Ang Patnubay sa Miyembro ay ginawa upang:
Maintindihan ang mga benepisyong matatanggap ng mga miyembro ng CAREWELL;
Ang paraan upang mapakinabangan ang mga benepisyong ito;
Ang sagot sa mga pangkaraniwang katanungan tungkol sa CAREWELL at ang mga programang pangkalusugan nito.
Frequently Asked Questions
(Mga Madalas na Katanungan)
Ano ang HMO?
Ang Health Maintenance Organization o HMO ay nagbibigay sa mga miyembro nito ng serbisyong pangkalusugan sa pamamagitan ng mga piling ospital, klinik at doctor nito.
Ang CAREWELL ay isang HMO.
Sinu-sino ang maaaring maging miyembro ng CAREWELL?
Anu-ano ang mga benepisyong binibigay ng CAREWELL sa mga miyembro nito?
Ang mga benepisyong pangkalusugan ng CAREWELL ay ang mga sumusunod:
a) Pag-iwas ng sakit.
b) Pagpapagamot sa doctor sa mga piling klinika nito.
c) Pagpapa-admit sa mga piling ospital nito
d) Emergency na pagpapagamot sa mga emergency room ng ospital o sa mga klinika nito.
e) Pagpapagamot sa mga piling dentista nito
Ang mga benepisyong ito ay binibigay ng CAREWELL sa lahat ng miyembro nito ayon sa mga sumusunod na kondisyon:
A. Serbisyong pang-iwas sa sakit
- Pisikal na pagsusuri matapos ang isang taong tuluy-tuloy na pagiging lehitimong miyembro ng CAREWELL
- Pagpapabakuna (maliban sa gamot)
- Pagtuturo ng wastong pangangalaga sa kalusugan
B. Pagpapakonsulta o pagpagamot sa mga piling klinika
- Pagpapakonsulta o pagpapagamot ng simpleng pinsala o sakit na nakapaloob sa mga oras na bukas and mga klinikang ito
- x-ray, laboratory at diagnostic na pagsusuri
- pagpapapunta sa espesyalistang manggagamot
C. Pagpapa-admit sa ospital
ang miyembro ng CAREWELL ay puwedeng ma-admit sa isang piling ospital (kung ito ang naging desisyon ng CAREWELL doctor-coordinator) at makapag-avail ng mga sumusunod na serbisyo:
- kwarto at pagkain ayon sa programa ng miyembro
- operating at recovery room
- anesthesia.
- serbisyo ng espesyalistang manggagamot
- suwero at pagsalin ng dugo
- pagsusuring laboratory
- mga gamot habang nakaconfine
- dressing, plaster cast, tahi, at ibat-ibang serbisyong may kaugnayan sa sakit o pinsala ng miyembrong naconfine
Lahat ng ito ay hindi lalampas sa Maximum Benefit Limit (MBL) ng programa gaya ng Ward, Semi-Private or Private.
D. Mga kasong emergency na hindi kinakailangan ma-confine:
- Serbisyo ng doctor
- Gamot, x-ray, pagsusuring laboratory, at iba pang ginagamit sa emergency treatment ng pasyente
E. Serbisyo ng dentista ng CAREWELL
- Prophylaxis pagkatapos ng isang taong membership
- Simpleng pagpapabunot
- Pansamantalang pagpapapasta
- Recementation
- Pagpapagamot ng sakit at pinsala sa ngipin pati narin ang singaw
- Pagpapagamot ng gilagid na di kinakailangan ng surgery
MGA PAMAMARAAN NG PAGGAMIT
A. Pagpapakonsulta sa accredited klinik ng CAREWELL:
1. Pumunta sa pinakamalapit na klinik ng CAREWELL
2. Ipakita ang CAREWELL card at ang company ID card sa doctor
3. Susuriin at gagamutin ka ng doctor o di kaya ay bibigyan ka ng referral slip at papupuntahin sa isang espesyalistang doctor
4. Puntahan ang espesyalista, ipakita ang referral slip at ang ID cards mo
5. Kung kailangan ma-admit tumawag sa opisina ng CAREWELL para matulungan
B. Emergency admission sa Ospital
Accredited na Ospital
1. Pumunta sa emergency room
2. Ipakita ang CAREWELL card at ang company ID card mo
3. Ipatawag ang doctor
4. Tumawag sa CAREWELL upang sila ay makapagpapunta ng Liason Officer na magdadala ng Letter of Authorization o LOA na ibibigay sa Admitting Section
5. Bago ma-discharge, bayaran ang lahat ng gastos na hindi kasali sa benepisyo mo sa CAREWELL at mag-submit ng Philhealth Form 1 sa Credit and Collection Section ng ospital upang mabawas ito sa singil ng ospital
