What is an HMO

What is an HMO?

• A Health Maintenance Organization (HMO) is a private company that provides healthcare coverage in exchange for a regular premium.
• HMOs are regulated by the Insurance Commission under Insurance Memorandum Circular 2017-19.
• Layman’s definition:
  “Think of it like a prepaid card for health care – you don’t have to shell out a large amount when an emergency happens because the HMO shoulders the cost up to your plan’s limit.”

What are HMO-Type Benefits referred to in EO 64?

EO 64 gives government employees a ₱7,000 annual medical allowance to secure HMO-type coverage. This is not cash to take home – it must be used for actual healthcare services.

• Inpatient benefits
  coverage for room and board, doctor’s fees, laboratory tests, surgeries.
• Outpatient benefits
  consultations, minor procedures, lab tests, x-rays.
• Emergency care
  treatment for sudden emergencies, even in some non-accredited hospitals.
• Preventive care
  annual physical exams, health screenings.
• Dental care
  cleaning, extractions, and fillings (depending on plan).

What is a good Group HMO?

When selecting a group HMO provider, DepEd recommends that the provider should address high-risk cases, e.g. pregnant women, senior citizens, persons with disabilities (PWDs). Further the HMO must

• Be accredited by the Insurance Commission.
• Have a wide hospital and clinic network, especially in remote areas.
• Offer a complete benefit package – inpatient, outpatient, preventive, dental, and emergency care.
• Provide transparent terms – no hidden charges.
• Have an efficient claims process – quick and hassle-free.
• Demonstrate financial stability with a strong track record.
• Provide good value for money – maximizing the ₱7,000 allowance.
• Provide Value-added services such as teleconsultation, wellness programs, and health counseling.

Summary

• HMO – a private health coverage system, like a prepaid health card.
• HMO-type benefits – actual healthcare services (not cash) such as hospitalization, consultations, dental, and preventive care.
• DepEd Order 16 – sets clear criteria for selecting group HMO providers, including prioritizing employees with high-risk health needs.
• EO 64 – ensures the ₱7,000 allowance is used for meaningful health protection.