicare PCC Cebu

Lot 5, Block 6, Mindanao Avenue, Cebu Business Park, Ayala, Barangay Luz, Cebu City
Email Address: pcc.cebu@maxicare.com.ph
Tel. Nos: (032) 260-9067
4. Maxicare PCC W City Center

Address: W City Center 7th Ave cor 30th St. Bonifacio Global City, Taguig
Email Address: pcc.bgc@maxicare.com.ph
Tel. Nos: (02) 7908-6957
5. Maxicare Bridgetown
Unit 1-3, Zeta Tower, Bridgetowne, C-5 Road, Ugong Norte, Quezon City
Email Address: pcc.bridgetowne@maxicare.com.ph
Tel. Nos: (02) 7908-6959
6. Maxicare Ayala North Exchange
2/F The Shops, Ayala North Exchange, Ayala Ave. Cor Amorsolo and Salcedo Sts. Makati City
Email Address: pcc.ayalanorthexchange@maxicare.com.ph
Tel. Nos: (02)7908-6902
7. Maxicare Clark
G/F SM City Clark, Tech Hub 6, Manuel A. Roxas highway, Clark Freeport, Angeles, Pampanga
Email Address: pcc.clark@maxicare.com.ph
Tel. Nos: (045) 5998392
8. Maxicare Alabang
Address: G/F Southkey Hub, Indo-China Drive, Northgate Filinvest, Alabang
Email Address: pcc.alabang@maxicare.com.ph
Tel. Nos: (02) 7908-6960
9. Maxicare Davao
Ground Floor, Space 1C-1D, Abreeza Mall J.P Laurel Avenue, Bajada, Davao City
Email Address: pcc.davao@maxicare.com.ph
Tel. Nos: (082) 293-2446
10. Maxicare Centris

Address :G/F Cyberpod Centris 5, Eton Centris, Quezon City
Email Address: pcc.centris@maxicare.com.ph
Tel. Nos: (02) 7908-6925
11. Maxicare Cebu Skyrise

Block 8, Lot 3, Skyrise 4B, Cebu IT Park Subdivision, Barangay Apas, Cebu City
Email Address: pcc.cebuskyrise@maxicare.com.ph
Tel. Nos: (032) 260 9069
12. Maxicare VV Soliven

Address: GF-SOL1 (Centro Del Sol), VV Soliven Shopping Complex, EDSA Greenhills, San Juan City
Email Address: pcc.vvsoliven@maxicare.com.ph
Tel. Nos: (02) 7798 7788
ADVANTAGES OF AVAILING AT MAXICARE PCCs:
● Maxicare PCCs are exclusive to Maxicare members ONLY.

● PCCs provide easy access to Internal Medicine Specialists of Maxicare.
● Offers unlimited number of FREE consultations (consultation costs do not get deducted from the
value of the card)
● Maxicare PCCs are strategically and conveniently located in major hospitals in Metro Manila.
III. Access to MyHealth Clinics
MyHealth Clinics are Maxicare accredited or affiliated clinics that are located in
some selected malls in Manila.
ADVANTAGES OF AVAILING AT MYHEALTH CLINICS:
• Availability beyond 5 PM and weekends

• Access to state of the art medical facilities The
following are the locations of MYHEALTH CLINICS:
1. SM North Edsa
Level 2, Sm North Edsa
North Edsa, Quezon City
2. Festival
Supermall Level 2,
Festival Supermall
Filinvest, Alabang
3. Edsa Shangrila
Level 1, Shangrila Plaza
Shaw Blvd., Mandaluyong City
4. Robinsons Manila
3rd floor, Mezzanine Pedro Gil Wing
Malate, Manila City
5. Robinsons Cybergate,
Cebu Level 3, Robinsons
Cybergate Fuente Osmena,
Cebu City
6. MyHealth Venice Grand Canal

nd
Mall 2 floor, Venice Grand Canal
Mall, McKinley Hill Villas, Upper
McKinley , Road, Taguig Ci
MAXICARE HELPDESK
Get much needed help in Major Hospitals - Situated inside major hospitals within and outside Metro Manila,
Maxicare helpdesk aid Maxicare members by issuing a Letter of Authority (LOA)
● Chinese General Hospital

● Makati Medical Center
● St. Luke’s Medical Center - Quezon City
● St. Luke’s Medial Center- Global
● Cardinal Santos Medical Center
● The Medical City
● Maxicare Healthhub, Manila Doctors
● Asian Hospital and Medical Center
● Capitol Medical Center
● National Kidney and Transplant Institute
MAXICARE HEALTHHUB
Easy self-service health facility

Available video consulations with top-notch doctors
Paperless transactions for LOA & other medical records
Access to high quality digital health pods
Comfortable lounge chairs equipped with wireless and charging pods
Ultimately, it is only Maxicare where you experience healthcare at its finest.

IV. Maxicare Multifunction Card
Through the Maxicare Intelligent Card, members may avail of medical care
through online availment Approval System. Instead of the traditional way of
verifying the eligibility of membership, a simple swipe of the Maxicare card
at any of the designated POS terminals nationwide.
Moreover, activation and deactivation of membership within 24 hours are

made possible, giving our members hassle-free admissions and discharge at
our accredited hospitals at the same time control unnecessary availments.
This translates then to an effective “gate–keeping system “providing the
enrollees' coverage which is due them.
Apart from being a Membership Card, the Maxicare Intelligent Card now has
the capacity to receive approved reimbursements through electronic
crediting. Called the Maxicare Reimbursement Card (MRC), members
may now enjoy cashless payment of Maxicare reimbursements through
electronic card credits withdrawable via Bancnet, Expressnet, Megalink, and
EqB ATMs
As mandated by Bangko Sentral ng Pilipinas, all our cards will now be EMV compliant. The newest
improvement in the cards is to improve payment security, making it difficult for fraudsters to successfully
counterfeit stolen cards
Benefits of the Reimbursement Card
• Immediate availability of funds upon reimbursement approval (no more 3-day clearing)
• 24/7 access to funds via Equicom, and other Bancnet, Megalink and Expressnet ATMs.
• Real-Time Balance Inquiry via Mobile and Internet Banking services of Equicom.
• Timely notification via SMS whenever cash is loaded.
• Cashless purchase in over 2000 Bancnet, Megalink, and Expressnet accredited merchants.
• Free monthly Statement of Account via email upon request from Equicom Customer Service.
V. Extensive Customer Care Network
24/7 Customer Care Call Center

Maxicare also takes pride in its own Customer Care Center,
which primarily assists members on benefit inquiry and
availment. Customer Care Representative is available 24/7,
365 days. On top of these call center numbers, the
numbers of Maxicare’s key Sales and Marketing Officers will
also provide to you for emergency assistance or any related
concern.
Customer Care Center Numbers Head Office No. Provincial Toll-Free No.
+632 582-1900 (+632) 908-6900 1-800 -10-582-1900

+632 798-7777 1-800-10-798-7777
● Maxicare Satellite Office

These are provincial offices strategically located nationwide which provide services such as availment
approval, claims processing, and customer servicing. Some of the satellite offices also serve as Maxicare
provincial sales office which accepts application forms for Maxicare plans.
● Corporate Based Customer Support Specialists
Corporate Based Customer Support Specialists (CSS) are

account-assigned personnel who play a proactive role in
administering and assisting in the implementation of the
plan for the members/employees of that particular
account. This ensures that all standards of the plan
specifications are always met.
The CSS will assist the Human Resource personnel of the

account in their administrative functions of managing the
healthcare program, as well as the monitoring and
adjunction of some approvals needed for the availment of
the employees.
*CSS is assigned on-site and are requested by an account an additional cost.
● SMS Inquiry Service
0918-889MAXI (0918-8896294)
✔ Register in the SMS Inquiry Service

reg<space>Maxicare ID Number
Example: reg 05012345700
Other services:
✔ Request for List of Accredited Providers per area
✔ Request for the List of Accredited Doctors per specialization per
hospital.
● Email Support
Members may send their inquiries and concerns through email at:
callcenter@maxicare.com.ph / customercare@maxicare.com.ph
● Maxicare Social Media Pages
Members may like us on Facebook, Instagram, Twitter and Youtube
www.facebook.com/maxicarehealthcarecorp
https://www.instagram.com/maxicarehealthcare/
https://twitter.com/MaxicareHMO
Maxicare Healthcare Corporation Youtube channel

4. INNOVATIVE
I. Maxicare Website
▪ Provides information on Company profile and milestones;

▪ Allows access to the features and brief descriptions of Maxicare products and services;
▪ Provides members easier reference on accredited doctors, hospitals,
and Primary Care Centers;
▪ Keeps everyone informed on the latest updates and achievements of the organization;
▪ Presents to its channel partners such as agents/brokers basic essential information
such as incentives, membership/accreditation, and commission
Maxicare MEMBER GATEWAY is a portal on the Maxicare’s website which will
now provide members unparalleled visibility and information regarding their account
with Maxicare.
Through this portal, members have full access from one’s basic account information to
availment details.
Available Services under Maxicare Member Gateway Portal:
▪ Member User Registration

Module wherein the member can register to have access to their account.
▪ Member’s Information
Module wherein members/users can view the details of his/her membership with Maxicare
including the details of their dependents.
▪ Availment Summary
Module wherein members/user can view details of his/her availments
▪ ACU Scheduling
Member/user can schedule their/dependent’s ACU Benefit
(ACU scheduling will depend on account’s benefits and restrictions)
▪ Reimbursement Status
Inquire status of member’s reimbursement claims
▪ Online LOA Request

Online request of LOA for the following transactions: CONSULTATIONS, LABORATORY PROCEDURES
& CONFINEMENT
▪ Lost Card Report

Reporting is allowed for Individual and Family Accounts only. The card replacement fee is Php 200.
Reasons for Card Replacement:

1. Lost Card
2. Damaged Card
3. Lost in transit
Maxicare Mobile Applications:
A. MaxiHealth+
● Easily access your Maxicare e-card

● Consult a doctor anytime, anywhere
● Stay informed
● Use as e-wallet
B. Doctor Anywhere
Doctor Anywhere, regional tech-led healthcare company headquartered in Singapore.
With Maxicare’s strong network of established healthcare providers and experienced doctors, Maxicare
has partnered with Doctor Anywhere to enable and empower Maxicare members to cc mobile apps.
Users can consult a doctor anytime, anywhere, and get medication delivered to them within Manila.
Beyond Singapore, Doctor Anywhere uses the Ministry of Health Singapore’s stringent telemedicine
guidelines as our best practices to establish safe processes for both Healthcare Professionals and
patients.
About DA Virtual Clinic:
With DA Virtual Clinic, Maxicare Members can enjoy quick access to locally-licensed doctors anytime, anywhere, on Doctor
Anywhere’s platform.
Video consult doctors on the App within minutes. A convenient, efﬁcient, and cashless healthcare experience for Maxicare
Members.
Maxicare HR Viewpoint – Company HR can easily monitor members’ account
Maxicare Kiosk
MAXICARE KIOSK LOCATIONS
● Makati Medical Center-
● The Medical City – Ortigas
● St. Luke’s Medical Center – QC
● St. Lukes’s Medical Center – Global City
● Chinese General Hospital and Medical Center
● Cardinal Santos Medical Center
● Asian Hospital and Medical Center
● Manila Doctors Hospital
● Capitol Medical Center
● Calamba Medical Center
● Dr. Victor R. Potenciano Medical Center
MAXICARE LAB ON WHEELS

