Can I Use Maxicare and PhilHealth at the Same Time?

For many Filipinos, having dual coverage from a private health insurance provider like Maxicare and government health insurance PhilHealth is an optimal arrangement. This combination provides more comprehensive benefits and higher coverage limits. But can you really use both Maxicare and PhilHealth simultaneously? Let’s find out.

Overview of Maxicare and PhilHealth

Maxicare is one of the leading health maintenance organizations (HMOs) in the Philippines. It offers a wide range of prepaid health plans for individuals, families, small businesses, and large corporations. Maxicare has an extensive network of affiliated hospitals, clinics, and medical professionals across the country.

PhilHealth is the national health insurance program administered by the Philippine government. All employed Filipino citizens are automatically enrolled and required to make monthly contributions based on income. PhilHealth provides basic coverage for inpatient and selected outpatient care.

While both offer health coverage, there are some key differences:

• Coverage scope – Maxicare has wider coverage for inpatient and outpatient services including preventive care. PhilHealth covers confinement and some critical illnesses.

• Provider network – Maxicare has strictly accredited hospitals and clinics nationwide. PhilHealth is accepted at most healthcare institutions in the Philippines.

• Premiums – Maxicare premiums vary based on the plan. PhilHealth contributions are fixed percentages of monthly income.

• Benefit limits – Maxicare has higher coverage limits per illness and annual caps. PhilHealth has fixed caps per illness type.

• Claims – Maxicare is processed by accredited providers. PhilHealth requires submission of forms and documents.

Can I Be Covered by Maxicare and PhilHealth Together?

Yes, you can absolutely have simultaneous coverage from both Maxicare and PhilHealth. In fact, having this dual health coverage is a smart approach followed by many individuals, families, and companies in the Philippines.

Some key pointers regarding joint Maxicare and PhilHealth membership:

• All employed Filipino citizens are automatically PhilHealth members. Additionally enrolling in Maxicare provides supplementary coverage.

• Maxicare health plans are open to be purchased by individuals or groups without restriction on existing PhilHealth membership.

• During hospital admission or treatment, dual PhilHealth and Maxicare members can avail of benefits from both providers together.

• Premium payments need to be continued separately for PhilHealth (deducted from salary) and Maxicare (paid individually or by company).

• Certain Maxicare plans like Prima even include payment of annual PhilHealth contributions as an added benefit.

How Does Using Both Together Benefit Me?

Having the combined protection of government health insurance and private HMO coverage provides some invaluable advantages:

1. Wider range of benefits

Maxicare covers numerous outpatient services, preventive care, mental health services, emergency treatment etc. which PhilHealth does not. So you have access to more health services.

2. Higher coverage amounts

For hospitalization due to illness or accidents, the coverage limits are much higher when you can claim from both PhilHealth and Maxicare. This reduces large out-of-pocket expenses.

3. Access to accredited facilities

Maxicare opens the door to excellent affiliated hospitals and clinics under corporate tie-ups. Quality of care is assured.

4. Cashless transactions

Expenses like hospital deposits are waived for Maxicare members. Claims are directly billed to Maxicare instead of reimbursing like in PhilHealth.

5. International coverage

Some Maxicare plans include medical coverage even when traveling overseas. PhilHealth is only valid within the Philippines.

6. Better fiscal planning

Unexpected medical costs are a key cause of debt for many Filipino families. Dual coverage is a prudent way to manage this health expenditure risk.

How Do I Use Both Maxicare and PhilHealth?

Using both your Maxicare and PhilHealth membership together is quite straightforward. Here is a step-by-step process:

During Hospital Admission

1. Present your PhilHealth ID and Maxicare card.

2. PhilHealth benefit will be deducted from total bill.

3. Maxicare will cover balance bill amounts until your coverage limit.

4. Any remaining amount is your out-of-pocket expense.

For Outpatient Services

1. Present your Maxicare card at affiliated clinics to avail specialist consultations, treatments, diagnostic tests, etc.

