Hospital Confinement

MEMBERSHIP BENEFITS AND PRIVILEGES

1. The following no charge hospitalization (In-Patient) services will apply when MediCard physicians prescribe the hospitalization of members in any MediCard Hospitals or MediCard centers:Non-emergency confinement or surgery (elective cases) shall be subject to prior review and approval by the MediCard review board. MediCard reserves the right to direct the members to other physicians or specialist for further opinions as needed so as to protect the interest of both the member and MediCard.

    • No deposit upon admission
    • Room & Board according to type of enrollment
    • Use of operating theater and Recovery Room
    • Services of MediCard specialist like anaesthesiologists, internists, surgeons, etc.
    • Services and medications for general/spinal anaesthesia or other forms of anaesthesia deemed necessary for a surgical procedure.
    • Fresh whole blood transfusions and intravenous fluids
    • X-ray and Laboratory examinations
    • Administered medicines
    • Dressings, plaster casts, sutures and other items directly related to the medical management of the patient
    • ICU confinements, Chemotherapy, Radiotherapy, and Dialysis are covered subject to maximum limits and pre-existing conditions coverage
    • Modern therapeutic modalities and interventional surgical procedures such as, but not limited to laparoscopic surgery and lithotripsy, are covered up to P20,000 each per years subject to the pre-existing conditions coverage
    • CT Scan, MRI and ultrasound are covered up to P5,000 each per member per year subject to the pre-existing conditions coverage (inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure):
    • The following complex diagnostic examinations and the therapeutic procedures shall be covered up to P5,000.00 each per member per year subject to the pre-existing conditions coverage (inclusive of room and board, operating room charges , professional fees and other incidental expenses relative to the procedure):
    1. Angiography (e.g. coronary, cerebral, retinal, pulmoanry, GI, etc.)
    2. Pulmonary perfusion scan
    3. Tests involving use of Nuclear Technologies (Radionuclide Ventriculography/Thallium stress testing/Radionuclide/Thyroid scan, etc.), nuclear technologies such as Pyrosphosphate Scintigraphy, Positron Emission Tomography, Radio Isotope Scanning, etc.)
    4. Electromyography, Nerve Conduction Velocity Studies
    5. 24-Hour Holter Monitoring, 2-D Echo and Doppler
    6. Treadmill Stress Test
    7. Myelogram
    8. Endoscopy including one of video
    9. Orthopedic Arthroscopy
    10. Adrecortical Function (e.g. Primary Aldosteronism, Cushings Disease)
    11. Plasma/Urinary Cortisol, Plasma Aldosterone, etc.
    12. Mammography (breast cancer) and Sonomammogram
    13. Bone densitometry scan (Dexascan)
    14. Anti-nuclear antibody (ANA), C-Reactive protein (Rheumatic and its complications), Lupus cell exam
    15. Laboratory/ancillary services for conditions whose pathogenesis or subsequent clinical improvement is not yet fully established in Medical Science
    16. New modalities and / or diagnostic and treatment procedure for conditions with established etiologies and its use is only as alternative to the conventional methods.
    17. Genetic / Immunologic studies
    18. Radioactive Iodine therapy
  • Assistance in administrative requirements through the liaisons officers
  • All other items related to the management of the case

Note: Mentioned limits are inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure.

EXCESS CHARGES AND INCREMENTAL COSTS

Excess charges, more appropriately called excess in room and board are charges payable to the hospital when a mother is confined in a room rate higher than his actual coverage, but within the same level or category.

On top of the common excess of disapproved charges that a member might incur during confinement, incremental costs can be incurred by a member when he is confined in a room higher category or level than what his plan entitles him to. (e.g. availment of private room instead of a semi-private)

2. In case a member is simultaneously covered under more than one corporate or group health maintenance agreements with MediCard, the premiums for which are paid by the member’s employer and/or principal, the member, on a per confinement basis, shall only avail of the benefits accruing from one agreement. The member must choose which agreement will apply and his confinement will be governed by the terms and conditions and the limits of the agreement of his choice. The provision is without prejudice to the member’s availment of the benefits under another agreement which may apply for other confinements.

3. The maximum benefit limit shall be inclusive of consultations, diagnostic procedures, and hospitalization.

4. Hospitalization or in-patient coverage of a member will depend on his/her final diagnosis. All diagnostic procedures will depend on his/her final diagnosis. All diagnostic procedures will only be covered if results are within inclusions of this Agreement.

For confinements and availments in Makati Medical Center which has a blanket authority policy, all disapproved charges and excess in limits shall be settled directly with the hospital upon exhaustion of limit. Failure of patient to settle the excess bills shall necessitate MediCard to bill the MEMBER with corresponding 20% service fee and payable within ten (10) working days from receipt of billing.

Effective Feb. 6, 2001 Makati Medical Center (MMC) will only accommodate HMO patients enrolled under Plan 1100 or Small Private and up. Plans below 1100 or Ward and Semi-Private will no longer be applicable to the said hospital.