FEATURES
II. Maxicare Exclusive Wing
Maxicare Exclusive Wing gives Maxicare members priority and privileged treatment with regular
private and large private categories.
1. Makati Medical Center (with 21 rooms)

8th Floor Tower I Makati Medical Center, Amorsolo Street Legaspi Village, Makati City
2. The Medical City (with 21 rooms)

12/F Doctors Building, The New Medical City, Ortigas Ave., Pasig City
3. Victor Potenciano Medical Center (with 36 rooms)
163 Edsa Mandaluyong
4. Manila Medical Center (20 rooms)

th
8 floor, 850 United Nations Ave. Ermita, Manila
5. Metro Davao and Medical Research Center (with 12 rooms)

JP Ave., Bajada Davao City
Maxicare Liaison Officer
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.
Maxicare 24/7 Customer Care Call Center
Serve customers' needs by providing and delivering professional, helpful, high-quality service and
assistance before, during, and after the customer's requirements are met.
HOMECARE PROGRAM:
● It’s a value-added service to Maxicare members where

disease management is facilitated at home.
● It was created by Maxicare to provide additional support

to members in areas where hospitals are at full capacity
and help manage COVID-19 from progressing to a severe
case.
● The program has 3 components: 24/7 Telemedicine,

Telemonitoring, and Home Care.
CHAPTER 3
PRODUCTS
Terminologies
Funding Arrangement – Based on how the client funds their benefits
● Full Risk
o Products under full risk would require payment for the membership fees. Computation
for the membership fee (premium based) is based on certain factors such as age, nature
of work, number of enrollees, etc. In this type of funding arrangement, the risk is on
the part of Maxicare.
● Administrative Services Only

o Administrative Services Only requires the account to set up and maintain a revolving
fund with Maxicare from which money intended to pay for the incurred usage/claims of
the members will be drawn out. Maxicare imposes an administrative fee on the account.
In this type of FA, the risk is not entirely borne by Maxicare.
Contract Type – Based on what benefit does the client receive.
● Full HMO
o A full HMO product has a comprehensive array of healthcare benefits which includes
In-Patient, Out-patient, and Emergency Care as well as Annual Check-Up subject to
certain exclusions, limitations, and conditions.
● Unbundled
o An unbundled product consists of selected benefits falling either to outpatient

or inpatient coverage. Minimum of 100 heads to be enrolled
Benefit Limits
● MBL (Maximum Benefit Limit)

o The maximum amount that a member can avail per illness per member per year.
● ABL (Annual Benefit Limit)
o The maximum accumulated amount that a member can avail per year avail
Nomenclature - Standard room classification used in any hospital
Peso Based - Room classification with inner limit
Anti-Selection - The intention to acquire healthcare coverage is primarily for immediate availment of
medical services.
PRODUCTS
1. Prepaid
2. MyMaxicare
3. Maxicare Starter Plan
4. Maxicare Plus
5. Corporate
6. Business Essential
PREPAID PRODUCTS
EReady
EReady is a prepaid card that offers one-time coverage for emergency conditions only.
Eligibility & Validity
• Age : 15 days old to 65 years old (Open to all Maxicare members and non-members)
• Enrollment : No maximum number of cards for registration, but a member can only
register another card 3 months from the date of availment of the first registered card
• Card Activation : Card will be activated 7 days from date of registration
• Card Validity : Card will be valid for 1 year from date of Activation
Plan Options:
a. Titanium (P839): without access to 6 major hospitals
b. Platinum (P1039): with access to 6 major hospitals
1) Asian Hospital and Medical Center 4. St. Luke’s Quezon City
2) Cardinal Santos Medical Center 5. St. Luke’s Global
3) Makati Medical Center 6. The Medical City
Card Coverage and Limitation

a) It provides coverage for Maxicare Emergency Standard Benefits
b) Maxicare EReady coverage is PhP 15,000 per individual to be availed at Maxicare accredited
hospitals only;
c) With coverage for Life with AD&D (Accidental Death and Dismemberment) up to PhP 50,000.00;
d) Cardholders are entitled to a 10% discount on all base Dental Services from Metro Dental Clinics
and 15% discount on Derma Services from My Health Clinics;
e) It is non-transferable once activated.
f) Maxicare ER Coverage ends once a patient is advised for confinement.
g) Member can avail in one (1) accredited hospital only within 24 hours.
h) Coverage is subject to exclusions such as but not limited to: Alcohol intoxication, Violation of law
or ordinances, Extreme sports
EReady Advance
EReady Advance is a prepaid health card that provides a one-time coverage for
emergency-related cases including those requiring confinement in all Maxicare affiliated hospitals
nationwide. It also covers free and unlimited consultations in all Maxicare Primary care clinic.
Eligibility & Validity

● Age : 15days old to 65 years old (Open to all Maxicare members and non-members)
● Enrollment : No maximum number of cards for registration, but members can only
register another card 7 days from the date of availment of the first registered card.
● Card Activation: Card will be activated 7 days from the date of registration
● Card Validity : Card will be valid for 1 year from the date of activation.
Plan options:
a. Titanium (4,999) without access to 6 major hospitals
b. Platinum (5,999) with access to 6 major hospitals
1) Asian hospital 4) St. Luke’s Quezon City
2) Cardinal Santos Medical Center 5) St Luke’s Global
3) Makati Medical Center 6) The Medical City
Outpatient emergency coverage includes:

1. Doctor’s services for emergency treatment
2. Emergency room fees
3. Medicines used for immediate relief and during treatment
4. Oxygen, IV fluids, whole blood, and human blood products
5. Dressings, casts, sutures
6. X-ray, laboratory, and diagnostics exams
Inpatient coverage includes

1. Room and board accommodation in a regular private room
2. Use of Operating Room, Intensive Care Unit (ICU), Isolation Room (if prescribed by the attending accredited
physician) and Recovery Room
3. Professional fees
4. Standard nursing services
5. Medicines when in confinement
6. Whole blood products, and IV fluids transfusion
7. X-ray, laboratory tests, and diagnostic tests
8. Anesthesia, oxygen and its administration
Other Inclusions:
○ Group Life with ADD&D (Accidental Death,
Dismemberment & Disablement) of up to P 50,000.
○ Emergency medical evacuation for members who are more
than 150 km away from their place of residence.
○ 10% discount on Metro Dental services.
○ 15% discount on MyHealth Clinic services.
Exclusions and Limitations
1. Services obtained for emergency conditions from physicians and hospitals in any of the
following circumstances:
a. Non-affiliated physicians in non-affiliated hospitals.
b. Affiliated physicians in non-affiliated hospitals or other non-affiliated healthcare
facilities.
2. Injuries, infections or conditions from negligence, alcoholic liquor intake, unauthorized use of
prohibited drugs or regulated drugs, violation of law or ordinance or unnecessary exposure to imminent
danger,
EREADY VS. EREADY ADVANCE COMPARISON
EREADY EREADY ADVANCE

15, 000 EMERGENCY ROOM BENEFIT ONLY 50,000 EMERGENCY ROOM & IN-PATIENT
BENEFITS
Client can register another card 3 months after the Client can register another card 7 days after the
first availment. first availment.
No unlimited consultations at Maxicare Primary Unlimited consultations at Maxicare Primary Care

Care Centers Centers
EREADY AND EREADY ADVANCE SUMMARY
SPECIFICATIONS E-READY E-READY ADVANCE

Age eligibility 15 days old - 65 years old 15 days old - 65 years old
Variants and price TITANUM (P839) PLATINUM (P2950)

PLATINUM (P1039) PLATINUM(P3950)
Benefits and -Php 15,000 one time coverage for -50,000 one time coverage for emergency
coverage Emergency standard benefits standard benefits including those requiring
confinement in a regular private room.
-Up to 50,000 life ADD%D coverage
(accidental death & dismemberment) -Free and unlimited consultations in
maxicare primary care clinic nationwide
-Cardholders are entitled to a 10% discount
on all base dental services from metro -Access to maxicare 24/7 teleconsult and
dental clinics and 15% discount on derma 10% discount in selected metro dental
services from myhealth clinics services
-Up to 50,000 life ADD%D coverage
(accidental death & dismemberment)
-Emergency medical evacuations for
members who are more than 150km from
the place of residence
PRIMA
● A renewable prepaid card that offers unlimited consultations and unlimited laboratory procedures at PCCs only.
● Pre-existing conditions are covered.
● Unlimited VideoConsultation via Doctor Anywhere
Plan Variants:
1. Maxicare Prima: SILVER (Php 4,999)

● Age eligibility: 0-59 years old
● Coverage for Maternity Consultation PCC Obstetrician-Gynecologist (OB-GYN)
● Dental Coverage at Metro Dental
2. Maxicare Prima: GOLD (Php 12,999)

● Age eligibility: 60 years old and up
● Access to PCC + MyHealth Clinic Branches
● Emergency coverage up to Php 20,000 ABL Dental Coverage at Metro Dental
CARD ACTIVATION:
● Voucher or reference number must be registered within 3 months from the date of purchase.
● Membership will expire within One (1) year from the date of registration.
● You can use the Prima for consultation and laboratory within 24 hours from the registration period.
● For the emergency coverage of Prima Gold, activation is after 7 days from the date of registration.
PCC SPECIALIST:
● Internal Medicine
● Obstetrician-gynecologeist
● Ears-Note-Throat Specialist (Except in PCC Davao)
● Dermatologist Pediatrician Opthamologist (PCC Davao and PCC Iloilo)
Dental Benefits:
● Mild Oral Prophylaxis (Cleaning)

● Panoramic X-Ray (Full Mouth)
● Dental Consult
● Emergency relief of dental pain through medication
● Cosmetic/Oral Rehab treatment planning
● Dental nutrition and counselling
● Dental Health Education
● Preparation of dental certificates
● Safekeeping of dental records as required by law and/or client
NEW PROCEDURES:
● 2D ECHO is already available in BGC, Bridgetown and Cebu.
● TREADMILL STRESS TEST is available in Bridgetown and Cebu
Product Features:
Contract Type – Modified Out-Patient (OP) Unbundled
Funding Arrangement – FULL RISK (renewable)
Enrollment – 1 card enrollment per member
Voucher Validity – Member has 3 mo. from the date of purchase to register the voucher
Membership Validity – Once registered, the card will be valid 1 year from date of registration
Reminders:
1. This card is non-transferable once registered.
2. Only those ages 0-59 above may avail of the PRIMA Silver and only those ages 60 y.o. and above
of the PRIMA Gold.
3. The Php 20,000 Emergency Coverage for PRIMA Gold uses the ABL benefit limit.
4. Emergency Coverage is allowed in any Maxicare affiliated/accredited hospital including major

hospitals.
5. OP Laboratory Procedures can only be done in Maxicare Stand-alone PCC. PRIMA Gold
cardholders can go to MyHealth Clinics for their OP Lab Procedures.
6. Dental benefits are covered once a year per benefit, to be availed at MetroDental Clinics.
7. Only procedure/s advised and requested by a Maxicare Primary Care Physician will be covered.
8. Pre-existing conditions are covered
9. Access to the 24/7 TeleConsult Service: (02) 582-1980

Chapter 1: Prepaid Products: Sales Process/SVP/Agent Support
Definition of Terms:
1. Partners - Maxicare sellers - agents, brokers, distributors or merchants
2. NIC - Non-Intrinsic Card - a card that has no value and could not be registered
3. Token - Provided to agent/merchant once bought in Sales Viewpoint to activate a card
4. App - Android/Apple mobile app used to activate NIC if an agent has a token
5. Activated Card - A system used for registering activated cards to make them ready
6. Member Viewpoint - A system used for registering activated cards to make them
ready for availment
7. Registered Card - A card that is already tagged/registered to a member
8. E- Voucher - An email that contains an activate reference # - only issued in Maxicare