2. Maxicare will directly settle the bill based on your plan benefits. No need for reimbursement claims.

3. For expenses not covered by Maxicare, you can submit to PhilHealth for claims processing.

For PhilHealth Premiums

1. If self-employed or voluntarily enrolled, continue paying your monthly PhilHealth contributions.

2. If employed, PhilHealth contributions will be deducted from your salary by the employer.

3. For select Maxicare plans like Prima, annual PhilHealth premium amount is paid on your behalf.

What is the Coverage Process During Hospitalization?

Here is a more detailed overview of the combined coverage process when you are hospitalized:

1. Upon admission, present your PhilHealth ID and Maxicare card.

2. The hospital will first bill PhilHealth up to its benefit limit for your illness/procedure. This is typically a fixed amount.

3. The balance amount will then be billed to Maxicare up to your plan’s coverage limit.

4. If there is any remaining amount after step 1-3, it will be your out-of-pocket expense. You immediately settle this to the hospital.

5. For expenses within PhilHealth and Maxicare limits, you have no upfront payments during discharge. The insurers will directly settle with hospital later.

6. For medicines or services not covered, you need to pay the hospital yourself.

What Documents are Needed?

When you avail of treatment, these are the documents you need to carry and present:

• PhilHealth ID – This national ID contains your PhilHealth membership details.

• Maxicare Membership Card – Your Maxicare card has your member details, plan information, coverage validity etc.

• Valid ID – Government-issued ID like passport, UMID, driver’s license for identification.

• Referral – If admitted via Maxicare doctor’s referral, carry the referral form or letter.

Can I Get Reimbursement for Excluded Services?

Sometimes certain expenses may not be outrightly covered by PhilHealth or Maxicare such as:

• Elective procedures or aesthetic treatments

• Experimental medical procedures

• Alternative therapies

• High-cost medications

• Services availed outside accredited hospitals

For such excluded services, you cannot directly settle the bill with PhilHealth or Maxicare. But you can pay the hospital yourself first and then submit the documents later to the insurers for reimbursement consideration. Whether you can get reimbursed will depend on the policy terms.

What is Not Covered by Maxicare and PhilHealth?

There are some general exclusions not covered by both Maxicare and PhilHealth. These include:

• Cosmetic surgeries purely for beautification

• Harm or injuries caused intentionally, illegally or through gross negligence

• Suicide or attempted suicide

• Alcohol, drug or substance abuse

• Hazardous sports, activities or adventures

• Experimental procedures and unproven treatments

• Convalescent, custodial or sanatorium care

• Alternative medicine systems like herbal therapy, acupuncture etc.

Can Dependents Be Covered Together?

For family plans, both the individual member and declared dependents can be covered by Maxicare. Eligible dependents include:

• Legal spouse

• Children below 21 years

• Elderly parents

• Siblings

Dependents will be included together in the PhilHealth membership as well. During claims, each dependent can utilize their joint Maxicare and PhilHealth coverage.

What is the Maxicare-PhilHealth Payment Sequence?

Here is the standard sequence followed by accredited hospitals when processing billing and payments for members with both Maxicare and PhilHealth coverage:

1. The hospital will first claim from PhilHealth up to the amount it provides for the case.

2. The remaining balance will then be claimed from Maxicare as per the member’s plan entitlement.

3. If there are any amounts not covered after the PhilHealth and Maxicare deduction, this balance has to be paid by the patient themselves.

4. For medicines, devices etc. prescribed but not covered, the member will need to directly pay the hospital.

5. The member should not have any upfront payments to the hospital during discharge for items covered within limits.

Which Provides Higher Coverage in Most Cases?

While both are beneficial, Maxicare generally provides the larger share of coverage amounts compared to PhilHealth for most hospital expenses, medical services and procedures:

• Maxicare has higher limits for room & board accommodation.

• Doctor