Hindi Accredited na Ospital
1. Pumunta o magpatawag sa emergency room ng pinakamalapit na ospital
2. Tumawag sa CAREWELL para matulungan sa pagpapaconfine
3. Magfill-up ng Philhealth Form 1 at ibigay sa admitting section
4. Ipunin ang lahat ng resibo sa gamot at serbisyo at kung maari ay ilagay sa pangalan ng miyembro
5. Bago ma-discharge, bayaran lahat ng hospital bill para hindi ma-delay ang pag-discharge at madagdagan ang gastos mo.
6. Ipadala ang lahat ng dokumento at resibo sa CAREWELL upang maibalik agad ang ginastos mo sa pagpapagamot Upang mabayaran pa ito hindi maaring sumobra sa sampung araw (10) simula sa pagka-discharge sa ospital ang pagpasa o pagsumite ng kumpletong mga resibo at dokumento sa pagpapagamot sa CAREWELL.
C . Non-emergency admission (sa Accredited na Ospital lamang)
1. Ipaalam sa CAREWELL ang sakit o pinsala.
2. Pumunta sa pinakamalapit na CAREWELL klinik at ipakita ang membership card at company ID.
3. kung ang CAREWELL doctor ay nagpasya na ikaw ay kailangang ma-admit sa ospital, bibigyan ka niya ng referral slip para sa CAREWELL doctor ng isang malapit na accredited ospital
4. Pumunta sa CAREWELL doctor ng accredited na ospital at ipakita ang referral slip, ang membership card at ang company ID card
5. Tumawag sa CAREWELL upang magpadala sila ng empleyado na maaring magdala ng Letter of Authorization para sa iyong admission o makapagfax ng kopya nito sa kaukulang ospital.
6. Tumawag sa iyong kumpanya at humingi ng Philhealth Form 1, sagutin, pirmahan at ibigay ito sa Admitting Section
7. Bago ma-discharge, bayaran ang gastos na hindi kasali sa iyong programa sa CAREWELL.
Ano ang Pre-existing Conditions?
Ang mga sakit o pinsala dalawang taon bago ka pa naging miyembro ng Carewell na:
• Napakonsulta o napagamot mo na
• Naramdaman o kaya’y alam mo na
• Nag-umpisa na o noon pa kahit di mo pa nalalaman
Ano ang Dreaded Disease?
Ano ang hindi sasagutin ng CAREWELL?
EXCLUSIONS
*These exclusions should not in any way prevent a member from undergoing whatever treatment procedures deemed necessary by the attending physician.
A. Confinement without the official recommendation of the Carewell Medical Director, Accredited Outpatient Physician Coordinator or their representatives including confinement after effectivity of discharge order issued by attending or Carewell Physician Coordinator.
B. Extra services not directly related to the member’s health management such as, but not limited to, service of private nurse, extra food, bed, TV, electric fan, DVD players, telephones, ID bracelet, thermometer and others.
C. Hospitalization and treatment abroad.
D. Prescribed medicines for outpatient cases including vaccines.
E. X-ray, laboratory and procedures not prescribed or approved in writing by the Carewell Medical Director, accredited outpatient physician coordinator or attending physician.
F. Congenital defects, slipped disc, spinal stenosis and hearing impairment.
G. Correction of all physical deformities.
H. Guillian-Barre Syndrome, Multiple Sclerosis, Epilepsy and other autoimmune neurological diseases.
I. Psoriasis and Vitiligo.
J. Plastic and reconstructive surgery for cosmetic purposes or congenital deformities and abnormalities.
K. Physical examination required for obtaining or continuing employment, insurance or government licensing.
L. Experimental medical procedures and other alternative forms of medicine such as acupuncture or cupping.
M. Services related to reproductive capacity i.e. abortion, sterilization, ligation, male/female fertility treatments etc.
N. Purchase or lease of durable medical equipment, oxygen-dispensing equipment and oxygen except during covered inpatient care.
O. Corrective appliances, artificial aids and prosthetic devices.
P. Human blood products like platelets, packed red blood cells (PRBC), plasma, etc.
Q. Psychiatric care, rehabilitation treatment, physiotherapy and speech therapy.
R. Open heart surgery, organ transplant and craniotomy sequelae.
S. Injury or illness resulting from participation in war-like or combat operation, brawls, riots and civil disturbances except those resulting from unprovoked assaults.