Online Store
9. E- Card - An electronic Card containing member details and QR code
WhAt is SAles Viewpoint?
This is a channel that will be used by Maxicare consumer sales’ intermediary partners, such as
agents (AIA, HBA, AUM, AUH), brokers and merchants, to digitally buy, sell & pay prepaid
products using a web portal, mobile app, & non-intrinsic cards (NIC).
it will also serve our partners and sales team’s needs to view sales reports.
Benefits of this digital channel are:
● savings on inventory cost thru NIC instead of EMV cards

● self service ordering & buying of products by our intermediary partners
● digital monitoring & controlling of sales

Two Components:
● Web Portal - Intermediary partners will need this to create their user accounts, order
products, view sales reports, then will need a mobile app to activate non-intrinsic cards
(NIC).
https://salesviewpoint.maxicare.com.ph/- Click the Web Portal link to log-in & place order.
● Mobile Application - Then they will need the app (will be available for Android & iOS) to
activate non-intrinsic cards before customers can register and consume the products
ordered from them.
Download the app via Google Play for

Android user and App Store for for IOS User.
*Android hardware requirements:
\ OS: Android Nougat (7.0 – 7.1.2) or Higher
Minimum RAM: 4GB
*IOS hardware requirements
OS: 10 or Higher
Minimum RAM: 4GB

User MAnuAl For Agents:
1. User Account Cre Ation:
Prerequisite: Agent/Broker User was accredited and created in C4C by the Accreditation Team & tagged
as Active
Note: Unlike a Merchant, an Agent/Broker can create his own user account
2. Account Log in:
Prerequisite: Agent/Broker User must have been successfully registered and verified in the
Sales Viewpoint portal

3. Forgot PAssword:
4. PLACE ORDER - USING PAYNAMICS
User Guide on Sales ViewPoint with Paynamics
● Click on the “Ordering” tab then select “Place Order”.

● Once clicked, a list of prepaid products will appear.
● Click on the “+” button on the corresponding products you wish to purchase. The numbers in
between the + and - sign indicate the total quantity of certain product/s you wish to purchase.
● Once the order is finalized / complete, click on the “Proceed to Checkout” button, on the right side of
the screen.
● Order Summary page will be shown, on the right side of the screen, select “Pay Now” under
Payment Options.
● A list of payment options under Paynamics will be displayed.
● Select the payment option you wished to settle your order with. For example GCash. Click on
GCash, then key in your GCash number then click on “Continue”.
● Make sure to click on the terms and conditions tickbox
● The GCash owner will receive an OTP, and key in
the received OTP to complete the transaction.
● An Order Summary email containing the SVP

Reference # of such a transaction will be received.
● A successful transaction page will be displayed

once completed. Click on the “Continue” button to return
back to SVP Homepage.
● An Order Summary email containing the SVP

Reference # of such a transaction will be received.
5. VIEW ORDER HISTORY & DASHBOARD
6. VIEW DISCOUNT
7. MOBILE APP: CARD ACTIVATION
A. Log-in
B. Overview of mobile app functionalities

C. Activation
8. MAXICARE ONLINE STORE: SELLING USING AGENT’S CODE

DIFFERENCE BETWEEN SVP AND MAXICARE SHOP LINK:
SVP
- Only agents & brokers have access.
- More favorable if agent/broker wants to have ready stock NICs.
- Prices are already discounted upon purchase ( depending on the comm rate per product) Agent will receive
his/her commission upon payment of the client.
- No minimum order
- Delivery will take 5-7 days / Office pick-up
- NICs still need to be activated using the SVP app.
MAXICARE SHOP
- Everyone has access
- More favorable if agent has clients living far away ( Vis/Min)
- SRP
- Client has to input the agent's SVP user name upon checkout.
- Commission will be credited to the agent's bank account 5-7 days from the date of client purchase.
- No need to activate the cards. E -vouchers will be sent directly to the client.
FULL HMO/FULL RISK PRODUCTS
MYMAXICARE
MYMAXICARE
A full HMO & full risk product with standard/boxed type health coverage intended for individual
and family members.
MyMaxicare Variants (Individual and Family)
Hierarchy Ruling - Unless there is a valid reason for the non-enrollment of certain dependents (i.e.
currently enrolled in another HMO, abroad, separated, deceased, etc.), applicants should enroll their
dependents in the priority specified by Maxicare.
● For Married Employees - first priority, spouse and second priority, children (eldest to youngest
in that order);
● For Single Employees - first priority, parents (anyone ahead of the other) and second priority,
brothers and sisters (eldest to youngest in that order);
● For Single Parent Employees (including widow and widower employees) - first priority, either
his or her own children (eldest to youngest in that order) and/or parents (anyone ahead of the
other) and second priority, brothers and sisters (eldest to youngest in that order).
Age Eligibility
Principal
- Age (Adult):18 years old to 60 years and 5 months old for initial enrollees; up to 65 years old
for renewing enrollees
- Age (Minor): 15 days old; up to 17 years old with appointed Guardian
Dependents
- Age (Adult): up to 60 years and 5 months old for initial enrollees w/o renewing principals; up
to 65 years old for enrollees with renewing principal
- Legitimate Spouse and Parents
-Age (Minor): 15 days old; up to 21 years old

-Legitimate, legitimated and/or legally adopted Children and Siblings
-Unmarried, unemployed and financially dependent to the Principal Member
Individual Membership Requirements:

• Application Form
• Photocopy of alien certificate of residency if foreign nationality
• Valid ID
Family Membership Requirements:
• Application Form
• Photocopy of alien certificate of residency if foreign nationality
• Copy of Birth Certificate
• Copy of Marriage Certificate
• Valid ID
MyMaxicare Ineligible Professions:

Acrobats AFP/Military Personnel Electrical Linemen
Explosive Factory Workers Loggers Mines/Quarry Workers
Night Club/Bar Workers NBI/Private Investigators Prostitutes
Wood Worker Machinist Police and Law Enforcers Professional Sportsmen
Sawmill Workers Construction workers
Security and Body Guards Oil rig workers
Firemen Politicians (elected positions)
HIERARCHY OF ENROLLMENT:
Unless there is a valid reason for the non-enrollment of certain dependents (i.e. currently enrolled in
another HMO, abroad, separated, deceased, etc.), applicants should enroll their dependents in the
priority specified above (e.g. spouse first if married, followed by first born child and so on). This is called
the Hierarchy or Anti-Selection.
Skipping of hierarchy may be allowed on the following conditions:
● Deceased.
● Has an existing HMO card as provided by the spouse’s current employer.
● Staying/living/working abroad.
● Separated
Sufficient documentation shall be requested by Maxicare from the applicant to validate the non-eligibility
of the dependent (i.e. photocopy of HMO card, certificate of employment from a company abroad, death
certificate, etc.)
ENROLLMENT PROCESS & GUIDELINES

1. Fill out the MyMaxicare application form completely. Indicate the Tax Identification Number (TIN) on
the front page if applicable;
2. Dependent’s plan must be the same plan as the Principal or one plan lower;
3. Forward the accomplished application form and medical requirements (if applicable) to the Account Officer
for processing;
4. Once the application has been approved, the Statement of Account shall be sent to the billing address of
the applicant for settlement. Payments (cash or check) may be made at the Maxicare Head Office or at
any Banco de Oro and Equicom Savings Bank branches via bills payments;
2. Member will receive Maxicare ID card as proof of membership;
Plan Effective Dates:
Philhealth Provision
MyMaxicare – Member has the option to file or not to file for Philhealth
Payment Provisions –
Lapsation (1day from renewal or subsequent date)

-is defined as the member’s failure to pay the premium due on due date leading to suspension of coverage.
Reinstatement (within 45 days from renewal or subsequent date)

-is eventually paying a premium due within the given time frame, with additional charges as
deemed applicable by the Company leading to activation of the healthcare coverage.
Conditions for Reinstatement

1. Penalty fee of PhP 500.00
2. Advance Payment for the next period (if quarterly)
3. 0 days non-coverage upon payment
During the reinstatement period, Maxicare Healthcare coverage will be suspended.
Re-application (after 45 days of non-settlement from renewal or subsequent date)
-is failure to pay premium due within the reinstatement period, leading to plan termination. Member
has the option to re-apply for MyMaxicare but application will be treated as new.
Re-application will be subject to evaluation and approval of Underwriting and Enrollment Fulfillment
team based from the membership experience.
Coverage on Pre-existing Conditions:
Pre-Existing Condition is an illness or disease that exists prior to the effective date of the member’s
coverage to Maxicare, for MYMAXICARE, within the first 12months from the effective date.
● The member has obtained professional advice or treatment prior to the effective date of
member’s coverage
● The illness or injury was evident upon medical examination in connection with the member’s
applications
● The natural history of the illness or injury can be clinically determined to have started prior to
the effective date of coverage whether or not the member is aware of it.
Acquired Condition
An illness or injury considered and can be clinically determined to have manifested/occurred

after the effective date of Member’s coverage.
For MyMaxicare accounts, Acquired Condition is any condition that was not diagnosed, or for
which no medical care or advice was rendered, prior to or within 12 months from date of effectivity.
Year Pre-existing Dreaded Pre-existing Non- Acquired Dreaded &

Condition dreaded Condition Non- Dreaded
• Platinum Plus – 20,000/illness/member/yr.
• Platinum - 15,000/illness/member/yr.
1st Year of Membership
• Gold - 10,000/illness/member/yr.
• Silver - 5,000/illness/member/yr.
Subsequent Years of Same as above 100% MBL 100% MBL
Membership
ChApter 2: My M AxicAre Product: Product SpecificAtions And SAles Process

Selling Proposition:
● Comprehensive Healthcare Coverage on year 1

● Access to major hospitals nationwide
Requirements:
1. Individual Membership
● Valid ID
● Filled up Application Form
● Photocopy of Alien Certificate of Residency (ACR) if a Foreign national
2. Family Membership
● Valid ID
● Filled – up Application Form
● Copy of Marriage Certificate
● Photocopy of Alien Certificate of Residency (ACR) if a Foreign national
● Copy of Birth Certificate (per Child)
SALES PROCESS – NEW BUSINESS
1. Client fills-out and submits all required documents.
-Ensure all client details are complete especially the contact details
2. HBA will do the initial screening of the documents submitted.
3. Complete documents will be endorsed to After sales IFG team
4. After sales IFG team will endorse the application to Underwriting for evaluation.
5. Underwriting will endorse the enrollment to billing team for the generation of Statement
of Account
-TAT : 2 working days for Clean Application
-TAT: 5 working days for apps with medical requirements, BMI concern and previous
member
6. Billing Team will release the Statement of
Account. Pay at any of these channels:
● Maxicare Head Office, 3rd Floor

● Banco de Oro branches
● Equicom Savings Bank branches

● Bayad Center
*Statement of Account Billing Schedule:
For New Business : 1-2 days upon approval
Via Email and Snail Mail c/o Servicing Agent
7. Once the client settles, treasury will inform Underwriting for the printing of ID cards.
8. Underwriting will release the ID cards, 15 working days from the receipt of payment.
SALES PROCESS – RENEWAL BUSINESS
1. Underwriting will evaluate all renewing Individual/ Family Members.
- All approved members will be endorsed to billing team 65 days prior renewal date (Including
all members for further medical evaluation, members no longer eligible to renew due to age,
transfer of membership from Family to Individual due to age)
2. Underwriting will send a letter of conforme regarding current renewal status of

members for further medical evaluation.
3.Billing team will prepare the SOA based on the list of all approved renewing I/F members.
4. Billing team will send the Statement of Account and the renewal notice to the Servicing
Agent and Member.
5. The SA and member will receive the renewal notice and billing, should there will be
any renewal concern(s), the Renewal AO will handle the request (e.g. downgrading /
upgrading of plan, change in mode of payment, inclusion / exclusion of dental coverage,
marketing discount – to be approved by JZP, etc.)
6. Member settles the premium through our Payment Center (BDO, EQB, BAYAD CENTER)
7.Payment will be confirmed by Treasury and endorsed to Underwriting for retain Active Status
REINSTATEMENT PROCESS
● Aftersales will inform the member regarding reinstatement status.
● Once the reinstatement request has been approved / processed and client already settled
the fee including penalty charge, URG will reactivate the membership after 30 days upon
receipt of the payment in compliance to I/F standard membership agreement
● Treasury team will send the list of the members for reinstatement to aftersales team.
● Aftersales team will generate / prepare and release the reinstatement notice. This is done 1
day after the list is generated.
● If the member is amenable to reinstate the membership, it will be subjected for evaluation
and standard reinstatement provision shall be imposed.
*Important: Agents, DO NOT DELAY THE REMINDERS to your clients! Delays will cause
suspension to the membership of your clients.
Unpaid Individual / Family accounts
● Treasury and Sales team will follow-up the I/F clients if payment was not received on the
said due date.
● Treasury team will send the list of unpaid accounts (Renewing members, new members,
subsequent SOA of new and renewing members) to Sales Team 1 day after the due date to
follow-up the status of payment / renewal. If no payment was made, account is
immediately suspended on the 3rd day.
SME PROGRAM : MAXICARE STARTER PLAN AND MAXICARE PLUS
MAXICARE STARTER PLAN
Maxicare Starter Plan is a boxed-type program that can be readily available for accounts with a
minimum of three (3) up to nine (9) principals, up to a maximum number of 99 enrollees (principals and
dependents).
Age Eligibility
Principals
• All regular and full-time employees only
• Age Eligibility: 18 - 65 years old
Dependents
Adult dependents:
• Legitimate Spouse and Parents
• Age Eligibility: up to 65 years old
Minor dependents:
• Legitimate, legitimated and/or legally adopted Children and Siblings
• Unmarried, unemployed and fully dependent with the Principal Member
Age Eligibility: 15 days old to 21 years old
Benefits
A. Standard IP and OP benefits except for the following:
Scoliosis up to Php 60,000 per member per year
Congenital conditions up to Php 60,000 per member per year
Passive and active vaccines up to Php 40,000 per member per year
PEC Coverage
1st year with limit:
Dreaded – Up to Php5, 000 / member / illness
Non-Dreaded – Up to Php 5, 000 / member / illness
2nd year coverage and its succeeding years:

Dreaded – Up to Php5, 000 / member / illness / year
Non-Dreaded – up to MBL
Note: Application of PEC coverage will be based on member’s effective date.
MAXICARE PLUS
A full HMO & full risk product with standard/boxed type health coverage intended for small enterprises
with a minimum number of 10 PRINCIPALS. No limit on the total number of enrollees (principals and
dependents).
Age Eligibility
Principals
Dependents
Adult dependents:
Minor dependents:
Age Eligibility: 15 day old to 21 years old
Benefits
A. Standard IP and OP benefits except for the following:
Scoliosis up to Php 60,000 per member per year
Congenital conditions up to Php 60,000 per member per year
Passive and active vaccines up to Php 40,000 per member per year
Maxicare Plus Variants:
a. Maxicare Plus Nationwide

● With Access to 9 Major Hospitals
a. Asian Hospital and Medical Center f. The Medical City
b. Cardinal Santos Medical Center g. Chong Hua Hospital
c. Makati Medical Center h. Cebu Doctors University Hospital
d. St. Luke’s Medical Center –Global City i. Davao Doctors Hospital
e. St. Luke’s Medical Center –Quezon City
● Without Access to 9 Major Hospitals
Product Variant and Network Headcount Requirement

Access
Standard/Rated/Graded Maxicare Plus-Nationwide
Group Minimum of 10 Principals up to 19
Principals. No limit on the total number
of Principals and Dependents.
Small Minimum of 20 Principals. Up to 99

Principals. No limit on the total number
Standard/Rated/Graded Maxicare Plus-Provincial

Northern Luzon except Baguio Minimum of 20 Principals up to 99
Southern Luzon Principals. No limit on the total number
Visayas
Mindanao
Visayas and Mindanao (VisMin)
PEC Coverage:
A. Covered up to MBL beginning 1st year of coverage.
a. Nationwide
b. Visayas
c. Mindanao
B. 1ST YEAR WITH LIMIT PER PLAN
a. Northern Luzon – Regions I, II, III & CAR except Baguio

b. Southern Luzon (Except Batangas City) – Regions IV & V
PEC Coverage (with limit)
1 Platinum Plan Up to Php20,000

2 Gold Plan Up to Php15,000
3 Silver Plan Up to Php10,000
4 Bronze Plan Up to Php5,000
2ND YEAR onwards COVERED UP TO MBL
INELIGIBLE INDUSTRIES:
Philhealth Provision
Maxicare Starter and Plus - Additional fee for non-PhilHealth enrollees on the onset of enrollment is Php
2,400 per member per year. This is not pro-ratable and nor refundable. Philhealth surcharge are covered
for expats and dependents only.
PARTICIPATION REQUIREMENT FOR MAXICARE PLUS

Participation requirement refers to the required number of heads to be enrolled.
PRINCIPALS
Non - Contributory
1. 100% Participation Requirement is met;
2. The Company must submit the complete list of employees so as to check if the
participation requirement has been met;
Contributory
1. At least 75% of the principals must enroll;
● Account is required to submit a certification coming from their HR that the account is
under Contributory
2. Only ANNUAL Mode of payment shall
apply.
DEPENDENTS
Minimum Participation Requirement for Dependents is always 75% of total number of principals
enrolled.
If the Participation Requirement for Dependents is not met, Maxicare will still accept enrollment with
application of Escalation Clause * (additional rates charged per head).
Participation Requirement Applicable Rates
60% - 74.9% + 10% to standard rates

40% - 59.9% + 20% to standard rates
39.9 % and below + 35% to standard rates
Payment Provision & Effective Date
GROUP SMALL
10 principals up to 19 principals. No atleast 20 principals up to 99 principals.
limit on the total number of enrollees. No limit on the total number of
enrollees.
Payment Provision Payment First
Mode of Payment Annual & Semi Annual Annual, Semi Annual
Billing Schedule Within 5-7 working days upon receipt of complete documents and signed
conforme
Plan Effective Date 3 working days from O.R. issuance (Starter Plan)
5 calendar days from O.R. issuance (Maxicare Plus)
PAYMENT TERMS
New Business
Group Accounts (10-19 members)
● Payment first before activation of account/effectivity of membership
● Maxicare must receive the signed Conforme, final masterlist, other enrolment requirements
and payment of the total amount due on the Statement of Account (SOA) at least five (5)
calendar days from intended effective date of coverage.
● Mode of payment shall be limited to Annual and Semi-annual only.
● For accounts paying in Semi-annual mode, 2nd Semi-annual SOA shall be released by Billing
Team at least fifteen (15) calendar days before effective date of the 2nd semi-annual
coverage.
● If the total amount due for the 2nd Semi-annual SOA is not paid on due date, account will be
automatically suspended.
Small Accounts (20 – 99 members)

● Conforme to effect the program; payment to follow.
● Mode of payment shall be limited to Annual, Semi-annual and Quarterly only.
● Grace period of fifteen (15) calendar days from receipt of SOA.

● If the total amount due is not paid on due date, account will be automatically suspended.
Renewal Business - Group and Small Account

● Mode of payment shall be limited to Annual, Semi-annual only. However, accounts
paying in monthly mode may retain to pay monthly provided they have good payment
habit (pays the total amount due on or before the due date).
● Grace period of fifteen (15) calendar days from receipt of SOA
● If the total amount due is not paid on due date, account will be automatically suspended.
Modal Factors:
Semi – Annual : 0.54
BENEFITS DESIGN
1. Benefits modification/s when coverage is already effective shall be subject to the following
conditions:
a. If modification is requested within thirty (30) days from the effective date, subject to
approval of Underwriting, the following additional fee shall be charged per member:
● Php100 per member for additional riders
● Php1,000 per member for change in network access or upgrading/downgrading of plans
2. Any modification beyond thirty (30) days shall be subject to the COO’s approval.
3. Any other request deviating from standard guidelines of Maxicare Plus shall be subject to
President’s approval.
4. Benefit program for principals should be on a uniform basis, superior according to their rank
classification or tenure of employment.
5. Dependents should not have benefits that are higher than their principals. Dependents can only
have the same or lower benefits than their principal. Also, uniformity in plan must be
implemented for all direct dependents of an employee.
6. Riders and Wellness Programs may be offered per membership type but principals should have
higher benefits than dependents.
7. ACU/ ECU and access to major hospitals may be offered per rank classification but should be on
a uniform basis.
8. Maxicare Dental Hub shall be the standard dental provider for all Maxicare Plus accounts.
COVERAGE FOR PRE-EXISTING CONDITIONS

Coverage for pre-existing condition commences on the effective date both for principals and
dependents up to their limit (MBL).
FRANCHISING
Maxicare Plus accounts need not be franchised.
BUSINESS ESSENTIALS
An unbundled & full risk product with outpatient unbundled or full HMO benefits.
I. Age Eligibility
Principals
Dependents
Adult dependents:
Minor dependents:
Age Eligibility: 15 day old to 21 years old
II. Product Features
Plan Type ABL Inner Limits for OP

Laboratories/Diagnostic/Therapeutic
Procedures
OP Unbundled
Principal
Gold Php 100,000 Php 50,000
Silver Php 50,000 Php 25,000
Dependent
Gold Php 100,000 Php 50,000
Silver Php 50,000 Php 25,000
III. Product Types
Name of Product Product Type Description
Maxicare Business Essential - Accounts with 3 to 9 Principals up to 99
Starter enrollees- Nationwide
Maxicare Business Essential - Accounts with 10 to 19 Principals up to

Group 99 enrollees- Nationwide
Maxicare Business Essential – Accounts with 10 Principals up to 99

Southern Luzon enrollees- Southern Luzon

Maxicare Business Northern Luzon (except Baguio) enrollees- Northern Luzon except
Essential Baguio

Visayas enrollees- Visayas
Maxicare Business Essential - Accounts with 10 Principals up to 99

Mindanao enrollees- Mindanao
Maxicare Business Essential - Small Accounts with 20 Principals up to 99

enrollees- Nationwide
IV. PEC Conditions

PEC Coverage Product Type 1st Year Succeeding Years
Maxicare Business Php Php
Essential - Starter 5,000/member/year 5,000/member/year
Maxicare Business Up to ABL Up to ABL
Essential - Group
Maxicare Business Php Up to ABL
Essential – Southern 10,000/member/year
Luzon
Maxicare Business Php Up to ABL
Essential – Northern 10,000/member/year
Both Dreaded and
Luzon (except Baguio)
Non-Dreaded
Essential – Visayas
Essential - Mindanao