T. Hazardous job-related illness or injury.
U. Injuries that are self-inflicted or attributable to member’s own misconduct, gross negligence, mental state, drug and/or alcohol use, vicious or immoral/promiscuous habits, participation in crime, any conduct in violation of law or ordinance, and unnecessary exposure to imminent danger or hazards to health including treatment for alcoholism and drug addiction/abuse.
V. Any injury sustained whenever the member is determined by attending physician to have taken alcohol.
W. Maternity care and other conditions as a result of pregnancy and its origin (unless otherwise specified in the healthcare service contract).
X. Custodial, domiciliary, convalescent, and intermediate care.
Y. Sexually transmitted diseases and origin including gonorrhea, herpes and AIDS.
Z. Adverse medical conditions arising from treatment by non-accredited physicians, clinics, and hospitals.
EXCLUSIONS (CONDITIONS NOT COVERED)
1. Availments / hospital expenses coursed through non-affiliated doctors/clinics/hospitals except in emergencies wherein the emergency provisions of the contract shall apply.
2. Surcharges resulting from additional personal amenities/request or services (i.e. telephone, television and other incurred charges after the Carewell physician has authorized the discharge of the member).
3. Physical examination required for obtaining employment, insurance, government license, entrance for school or military purposes, executive check-ups and annual physical examination (APE) not authorized by Carewell, medical clearance for physical workouts, etc.
4. Availments / disease relative to epidemics as declared by the national or local government except for those disease / availments within limits set forth in the contract for local epidemics.
5. All expenses related to the actual bloodletting, screening and cross-matching of blood, in cases when blood for transfusion will be from the voluntary blood donor (provided for in the National Voluntary Blood Donation Program of the government).
6. Diseases or injuries wherein the care or reimbursement is provided by law or a government program up to the stipulated limits (e.g. PhilHealth / Medicare / ECC benefits); program thrusts of the Department of Health (DOH) and other national agencies where medication / care / treatment is provided (e.g. Leprosy Control Program).
7. Rest, custodial, domiciliary or convalescent cures, long-term rehabilitation care, psychiatric care.
8. Medical and surgical procedures that are not generally accepted as standard medical treatments by the medical professions (e.g. hilot, herbal medicines, acupuncture, reflexology, chiropractic treatment, etc).
9. Take-home medicines in case of hospitalizations.
10. Conditions / illnesses resulting from research experiments (e.g. AIDS – vaccination).
11. Hepatitis screening and all diagnostic exams for employment purposes.
12. Any complications resulting from dental conditions, except for those covered under the Dental Benefit Rider.
13. Prescribed medications for Hormonal Replacement Therapy (HRT).
14. Procurement or use of corrective appliance, artificial aids and orthopedic hardware used in nailing, pinning, and bracing metals plates during craniotomy, wheelchair, cervical collar, abdominal braces, clutches, hearing aids, contact lens, intraocular lens, etc. Purchase or lease of durable medical equipment, oxygen dispensing equipment and oxygen except during covered inpatient care.
15. All congenital abnormalities (for example Kyrphoscoliosis, Spinal Stenosis, Coarctation of the Aorta, Tetralogy of Fallot, Patent Ductus Arteriosus, Ventricular Septal Defect, Ebstein Anomaly of the Great Vessel, AV malformations, etc.) and inborn errors of metabolism, physical deformities prior to enrollment, Spinal Stenosis, Inguinal and Umbilical hernia, and other related conditions. Conditions / Illnesses arising from Perinatal / Natal complications like Cerebral Palsy & other related conditions; Metabolic Disorders that are congenital in nature.
16. Blood Dyscrasia (Hemophilia, Sickle Cell Anemia, Leukemia, etc).
17. All types of Aneurysm and Angiography
18. All cases requiring Craniotomy and Burr holing.
19. Severe autoimmune disease e.g. Systemic Lupus Erythematosus (SLE); Vitiligo, Psoriasis and its complications, etc.
20. Functional disorders of the mind (psychiatric disorders) including mental retardation.
21. Sterilization of either sex or reversal of such, artificial insemination, sex transformation or tubal ligation, in-vitro fertilization, circumcision, IUD insertion and complications arising from these procedures.