Essential - Small
ChApter 3: MAxicAre Plus Product SpecificAtions, New/RenewAl Business And SAles Process
MARKET FOR MAXICARE PLUS
1. GENERAL MERCHANDISING / RETAIL/ TRADING / SALES :
Eg. Grocery, Bakery and Pastry Shop, Distribution of Goods, Fashion Boutique, Water Refilling
Stations
2. SERVICES :
Eg. Banks, Beauty Salon, Cable Sales and Services, Canteen Concessionaires, Mechanical Shops,
Consultancy Services, Courier Services, Tailoring, Trucking and Hauling, Domestic and Personal
Services, Electrical Services
3. OTHER INDUSTRIES :
Eg. Manufacturing, Education (Pre-School), Feedmills, Hotels, Insurance Services, Lending

Company, Pawnshop, Printing Press, Real Estate, Restaurant, IT
Note: ADDITIONAL INDUSTRIES MAY BE ADDED AS LONG ITS NOT PART OF THE INELIGIBLE
INDUSTRY
SELLING PROPOSITION
Pre-existing coverage up to MBL on the 1st year of membership
Flexibility in cost in terms of:
1. Access to major hospitals in Metro Manila
2. Access to provider networks based on geographical location of the account
3. Rider Options
4. Superior and comprehensive healthcare coverage in one

SALES PROCESS: NEW BUSINESS
● Enrollment forms/excel file containing all information of the employee/members

● SEC Certificate / DTI Certificate
● General Information Sheet

● Articles of Incorporation
● Appointment Letter to authorize the contract signatory and contact person (if
President/CEO is not the contract signatory or the contact person)
● Photocopy of Company ID and any other valid ID of owner/authorized signatory and

contact person
● If your company is VAT-exempt or Zero-rated, please furnish us with the following

documents for the application of the VAT-exempt/ Zero-rated rates:
● PEZA registration
● BIR Registration
● Certificate of VAT exemption (if applicable)
● SSS List with name of all members / Philhealth MDR / BIR 1604
SALES PROCESS: RENEWAL BUSSINESS
1. Renewal Business receives endorsement 3 months after closing.
● All closed accounts of Consumer New Business Team will be endorsed to Consumer
Renewal Team after 3 months through email.
2.Account Management
● Your role as an agent doesn’t end when the account signs the contract.
● It is only just the BEGINNING.
Account Management activities of agent include
-Monitoring of account activities:
● Eg. Billing, Signed Contract, Payment, Annual Check Up Requests.

● Special endorsement for accounts’ urgent concerns.
● Requesting of benefit orientation
3. Sales Order Fulfillment receives renewal rate sheet and Loss Ration from actuarial
(65 days before the renewal date.) Maxicare Plus Program, has a scheduled rates based on the
annual utilization of all accounts.
Factors Affecting Maxicare Plus Rates
1. Annual Utilization of the Account
● Account’s utilization will be reviewed every year to generate the Medical Loss Ratio (MLR).
● Standard MLR – 0 – 119% : status qou standard rate
● Class A – 120 – 219 % : Twice the standard rate
● Class B – 220 – 319 %: Trice the rates
● Class C – 320 % and above – Ineligible for renewal ( Account will be tranfered to My
Maxicare)
2. Annual Medical Inflation
● Providers’ proffesional fees and services varries every year. Thus, we also need to adjust
our rates depending on the inflation.
3. Maxicare Plus Pooled Utilization
● All maxicare Plus accounts’ utilization will be pooled every year to evaluate if the rates will
remain the same or if there will be an increase across all accounts.
4. Proposal Generation
● Sales order fulfillment team generates the renewal proposal based on the rate sheet, MLR
provided by Actuarial department.
5. Renewal Business AO receives and validates the proposal
AO will check if the rates , coverage, plan type, addressee and riders are correct.
6. Renewal Business AO sends the proposal to the agent
AO will coordinate with the Agent regarding the renewal of their accounts and will inform them
if there are any changes in rates, high utilization and the likes. ( 1 month before the renewal
day.)
RENEWING BUSINESS
● Facilitate renewal of the account

● Gather necessary information for the renewal negotiations
● Utilization review
● Aggressively Pursue account Recovery ( for not renewed accounts from the previous year)
● Client visit (to build rapport)

● Courtesy call
● Upselling / Expansion
CORPORATE PLANS
CUSTOMIZED PLAN
Corporate Plan is a customizable product of Maxicare, with benefits that could either be
standard or non- standard for corporate accounts of *100 heads and above.
Account Categories
• Small : 20 - 99 members
• Medium : 100 - 499 members
• Large : 500 - 999 members
• Jumbo : 1000 - 4999 members
• Super Jumbo : 5000 and up
Account Level
• Level A – Officers only
• Level B – Staff Only
• Level C – Dependents of Officers only
• Level D – Dependents of Staff only
• Level E – All
Customized Plan Options:

1. Full Risk (premium-based)
a. Healthcare benefits may either be standard or non-standard
b. Actuarial will compute for the Total Contract Value (total premium due) based on
preferred coverage of the account or existing benefits with reference on age, historical
utilization and nature of business.
2. Administrative Services Only (ASO)
● Healthcare benefits may either be standard or non-standard
● Account has to maintain a revolving fund with Maxicare which is equivalent to 3 months claims
● Requires minimum number of enrollees = 200
● Threshold Limit (equivalent to 1 month claims)
● Standard Network Access Fee (NAF) =Ph 1000
● Standard Processing Fee (EMV card fee)=Php 200
● Standard Claims Handling Fee (CHF) = 10% (Subject to 12% VAT)
● 13.5 % of Actuarial department’s estimate claims for the year for new accounts
● 13.5% of utilisation of the previous year for renewing accounts
2. Sample Computation for ADMINISTRATIVE SERVICES ONLY (ASO)
● Equation: RF+NAF+CHF+EMV Charge= TCV

● REVOLVING FUND: PHP 500,000.00
● NAF - 50,000 ( example 50 employees)
● CHF - 10% (the assumed utilization for the year.
● For example, according to actuarial 200k utilization =20k total CHF)
● EMV charge - 200 x 200 employees - 40,000
3. FULL HMO
A comprehensive array of healthcare benefits which includes In-Patient, Out-patient and Emergency
care as well as Annual Check-Up subject to certain exclusions, limitations and conditions.
4. Unbundled Products
a. Requires at least 100 members
b. Standard unbundled products will only be:
i. Unbundled Inpatient
Consists of IP standard benefits, OP surgery, Therapeutic procedures, preventive care, &
emergency treatment (may lead to IP or not)
ii. Unbundled Out-Patient

Consists of OP standard benefits, preventive care, & emergency treatment (not leading
to IP) OP benefits included in IP unbundled is not included in this package
Benefit Limit Options for Corporate Plans:

● MAXIMUM BENEFIT LIMIT (MBL)
o Maximum amount that a member can avail of per illness or injury during the coverage year;
o Does not include ACU
● ANNUAL BENEFIT LIMIT (ABL)

o Maximum accumulated amount that a member can avail of for all types of illnesses during
the coverage year.
o Does not include ACU
Franchising of Corporate Accounts

Franchising awards the right to a selling entity/channel to solely negotiate and present Maxicare’s
products and services on a specific time frame. When an account is under franchise, no other selling
channel/entity can tap or present or forward a rate until such time that the franchising period has lapsed.
Note that any corporate account must be franchised first.
In Franchising a Corporate Account, a Prospective Corporate Account Form or PCAF must be

submitted. Initial Franchise Validity – 90 days (3 Months)
Extension up to:
● Additional of 90 days for fresh accounts
● or until the renewing date for competitors account
NOTE:
IN CASES WHERE THE CLIENT DOES NOT WANT TO ISSUE ANY SIGNED DOCUMENT ANY OF THE FOLLOWING CAN BE
ACCEPTED:
1. An email confirmation (sent through the company email) stating the request for proposal or indicating that
the account is negotiating with the franchise
2. Latest statement of account from the other HMO
3. Invitation to bid
FRANCHISING PROCESS:
CONFLICT RESOLUTION:
1. Franchise of Accounts with an Active Franchise

● The Franchising Officer shall only honor authorization documents signed by a similar/higher ranking
signatory than that of the first franchisee.
● The Franchising Officer shall communicate with the identified contact persons of both franchisees
such is to ensure that the authorized contact persons of the account are made aware of all updates .
● In the absence of the identified contact person/s, the Franchising Officer shall communicate and get the final
direction from the account’s HMO in-charge/coordinator.
2. Franchise of Existing Maxicare Accounts

● The Franchising Officer shall honor authorization documents signed by a company representative that holds
an officer/supervisory role
● The Franchising Officer shall confirm the final direction from the existing account’s contact person, as
identified in Maxicare’s system.
● In the absence of the identified contact person, the Franchising officer shall communicate and get the final
direction of the account’s HMO in charge/ coordinator
●
CORPORATE
NEW BUSINESS PROCESS
1.LEADS GENERATION
● HBA/AUM/AUH is expected to generate his/her own leads and represent themselves as an

accredited agent of Maxicare not as Maxicare employee
● Agents should secure PCAF (Prospective Corporate Account Form) from the New Business
(NB) Prospect.
2.FRANCHISING
● Agents should forward the PCAF to Franchising Officer (FO).

● Once cleared, FO shall deck the account to assigned HBA
3.PROPOSAL
● HBA shall coordinate with the Agent to obtain the required documents needed to create an
NB proposal.
Requirements:
A. TOR (Terms Of Reference) or Summary of Benefits
B. Masterlist
C. Utilization Report
4.PRESENTATION
● Agent shall secure a meeting schedule with the NB prospect for Maxicare to present the
proposal.
● Note: Agent is expected that he/she can present the proposal of Maxicare with the
prospect account
5.REVISIONS
● Optional: If there are items for revisions, HBE shall revise proposal accordingly.
● TAT: 3-5 working days
6.CLOSING
● For CLOSED accounts, the following are required:

A. KYC documents
B. Signed Conforme
C. Masterlist
● Note: It is recommended to submit all the requirements at least a week before effective
date to ensure timely activation of account.
RENEWAL BUSINESS PROCESS
1.ENROLLMENT
● Masterlist should follow prescribed Maxicare template.

● Validated masterlist will be sent to the account/Agent.
● TAT for Distribution of ID Cards: 10 working days from effective date.
2.BILLING
● Ideally, Statement of Account (SOA) shall be released 8 working days from the effective
date.
● Agent shall monitor if payment has already been made.

● Maxicare shall also issue Reminder Notices prior to the due date
3.ACCOUNT MANAGEMENT
● Agent should have a calendar of activities in coordination with the assigned HBE for each
account they manage. This includes regular client visits, sending of Utilization Reports,
monitoring of other deliverable.
4.PROPOSAL
● Assigned HBE shall generate initial Renewal Proposal at least 90 days prior to effective date.
● HBE shall review the proposal prior to sending to HBA/AUM/AUH
5.PRESENTATION
● HBA/AUM/AUH should schedule a meeting with the Account to present the Renewal
Options.
● If needed, Top (Utilization) Reports and Annualized Claims shall also be presented during
the meeting with the assistance of the assigned HBE
6.
REVISIONS
OPTIONAL
● If there are items for revision/enhancement, HBE shall revise the conforme accordingly and
seek necessary management approval.
● TAT for Revised Conforme: 3 to 5 working days.

RENEWAL
● For RENEWED Accounts, the following documents are required:

● Signed Conforme
● Movement List (Addition, Deletion, and Change of Plans).
● It is recommended to confirm renewal at least a week before expiry to ensure timely

activation of account.
ENROLLMENT
● Validated Masterlist will be provided by URG to the account.

● ID Distribution for New Members
● Enrollment Period: 30 days
BILLING
● Ideally, Statement of Account (SOA) shall be released 8 working days from the effective
date.
● Agent shall monitor if payment has already been made.

● Maxicare shall also issue Reminder Notices prior to the due date
IMPORTANT REMINDERS
A.ENROLLMENT
● Enrollment Period: 30 days from effective date.

● All new members endorsed for enrollment within this period will be enrolled on start of
contract period.
B. SUBSEQUENT ENROLLMENT
as follows:
Date of hire : enrolment date should be within 30 days for date of hire
Date of regularization : enrolment date should be within 30 days from date of regularization
New Married employees : enrolment of dependent should be within 30 days from date of
marriage
Newborn dependent : enrolment of child dependent should be within 30 days for date of birth
of the child dependent
C. CANCELLATION
● Cancellation/Deletion of Members will be based on the cancellation date (indicated in the

template) or date when the endorsement was sent, whichever is later.
D. REFUND
● Refund can only be provided if no availment has been made prior to cancellation.
● Refund is only available if the client has paid its Annual or Semi-Annual MF
● No refund if member’s remaining coverage is 6 months or less

CHAPTER 4
Standard Healthcare Coverage
Plan Types
Applicable for MyMaxicare, Maxicare Starter, and Maxicare Plus only
Plan Room & Board Maximum Benefit Limit
Platinum Plus Large Private 200,000
Platinum Regular Private 150,000
Gold Regular Private 100,000
Silver Semi-Private 60,000

For Corporate Product lines, limits of each plan type may be customized.
Comprehensive Healthcare Program

● Preventive Health Care
● Annual Check-up
o Standard for My Maxicare
o Optional Rider for Maxicare Plus and Corporate Plans
● Out-Patient Benefits
● In-patient Benefits
● Emergency Care Benefits
● Dental Care Benefits
● Benefit Enhancements
Preventive Healthcare
Individual and Maxicare Corporate
Family Plan Starter/Plus
(applicable
both for
Nationwide
and Provincial
Based access)
Periodic monitoring of health problems
Consultation on diet, exercise and other
healthful habits
Counseling on family planning
Immunization excluding costs of vaccine X X
Health seminars As Per contract
*Immunization is not covered under Individual, Family, Maxicare Starter and Maxicare Plus.
HEALTHCARE BENEFITS COVERAGE/LIMIT
I. OUT-PATIENT (OP) CARE
1 All outpatient consultations and outpatient Subject to MBL/ABL

procedures (as long as it medically necessary)
II. OUT-PATIENT CARE WITH SPECIFIC LIMITATIONS
1 Eye laser therapy only for retinal tear, retinal Up to P10,000/eye/member /year
hole, retinal detachment and glaucoma
prescribed by an Affiliated
Physician/Specialist. Eye correction such as
Lasik, PRK and the like are not covered.
2 Electrocauterization of skin lesions such as Up to P1,000/member/year

plantar warts, flat warts, periungual warts,
filiform warts and molluscum contagiosum, in
any part of the body prescribed by an
Affiliated Physician/Specialist.
3 Sclerotherapy for varicose veins (except Up to P5,000/leg/member/year

medicines and for cosmetic purposes) as
prescribed by an Affiliated Physician, to be
availed through affiliated vascular surgeons.
4 Allergy Testing/ allergy screening and other Up to P2,500/member/year

related examinations prescribed by an
Affiliated Physician.
5 Speech therapy for stroke patients only. Covered as charged up to P10,000 /
member/year on reimbursement basis.
Note: Consultations shall be part of the limit

and treated as sessions.
7 Tuberculin test Up to P600/member/year
III. IN-PATIENT CARE
1 Room and Board Accommodation Subject to the Member’s Room and Board limit
2 All other items directly related in the medical Subject to MBL/ABL

management of the patient, as deemed
medically necessary by the Attending
Affiliated Physician
3 Room upgrade in case of room unavailability Covered for the first 24 hours
(Emergency case leading to confinement)
IV. DIAGNOSTIC / THERAPEUTIC PROCEDURES
1 All conventional / therapeutic procedures Covered 100% subject to MBL/ABL

medically necessary for treatment
V. DIAGNOSTIC / THERAPEUTIC PROCEDURES WITH SPECIFIC LIMITS
1 All conventional / therapeutic procedures 100% of Actual Cost subject to MBL

medically necessary for treatment
2 Arthrocentesis Up to MBL
3 Continuous Positive Airway Pressure (CPAP) Up to P60,000 (shared limit for OP and IP)
titration for sleep study
4 Dialysis Up to MBL for IP and up to twelve (12) sessions

subject to MBL for OP
5 Non-oral chemotherapy (for cancer treatment Up to MBL for IP and up to twelve (12) sessions
only) subject to MBL for OP
6 Oral chemotherapy (for cancer treatment Up to P60,000 (shared limit for OP and IP)
only)
7 Physical therapy / Occupational therapy Up to MBL for IP and up to twelve (12) sessions
excluding subspecialties such as cardiac subject to MBL for OP
rehabilitation, pulmonary rehabilitation and
the like. Note:Therapy of one(1) body area shall be
considered as one(1) session.
8 Therapeutic Radiology:
a. Brachytherapy Up to MBL for IP and up to twelve (12) sessions

b. Cobalt Up to MBL for IP and up to twelve (12) sessions

c. Linear Accelerator Therapy Up to MBL for IP and up to twelve (12) sessions

d. Radioactive Cesium Up to MBL for IP and up to twelve (12) sessions

e. Radioactive Iodine Up to MBL for IP and up to twelve (12) sessions

9 Transurethral Microwave Therapy of Prostate Covered up to P25,000/member/year
10 Stapled Hemorrhoidectomy Covered up to P5,000/member/year
11 Mammotome Covered up to P5,000/member/year
12 4D Ultrasound except for maternity-related Covered up to P5,000/member/year

cases
13 Esophageal Manometry Covered up to P5,000/member/year
14 Intensified Modulated Radiotheraphy Covered up to P5,000/member/year
15 Botox which is not cosmetic in nature nor for Covered up to P5,000/member/year

beautification purpose
16 Positron Emission Tomography (PET) Scan Covered up to P5,000/member/year
17 CT Pulmonary Angiography Covered up to P5,000/member/year
18 Other Modalities
a. Photodynamic Therapy Covered up to P5,000/member/year
b. Acoustic Radiation Force Covered up to P5,000/member/year
c. Alpha Globin/ Globulin Genotyping Covered up to P5,000/member/year
d. Anchored Periplasmic Expression (APEx)-2 Covered up to P5,000/member/year

Hyrbid
e. Antivascular Endothelial Growth Factor Covered up to P5,000/member/year

(VEGF) drugs (Avastin, Lucentis, Macugen)
for Retinopathy, Macular Degeneration and
other Optha indications
f. BCR-ABL by Quantitative Real-time Covered up to P5,000/member/year

Polymerase Chain Reaction (QRT-PCR, RT-PCR)
g. Beta Globin/ Globulin Genotyping Covered up to P5,000/member/year
h. Capsule Endoscopy Covered up to P5,000/member/year
i. Coblation Procedures Covered up to P5,000/member/year
j. Continuous Renal Replacement Therapy Covered up to P5,000/member/year

(CRRT)
k. Contrast Enhanced Ultrasound Covered up to P5,000/member/year
l. Contrast Enhanced Fluorodeoxyglucose FDG Covered up to P5,000/member/year

PET Scan
m. Ductoscopy (Breast) Covered up to P5,000/member/year
n. Duolink In-Situ Fluoresence Hybridization Covered up to P5,000/member/year

(DISH)
o. Endoscopic Ultrasound Covered up to P5,000/member/year
p. Endovenous Laser Treatment Covered up to P5,000/member/year
q. Endovenous Laser Ablation Covered up to P5,000/member/year
r. Enhanced Fluorescent Protein Voltage Covered up to P5,000/member/year

Sensor (VPSP2.1)
s. Enhanced Luciferase Complementation Covered up to P5,000/member/year

t. Enzymed-linked Immunosorbent Spot Covered up to P5,000/member/year
(ELLISPOT) Assay
u. Epidermal Growth Factor Receptor (EGFR) Covered up to P5,000/member/year

Mutation Assay / Test
v. ESAT-6 and CFP-10 Antigens Covered up to P5,000/member/year
w. Fluorescence In-Situ Hybridization (FISH) Covered up to P5,000/member/year
x. Gastric Electrical Stimulation Technology Covered up to P5,000/member/year
y. Image-guided Surgery / Radiotherapy Covered up to P5,000/member/year
z. Infrared Coagulation Hemorrhoidectomy Covered up to P5,000/member/year
aa. Infrared Thermography Covered up to P5,000/member/year
ab. Intravenous Ultrasound Covered up to P5,000/member/year
ac. JAK-2 Mutation Covered up to P5,000/member/year
ad. Karyotyping Covered up to P5,000/member/year
ae. KRAS Testing Covered up to P5,000/member/year
af. Magnetic Resonance Spectroscopy Covered up to P5,000/member/year
ag. Mammotome or Vacuum Assisted Breast Covered up to P5,000/member/year

Biopsy
ah. Monoclonal Antibody Therapy for Covered up to P5,000/member/year

Autoimmune conditions and Rheumatological
Diseases
(Note: Certain Monoclonal Antibodies have

immunosuppressive properties and this led to
their therapeutic application (monoclonal
antibody therapy) in autoimmune conditions
and rheumatologic diseases, such as SLE,
ankylosing spondylosis, rheumatoid arthritis,
etc.)
ai. Multiphoton imaging Covered up to P5,000/member/year

aj. Multislice / multidetector/ spiral / Covered up to P5,000/member/year
multirow CT
ak. Neutral Commet Assay Covered up to P5,000/member/year
al. Optical Glutamate Sensor Covered up to P5,000/member/year
am. Parkinson's Profile Covered up to P5,000/member/year
an. Percutaneous Discectomy CT Guided Covered up to P5,000/member/year

Intradiscal Electrothermal Ablation Technic
(IDET)
ao. Peritonial Dialysis Adequacy Test Covered up to P5,000/member/year
ap. Peritoneal Equilibrium Test Covered up to P5,000/member/year
aq. phaA and phaB genes test Covered up to P5,000/member/year
ar. Pharmacoscintigraphy Covered up to P5,000/member/year
as. Philadelphia chromosome Covered up to P5,000/member/year
at. Photodynamic Glutamate Sensor Covered up to P5,000/member/year
au. Platelet Aggregation Test Covered up to P5,000/member/year
av. Polymerase Chain Reaction (PCR) for katG Covered up to P5,000/member/year

and rpoB
aw. Polymerase Chain Reaction Single Strand Covered up to P5,000/member/year

Confirmation Polymorphism (PCR-SCCP)
ax. QuantiFERON Tuberculosis (QFTB) Covered up to P5,000/member/year
ay. Radiofrequency Ablation (RFA) and other Covered up to P5,000/member/year

RF procedures
az. Renal Denervation Covered up to P5,000/member/year
ba. Reverse Transcription Polymerase Chain Covered up to P5,000/member/year

Reaction (RT-PCR)
bb. Robotic Surgery / Robotically assisted Covered up to P5,000/member/year