22. All pregnancy-related conditions requiring medical or surgical care, except if with Maternity Benefit Rider.
23. Cardiovascular Diseases:
a. Cardiac Valvular Diseases, Aortic Stenosis, Mitral Regurgitation, Tricuspid Regurgitation, Mitral Stenosis, Mitral Valve Prolapse (MVP).
b. Cardiomyopathies
c. Arrythmias, Sick Sinus Syndrome, Stroke Adam Syndrome, Ventricular Tachycardia, Supraventricular Trachycardia, Second and Third Degree AV Block
d. Congestive heart failure Class III-IV
e. Malignant / Uncontrolled Hypertension with complications (such as Hemorrhagic cases that may or may not require craniotomy or burr holing)
f. RHD (Rheumatic Heart Disease)
24. Organ transplants, open heart surgery (coronary artery bypass) or any diagnostic procedures / tests related thereto (i.e. 2D Echo, coronary angiogram, cardiac catheterization, etc.); pacemaker incision; valve replacements.
25. Chronic Renal Disease (e.g. Chronic Glomerulonephritis, Chronic Renal Failure due to primary serial renal failure or other secondary causes, Nephrotic Syndrome, Chronic Pyelonephritis, Staghorn Calculi resulting to Renal Failure, Chronic Renal Failure secondary to Diabetes) except for acute renal disease with acute renal failure.
26. Neurocirculatory Asthenia; Anorexia Nervosa and its complications.
27. Human anti-rabies and other vaccines (except for the first does of anti-tetanus vaccine in case of emergency), Immunoglobulins and other biological products.
28. Cosmetic surgery including vein stripping, oral surgery, dermatological procedures for purposes of beautification except reconstructive surgery to treat a dysfunctional defect due to disease or accidental injury, warts, acne and moles not infected and no malignant tendencies (excluded for cosmetic purposes).
29. Sexually Transmitted Diseases, AIDS, AIDS-related (SY, CC, Herpes, Yaws, NGU, Monilia classified as STD) and other tests to diagnose these diseases.
30. Work-related injuries / illnesses for those working under hazardous conditions / occupations.
31. Injuries and illnesses due to military, paramilitary, police service or war (e.g. Army, Navy, Barangay Tanod, etc.).
32. Injuries sustained as a result of domestic fights and problems, hazardous sports (e.g. scuba diving, skydiving, mountain climbing, etc.) and professions (e.g. athletes, aerobatics, racecar drivers, professional entertainers, mining, underground workers, secret service, explosives factory workers, martial arts practitioners, etc.), avocation and other sports-related activities.
33. Injuries or illnesses due to attempted suicide; use of alcohol and/or drugs, vicious or immoral habits, participation or involvement in acts of war, terrorism, crime, riot or brawl, violation of law or ordinance, and unnecessary exposure to imminent danger to health – including complications of such conditions (e.g. alcoholic hepatitis).
34. Hospital confinement for purely diagnostic purposes except when covered under a special provision of the contract such as executive check-up.
35. Death related to motorcycle accident.
36. Professional fee medico-legal officer called for medico-legal cases.
37. Determining / ruling out of PEC during the first 12 months of membership.
38. Motorcycle vehicular accident cases.
39. PHIC uncompensable cases.
40. HEPA B and its complications.
41. All other illnesses, medications and diagnostic procedures that are not covered by your contract.
Ano ang mangyayari sa aking PHILHEALTH NATIONAL HEALTH INSURANCE PROGRAM (NHIP) benefits?
Ang benepisyo ninyo sa NHIP ay integrated sa Carewell Comprehensive Health Care Program. Sa oras ng pagpapa-Ospital, responsibilidad at obligasyon ng miyembro na magpasa ng na-accomplish na PHILHEALTH Form 1 sa kanyang employer.
Ang benepisyo ninyo sa pagpapa-ospital sa NHIP ay ibabawas sa kabuuang halaga na babayaran or sasagutin ng Carewell.
PHILHEALTH / ECC PROVISION
Carewell benefits under PhilHealth / Employees Compensation Commission (ECC) will be deducted first from the amount otherwise payable. Carewell will not pay or advance the costs of such benefits nor be responsible for filing any claims under PHILHEALTH or ECC.
• PhilHealth members must file the required PhilHealth forms and documents like the Member’s Data Record (MDR) prior to hospital discharge and for the PhilHealth-required outpatient procedures. Non-filing or late filing would mean payment of the PhilHealth portion by the member.
• Non-PhilHealth members must pay the PhilHealth portion.
For any concerns or questions regarding your PhilHealth
• Benefits & Coverage
• Eligibility
• Membership / Payments / Requirements
please consult your Human Resource Department or visit www.philhealth.com.
AFFORDABILITY
PROMPT PAYMENT
OPEN-DOOR POLICY
FLEXIBILITY
INVENTIVENESS