Surgery
bc. Single Incision Laparoscopy Surgery (SILS) Covered up to P5,000/member/year
bd. Spinal Angiogram Covered up to P5,000/member/year

be. Stereotactic Breast Biopsy Covered up to P5,000/member/year
bf. Stereotactic Radiation Therapy/ Covered up to P5,000/member/year

Stereotactic Radiosurgery
bg. Supramagnetic Ion Oxide (SPIO)- enhanced Covered up to P5,000/member/year

MRI
bh. Transarterial Hemorrhoidal Covered up to P5,000/member/year

Dearterialization (THD)
bi. Terahertz Imaging Covered up to P5,000/member/year
bj. Three-Dimensional Conformal Covered up to P5,000/member/year

Radiotherapy (3DCRT)
bk. Thyroplasty Covered up to P5,000/member/year
bl. Tomotherapy Covered up to P5,000/member/year
bm. Tractography Covered up to P5,000/member/year
bn. Ultrafast Electron Beam Computed Covered up to P5,000/member/year

Tomography
bo. Ultroid Hemorrhoid Management Covered up to P5,000/member/year
bp. Vulcan EAS (Electro Thermal Arthroscopy Covered up to P5,000/member/year

System)
VII. EMERGENCY CARE
1 Doctor services, X-Rays, laboratory and Subject to MBL

diagnostic examinations, and other medical
services related to the emergency treatment
of the patient
2 In Non-Affiliated Hospitals. Reimbursable up to 80% of hospital bills &

professional fees based on Maxicare rates
incurred during the first 24hrs. of treatment up
to P30,000/availment/member/year
3 Outside the Philippines. Reimbursable up to 100% of actual cost up to

P30,000/availment/member/year
4 Areas without Affiliated Hospital (within a 50 Subject to MBL
km. radius. Batanes and Tawi-Tawi)
5 Ambulance Service (Affiliated Hospital/Clinic Subject to MBL

to Affiliated Hospital/Clinic).
6 Ambulance Service (Non-Affiliated Reimbursable up to P2,500 per conduction

Hospital/Clinic to Affiliated Hospital/Clinic).
Note: The ambulance service provided herein shall be available regardless of the location within the
Philippines.
VIII. EMERGENCY CARE IN AFFILIATED HOSPITALS
1 Doctor services, X-Rays, laboratory and Covered 100% up to MBL/ABL

diagnostic examinations, and other medical
services related to the emergency treatment
of the patient
IX. EMERGENCY CARE IN NON-AFFILIATED HOSPITALS
1 In Non- Affiliated Hospitals Reimbursable up to 80% of hospital bills &

professional fees based on Maxicare rates
incurred during the first 24 hrs. of treatment
up to P30,000/availment/member /year
2 Outside the Philippines Reimbursable up to 100% of actual cost up to

P30,000/availment/member/year
3 Areas without Affiliated Hospital (no 100% based on Maxicare rates up to MBL/ABL
accredited hospital/clinic w/in a 50 km.
radius) namely: Batanes, and Tawi-Tawi
4 Ambulance Service within the Network Up to MBL/ABL

(Affiliated Hospital/Clinic to Affiliated
Hospital/Clinic)
5 Ambulance Service outside the network (Non- Reimbursable up to Php2,500 per conduction
Affiliated Hospital/Clinic to Affiliated
Hospital/Clinic)
X. CONDITIONS WITH SPECIFIC LIMITATIONS
1. Initial Treatment within 24 hours from time Not covered for IP and subject to MBL/ABL for
of bite of Animal bites (under ER and OP only) OP
2. Succeeding treatment after 24 hours from Not covered for IP and subject to MBL/ABL for
time of bite of Animal bites OP
3. Vaccines for treatment of tetanus and Not covered for IP and covered up to
animal bites (including administration fee but P18,000/member/year for OP
excluding ER Fees)
1 Scoliosis including necessary procedures, Up to P20,000/member/year (shared limit for

except physical therapy sessions, whether OP and IP)
congenital, pre-existing, developmental or
acquired Note: Physical Therapy sessions shall form part
of the Physical therapy/ Occupational therapy
limits
2 Congenital Conditions except physical therapy Up to P20,000/member/year (shared limit for

sessions and developmental disorders. OP and IP)
Note: Physical Therapy sessions shall form part

of the Physical therapy/ Occupational therapy
limits.
3 Chronic Dermatoses Consultations only
4 Hepatitis B except vaccines and screening Covered 100% subject to MBL/ABL if acquired
Claims Reimbursement Procedure
Maxicare Reimbursement Card
All claims must be submitted to the Maxicare Head Office within 90 days from date of discharge from
the hospital. The following are the required documents for reimbursement:
● Claim Reimbursement Form (CRF)
● Original Receipts of all hospital bills and professional fee of the Doctor
● Original Charge slip (With itemized breakdown)
● Clinical Abstract, Admitting History, and Medical Certificate
● Histopath/Surgical Report (if surgical procedure was done
● Police report in case of accident and medico legal cases
1. Processing of claims will be 7 - 15 business days upon receipt of the complete documents.
2. Once reimbursement has been approved, the amount will be credited to the member’s Maxicare card and an
SMS notification will be sent to the principal member.
3. Credited amount may either be withdrawn in Equicom ATMs or any of Bancnet, Megalink or
Expressnet’s ATM nationwide; or it may be used to purchase personal items in any of Bancnet’s
accredited merchant nationwide eg. SM department stores (for the complete list of the merchants,
please visit www.bancnet.com.ph)
-NON-MRC ACCOUNTS-
● Processing of Claims will be 30 business days from receipt of complete documents.
● For Non-MRC accounts, same reimbursement requirements shall still apply.
● •Members under Non-MRC accounts receives reimbursements via cheque.
● Bank account transfer is feasible but must be coordinated with AMS and Finance
Team.
BENEFIT ENHANCERS
CONDITION INDIVIDUAL/ MAXICARE

FAMILY STARTER/PLUS/
CORPORATE
● Coverage for Motor vehicular accident √ √

is up to MBL
● Coverage for Scoliosis and Congenital √ √
Conditions up to:
● Php 18,000 per member per year for IF √ √
● Php 60,000 per member per year for
MAXIPLUS √ √
● Congenital hernia covered up to MBL

√ √
● Coverage for Transurethral Microwave
Therapy of Prostate up
to Php25,000/member / year
RIDERS
1. Annual Check Up -
● Physical Exam
● Urinalysis
● Fecalysis
● Chest X-Ray
● Complete Blood Count
● ECG for members 35 y.o. and above
● Pap Smear for female members 35 y.o. and above
2. Dental Coverage – Dental Hub is the standard dental provider for boxed type plans (MyMaxicare,
Maxicare Starter, and Maxicare Plus)
• Oral Prophylaxis- once a year

• Simple tooth extractions
• Temporary Fillings - as needed
• Permanent Fillings – 2 teeth
• Emergency Dental Treatment
• Comprehensive Restorative & Prosthodontic Treatment Planning
• Desensitization of Hypersensitive teeth- 2 teeth
• Simple Adjustment of Dentures
• Emergency out-patient dental treatment – to be availed at accredited dental clinics only
• Recementation of loose crowns, inlays or onlays
3. Maternity Rider – only available for Corporate Plans (a minimum number of 50 female employee
enrollees are required) and SME plans (minimum of 20 female employees).
● Normal Delivery
● Caesarean Section
● Miscarriage
● Ectopic Pregnancy
● H. Mole Pregnancy
● Other complications during pregnancy
A. LOA Facilitated
● Maxicare to cover outright the availment, only if both hospital and doctor is accredited otherwise NOT
COVERED.
B. Reimbursement
● Member has option to avail in non-accredited hospital and/or doctor via reimbursement basis.
● If hospital is accredited but doctor is not accredited, both HB & PF is via reimbursement (unless otherwise
stated in
the SOB that Maxicare to cover outright the HB).
Nine (9) laboratories and workups costs are subject:

to MBL/ABL:
1. CBC and Blood Type
2. Urinalysis
3. Pap Smear
4. Transvaginal Ultrasound
5. Pelvic Ultrasound
6. Oral Glucose Tolerance Test (OGTT)
7. Hepatitis B Surface Antigen (HBsag)
8. Biophysical Scoring
9. Non-Stress Test (For ER Cases Only)
4. GROUP LIFE INSURANCE WITH ACCIDENTAL DEATH & DISMEMBERMENT
– face amount is Php 50,000. If death is due to natural causes, the benefit is Php 50,000. If death is due to
accident, double indemnity (Php 100,000) applies.
Disablement or Loss of of Use of Limbs Benefit

Both Hands 100% of Amount of Insurance
Both Feet 100% of Amount of Insurance
One Hand and One Foot 100% of Amount of Insurance
One Hand 50% of Amount of Insurance
Arm Between Elbow and Wrist 60% of Amount of Insurance
Arm at or Above Elbow 70% of Amount of Insurance
Leg Below Knee 60% of Amount of Insurance
Leg at or Above Knee 70% of Amount of Insurance
Loss of Hearing/Sight/Speech Benefit

Both Ears 100% of Amount of Insurance
One Ear 50% of Amount of Insurance
Both Eyes 100% of Amount of Insurance
One Eye 50% of Amount of Insurance
Loss of Speech 100% of Amount of Insurance
5. Cancer Insurance –
-An additional benefit is given as a lump sum to a member diagnosed by an accredited physician as terminally ill
due to cancer after the waiting period.
-face amount is Php 200,000
CANCER BENEFIT DEATH BENEFIT TERMINAL ILLNESS BENEFIT

• 100% of the Face • 10% of the Face • 5% of the Face Amount
Amount if: Amount if not will be given in advance
✓ Cancer is diagnosed to diagnosed terminally ill if the member is
be in the metastatic (Death of member medically diagnosed as
stage after one hundred happens beyond terminally ill and has a
eighty (180) days from 24mos) life expectancy of
member’s effective date • 5% of the Face Amount 12mos or less
✓ Cancer is diagnosed in if diagnosed terminally • 95% of the Face
any stage after two (2) ill (Death of member Amount will be given to
years from member’s happens beyond 7mos beneficiaries upon
effective date or latest to 24mos) death
reinstatement date
*Given to the beneficiaries and
on top of the Cancer Benefit
6. Optical Rider – only applicable for Corporate Plans
The following shall be covered subject to EO’s guidelines:
a. (1) Complete Eyeglasses (CEG) for reading and one CEG for distance
b. (1) CEG with progressive lenses and one CEG for reading
c. (1) CEG for reading and one package for contact lenses for distance
d. (1) package for contact lenses (may or may not include accessories or solution)
EO’s Guidelines:
e. Minimum .50 (reading or distance) grade prior to approval of availment
f. Minimum .25 grade for astigmatism prior to the approval of availment
g. No multiple availments of the same item with similar use
7. INTERNATIONAL ASSISTANCE PROGRAM

8. TELEMEDICINE
● Ensures that patients are provided with diagnosis, treatment, follow-up service, and/or patient education
even when the doctor is out via electronic transmission of information.
9. EXECUTIVE MEDICAL CHECK-UP
● A complete health assessment comprised of physical exams, medical consultations, and laboratory procedures.
10. PRE-EMPLOYMENT MEDICAL EXAMINATION
● Part of a Principal member’s benefit package available prior to employment. It Involves basic physical exams and routine
laboratory tests conducted on an outpatient basis.
11. AMBULANCE SERVICE
● Extends road ambulance assistance for transport of sick or injured members.
12. CLINIC MANAGEMENT PROGRAM
● Provides full clinic operations for organizations and companies that prefer a worksite healthcare service
13. OUTPATIENT MEDICINES
A benefit payable for the cost of medicines prescribed to a member which is necessary to the
treatment of a covered illness/condition. This is usually offered on a reimbursement basis
STANDARD LIST OF EXCLUSIONS:
1. Vitamins and food supplements

2. Alternative medicines
3. Pre and postnatal medicines
4. Contraceptive pills
5. Injectable medicines
6. Beautification/cosmetic products
7. Soaps/cleansers for skin diseases
14. HOSPICASH
A hospital income benefit that provides the Corporate and SME members the following:
● Daily Hospital Income benefit once hospitalized

● Personal Accident benefit for accidental death and accidental dismemberment
CHAPTER 5
General Exclusions
Notwithstanding any provisions to the contrary, the following shall not be covered except otherwise
covered as specified in this Agreement:
1. Services obtained for non-emergency conditions from Physicians and Hospitals in any of the
following circumstances:
● Non-Affiliated Physicians in non- Affiliated Hospitals

● Non-Affiliated Physicians in Affiliated Hospitals
● Affiliated Physicians in non-Affiliated Hospitals or other non
● Affiliated healthcare facility.
● POS BENEFITS & ITS APPLICATION:
● Accredited Hospital & Non-Accredited Physician Standard:
● HB via Reimbursement Basis, PF via Reimbursement Basis (80%-20% based on Maxicare Rate or up to Actual Cost).
Non Standard:
● Accredited Hospital under Non-accredited Physician.
● HB via Outright Covered; PF via Reimbursement based on actual cost.
● Non-Accredited Hospital & Non-accredited Physician.
● Via Reimbursement
*HB covered outright, PF covered outright
2. Additional hospital charges and physician’s professional fees resulting from:
● Room-upgrading beyond Member’s allowable time during emergency care

● Extension of hospital stay despite release of discharge order from Member’s attending physician
● Fees of the assistant surgeons / resident doctors who assisted the Attending Physician in the
process of rendering the medical services shall not be chargeable to the Member and/or
Maxicare except for hospitals that do not have resident physicians to assist during surgeries
subject to the prior approval of Maxicare.
● Use of extra bed, TV, electric fan, DVD/ VCD, and other similar items unless such appliances and
items are necessarily and ordinarily included in the Member’s Room & Board Accommodation
● Extra food
● Toilet articles like face towel, soap, toothbrush and the like
● Difference in room and board, the incremental rate differences for professional fees, diagnostic
and laboratory examinations, and other ancillary medical services brought about by obtaining a
room accommodation higher than the Member’s Room and Board Accommodation limit.
● Services of a private or a special nurse
● All other items not medically necessary in the medical management of the patient.
3. Custodial, domiciliary, convalescent and intermediate care.
4. Long-term rehabilitation and psychiatric care and/or psychological illnesses and conditions
including neurotic and psychotic behavior disorders; anxiety disorders.
5. Treatment for injury and its complications resulting from self-inflicted injuries including
infections as a result of tattoos, piercing of the ear or in any body part, whether self-inflicted or done by
a third party or attempted suicide or self-destruction, whether sane or insane.
6. Neuro - developmental disorders including functional disorders of the mind, such as but not
limited to Attention-Deficit Disorder (ADD)/Attention-Deficit Hyperactivity Disorder (ADHD), Autism
Spectrum Disorders, Central Auditory Processing Disorder (CAPD), and Mental Retardation.
7. Treatment of any injury received when there is:
● Negligence
● Unauthorized use of prohibited drugs or regulated drugs
● Alcoholic liquor intake
● Direct or indirect participation in the commission of a crime whether consummated or not
● Violation of a law or ordinance
● Unnecessary exposure to imminent danger, knowingly or unknowingly or hazard to health, by
the member.
Note: Maxicare shall be given a copy of the Police or Doctor's report (the “Report”), if any. To determine
whether or not such treatment is an exclusion under this paragraph, Maxicare may rely on the Report, as
well as on the evaluation of its own Medical Resource Group Provided, however, that if Maxicare has yet
to receive the Report or the evaluation of its Medical Resource Group, the Member shall shoulder the
expenses for medical treatment subject to Maxicare’s reimbursement should it be found, after
submission of pertinent documentary evidence, that the treatment is not an exclusion under this
paragraph. Reimbursement will be based on Maxicare standard rates.
8. Aesthetic, cosmetic and reconstructive surgery or any consultation or treatment for any
beautification purposes except if necessary to treat a functional defect due to accidental injury within
the initial confinement.
9. Oral surgery following accidental injury to teeth for purposes of beautification.
● Dental examinations, extractions, fillings, other dental treatment and their complications except
to the extent that are medically necessary for repair or alleviation of damage to the Member
caused solely by an accident.
● Medical care resulting from any dental related conditions.
10. Maternity care and all other conditions (except pre and post natal consultations) related to
and/or resulting from pregnancy and/or delivery which affect the conditions of the Member and the
unborn child.
11. Circumcision (except for treatment of urological conditions), sex transformation, diagnosis,
treatment and procedures related to fertility or infertility, artificial insemination, sterilization or reversal
of such and their complications.
12. Experimental medical procedures and its complications

13.
Acupuncture, chirotherapy and other forms of therapies and its complications.
14. All expenses incurred in the process of organ donation and transplantation if the Member is
the donor of such donation or transplantation, and its complications.
15. Routine physical examinations required for obtaining or continuing employment, requirement
in school, insurance/travel or government licensing, health permit and other similar purposes.
16. Purchase or lease of any medical equipment, oxygen dispensing equipment, and oxygen
except during covered in-patient care.
17. Corrective appliances, prosthetics and orthotics such as but not limited to eye glasses and
contact lenses, hearing aids, pacemaker, artificial limbs, valves, knee-tibial insert for total knee
arthroplasty, vascular grafts, titanium thread, myringotomy tube, intravascular catheters, vascular
stents, bone screws/plates, pins, wires, balloons, orthopedic internal fixator/fixation systems,
orthopedic external fixator or fixation systems, intraocular lens, braces, crutches.
18. Take-home medicine and out-patient medicine except:
● Anti-neoplastic chemotherapy medicine (except for cancer treatment)

● Medicine administered during an emergency treatment.
19. Congenital, genetic and hereditary diseases and their complications (except for hernias).
20. Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), and
AIDS related diseases and their complications.
21. Treatment of injuries/illnesses caused directly or indirectly by engaging in any professional sport
or hazardous activity such as but not limited to scuba diving, surfing, water skiing, mountain climbing,
rock climbing, mountaineering, parachuting, airsoft, drag racing, paintballing, wakeboarding and
bungee jumping, except for activities under company-sponsored sports activities.
22. Injuries resulting from direct participation in riots, strikes, and other civil disturbances.
23. Treatment of injuries or illnesses resulting from war or any combat-related activities.
24. Sexually transmitted diseases including genital warts not covered.
25. Treatment for chronic dermatoses (except consultations).
26. Infectious diseases (i.e. Avian Flu, Meningococcemia, etc.) that are declared epidemic or
pandemic by the Department of Health, World Health Organization or any recognized health authority.
27. Pre-existing Hepatitis B and screening and vaccines for all types of Hepatitis.
28. Benefits covered by PhilHealth and all other government funded healthcare entitlements
as provided for by law.
29. Laser procedures / treatments. Laser procedures/treatments. Eye correction such as Laser
Assisted in Situ Keratomileusis (LASIK), Photorefractive Keratectomy (PRK), Photodynamic Laser Therapy
and the like.
30. Speech therapy (except for stroke patients, depending on the plan)
31. Weight reduction programs, surgical operation or procedure for treatment of obesity,
including gastric stapling or balloon procedures and liposuction.
32. Cost of vaccines for immunization including its administration.
33. Professional fees of medico-legal cases.
34. Routine medical examination or check up or medical examination for employment or

medical examination for travel.
35. Intravenous Immunoglobulin (IVIG).
36. Treatment of work-related injuries of high-risk occupations such as but not limited to
construction workers, miners, loggers and drillers.
37. Cost of the medical services and professional fees in excess of the MBL.
38. Medical Certificate

ROLE OF AGENTS
A.CLOSING
● Submission of Proposals to Client

● Request for Presentation Meeting with Clients
● Facilitate completeness of data for enrollment per product type.
● Facilitate review of contract and Service Level Agreements.
B. ACCOUNT MANAGEMENT
● Monitor activities of the account :

Eg. Billing, Signed Contract, Payment, Annual Check Up Requests.
● Attend Meetings as requested by Client :

E.g. Pre ACU, Utilization Review, Renewal Meeting
C. RENEWAL
● Facilitate Renewal of the Account

● Gather Necessary information for the renewal negotiations

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Version: Q2 2022

Maxicare Healthcare Corporation

HMO stands for Health Maintenance Organization.

• In 1987, a group of Doctors from Makati Medical Center and a few

• In 2003, the official name of the company was changed to MAXICARE

• In 2004, the company reached its 1 billion sales.

• In 2005, Maxicare launched its Intelligent Cards.

Roberto K. Macasaet, M.D. - Founder and Chairman Emeritus

Roberto M. Macasaet, Jr. - Chairman of the Board

Antonio L. Go - Vice Chairman

Christian Argos - President and CEO

ADVISERS TO THE BOARD

Elizabeth H. Lee - First female president of CAMPI

Ramon Sy - Former Chairman of UCPB (United Coconut Planters Bank

Maxicare is a company-wide ISO 9001:2015 certified

✔ Unparalleled service delivery aimed at meeting customer requirements

✔ Improved efficiency in the day to day operations

✔ Increased customer satisfaction by integrating it as part of our corporate culture

✔ Defined processes operating on an ISO guideline

I. Vast Network of Providers Nationwide

Our Company Statistics now reaches the following:

▪ MEMBERSHIP POPULATION: More than 1,600,000 nationwide

II. Access to Primary Care Clinc (PCCs)

The following are the locations of Maxicare’s PCCs:

1. Maxicare PCC Double Dragon Meridan Park

2. Maxicare PCC Iloilo

3. Maxicare PCC Cebu

4. Maxicare PCC W City Center

10. Maxicare Centris

11. Maxicare Cebu Skyrise

12. Maxicare VV Soliven

● Maxicare PCCs are exclusive to Maxicare members ONLY.

III. Access to MyHealth Clinics

ADVANTAGES OF AVAILING AT MYHEALTH CLINICS:

• Availability beyond 5 PM and weekends

following are the locations of MYHEALTH CLINICS:

6. MyHealth Venice Grand Canal

● Chinese General Hospital

Easy self-service health facility

Ultimately, it is only Maxicare where you experience healthcare at its finest.

Moreover, activation and deactivation of membership within 24 hours are

Benefits of the Reimbursement Card

• Timely notification via SMS whenever cash is loaded.

24/7 Customer Care Call Center

+632 582-1900 (+632) 908-6900 1-800 -10-582-1900

● Maxicare Satellite Office

Corporate Based Customer Support Specialists (CSS) are

The CSS will assist the Human Resource personnel of the

*CSS is assigned on-site and are requested by an account an additional cost.

● SMS Inquiry Service

✔ Register in the SMS Inquiry Service

Members may like us on Facebook, Instagram, Twitter and Youtube

Maxicare Healthcare Corporation Youtube channel

▪ Provides information on Company profile and milestones;

Available Services under Maxicare Member Gateway Portal:

▪ Member User Registration

▪ Online LOA Request

▪ Lost Card Report

Reasons for Card Replacement: