mktg 2

1. M . A . P . P
Maxicare Agent’s Product
Presentation

2. Program Outline
I. The Need for Healthcare
II. Benefits of a Healthcare Program
III. Maxicare Healthcare Organization:
Your #1 Healthcare Provider
IV. Maxicare’s Edge:
1. Our Value Offering
2. Our Diversed Products
V. Provision and Guidelines
VI. Maxicare’s Extensive Healthcare Program & Seamless Availment
VII. General Exclusions
VIII. Agent’s Benefits and Incentives

3. Objectives of the Program
 Discuss the benefits of having an HMO;
Introduce Maxicare as an HMO Company to the agents;
 Familiarize the agents with Maxicare’s portfolio of products and services;
 Increase appreciation of partnering with Maxicare as an intermediary;

6. In times of sickness, there is
ayables
nxiety
nferior options
eglect

7. A trusted HMO will not only take away
the PAIN caused by sickness, but it
provides
EACE OF MIND
ayables
CONOMIC FREEDOM
nxiety
CCES TO QUALITY HEALTHCARE
nferior options
OMPREHENSIVE HEALTH COVERAGE
EXCELLENT CARE eglect

8. and when it comes to healthcare, there can only be one
HMO you can trust.

9. With 25 years of excellent healthcare service,
Leading HMO

10. More than 700,000
cardholders nationwide
1987

11. Our Roster of Clients
FOOD AND RETAIL INDUSTRY

12. Our Roster of Clients
EMBASSY AND AIRLINE INDUSTRY
AUTOMOTIVE INDUSTRY

13. Our Roster of Clients
PETROLEUM INDUSTRY
INSURANCE INDUSTRY

14. Our Roster of Clients
BANKING AND FINANCE INDUSTRY

15. Our Roster of Clients
MANUFACTURING INDUSTRY
BUSINESS PROCESS OUTSOURCE INDUSTRY

16. Our Roster of Clients
And a few more known brands and clients we serve....

17. Our Value Offering
• Vast Network of Provider
1
• Maxicare Intelligent Card
2
• Primary Care Centers and MyHealth Clinics
3
• Extensive Customer Care
4
• Maxicare Web Portal
5
• Lifestyle Partners
6
• Comprehensive Healthcare Program
7

18. Vast Network of
Providers
More than 1000 Accredited Hospitals and Clinics nationwide
 65% are tertiary hospitals
 All Maxicare centers are online
with Head Office
 Continuously growing in number

19. Vast Network of
Providers
More than 30,000 Accredited Doctors nationwide
At a minimum, our doctors should
be an Internal Medicine Specialist.

20. Maxicare Intelligent Card
 Real-time validation of membership
during availments
 Swipe facility using more than 1300 POS
units nationwide
 Immediate activation & de-activation of
memberships within 24 hours
 Cards need not be replaced
on a yearly basis

21. Maxicare Intelligent Card
Maxicare Reimbursement Card (MRC)
Withdraw the funds in
any ATMs
Purchase any item using the card’s
balance in any of the Bancnet
accredited shops

22. Primary Care Centers &
MyHealth Clinics
Primary Care Center (PCC) is a healthcare facility which has its staff of Customer
Service Representatives and Primary Care Physicians (who are either Internal Medicine
Specialists or Pediatricians).
ADVANTAGES:
 Exclusive to Maxicare Members Only
 Easy access to Internal Medicine Specialists
 Unlimited number of FREE consultations*
Majority are strategically & conveniently located
@ major hospitals

23. Primary Care Centers
Filomena Building
G/F Filomena Building
Amorsolo Street
Legaspi Village, Makati City
Monday to Friday: 7AM – 6PM
Saturday: 7AM - 4PM
*(Quality lab exams @ the least possible cost)

24. Primary Care Centers
Makati Medical Center
1st Floor Tower One, Makati Medical
Center, Amorsolo St. Makati City
Monday to Friday: 7AM – 7PM
Saturday: 8AM - 4PM

25. Primary Care Centers
 Quezon City
15/F Room 1501, North Tower, Cathedral Heights, QC
Monday to Friday: 7AM – 6PM
Saturday: 7AM - 4PM
 Global City
Room 325 Medical Arts Building, Rizal Drive Cor. 15th
Ave. & 32nd Ave. Fort Bonifacio Global City

26. Primary Care Centers
MGR04, Ground floor, Medical Arts
Tower 1, The New Medical City
Ortigas Ave., Pasig City
Monday to Friday: 7AM – 6PM
Saturday: 7AM - 4PM

27. Primary Care Centers
Chinese General Hospital
10th Floor Medical Arts and Parking
Building, Sta Cruz, Manila
Monday to Friday: 8am-5pm
Saturday: 8am-4pm.

28. Primary Care Centers
Asian Hospital & Medical Center
Lower ground floor, Asian Hospital
and Medical Center, 2205 Civic Drive,
FCC, Alabang, Muntinlupa
Monday to Friday: 8am-5pm
Saturday: 7am-5pm.

29. MyHealth Clinics
SM City North Edsa Festival Supermall
2nd Level Building F, SM City A-3 Level 2 Style Boulevard,
North Edsa, North Avenue, Festival Supermall, Filinvest
Quezon City Corporate City
Tel #: 441-4106 Tel #: 850-4855
7AM to 9PM 7AM to 8PM
Edsa Shangri La
Unit 146, Level 1, Shangrila Plaza
EDSA corner Shaw Blvd.,
Mandaluyong City
Tel #: 570-4325
7AM to 8PM

30. MyHealth Clinics
Robinsons Cybergate Calamba
CEBU
2nd Floor, Waltermart Center
3 Level, Robinsons Cybergate
rd
Calamba
Mall, Fuente Osmena, Cebu City Brgy. Real, Calamba City, Laguna
Tel #: (032) 268-8502 (049) 502 – 7130 to 32

31. Extensive Customer Care
Maxicare 24/7 Customer Care

32. Extensive Customer Care
Maxicare Helpdesk
Clinica Manila
2nd Floor, Unit 202 Building A
SM Megamall Complex
Don Julia Vargas Avenue, Mandaluyong City
Monday to Saturday
Tel. No: (0632)661-7777 local 102

33. Extensive Customer Care
Mary Mediatrix
Medical Center
2nd Floor, H.B. Calleja Building
Mary Mediatrix Medical Center
J.P. Laurel Highway, Lipa City, Batangas
Monday to Saturday
Tel. No: (043)784-9999 local 1152

34. Extensive Customer Care
Calamba Medical
Center
Ground floor , Central Registration,
Crossing, Calamba,City
Monday to Saturday

35. Extensive Customer Care
MANILA DOCTORS
HOSPITAL
Room 220, Manila Doctors Hospital
Monday to Saturday
Tel. No: (02)524-3011 local 4510

36. Extensive Customer Care
Maxicare Satellite Offices
BAGUIO
BAGUIO
PAMPANGA
PAMPANGA
HEAD OFFICE --Makati
HEAD OFFICE Makati
BATANGAS
BATANGAS
CEBU
CEBU
BACOLOD
BACOLOD
ILOILO
ILOILO
DAVAO
DAVAO DUMAGUETE
DUMAGUETE
CAGAYAN DE ORO
CAGAYAN DE ORO
GENERAL SANTOS
GENERAL SANTOS

37. Extensive Customer Care
Maxicare Roving Team

38. Extensive Customer Care
Email Support
callcenter@maxicare.com.ph
 Members can send their inquiries and
concerns through Email.

39. Extensive Customer Care
Maxicare’s Facebook Fanpage
www.facebook.com/maxicarehealthcarecorp
 Members can like us on facebook and
send inquires and concerns via chat.

40. Maxicare Web Portal
 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.
 Members will now have full access from
one’s basic account information to
availment details.

41. Available Services

50. Lifestyle Partners
up to 2%
Discount thru
delivery, online
or drive thru

51. Lifestyle Partners

52. Lifestyle Partners

53. Lifestyle Partners
 10% – 20 % discount on frames and
sunglasses (EO exclusive brands)
 5% - 10% discount on signature frames
and sunglasses (except Rayban and Oakley)
 Free Consultation ( Licensed Optometrist)
 Free Minor repair services
 Free Cleaning

54. Lifestyle Partners
 Extends 5% discount in generic
medicine purchases and 1% on
branded purchases.
 With over than 170 branches
nationwide.

56. Product Proposition
Full Programs

57. Product Proposition
Prepaid Programs
Maxicare
EReady

59. Ineligible Professions
 Acrobats/ Stuntment
 AFP Personnel
 Electrical Linemen
 Explosive Factory Workers
 Loggers
 Mines/ Quarry Workers
 Night Club and bar workers
 Oil Rig Workers
 Pensioner/ retirees
*Complete list of the ineligible professions are found in your manual.

60. *Restricted Professions
 Seamen
 Medical Practitioners
 Actor/Actresses
 Politicians
 Unemployed
 Personal Drivers
Application is subject for approval

61. Enrollment Guidelines
Philhealth Status
Required - filing of PHIC of member/patient is mandatory
Unemployed Enrollees
Annual mode is recommended to avoid account from lapsing.
For other modal factors, conditions are:
1. Provide PAYOR
2. For Lapsation:
First Offense - REINSTATEMENT
Second Offense - REAPPLICATION

62. Enrollment Guidelines
Payor/ Non-member Guardian
 All dependents aged from 2 to 17 years old need to have a payor.
Relationship of the payor should be established by submitting a birth certificate of
the member or a written request.
Dependents’ Plan
 It must be the same plan as the Principal or one plan lower.

63. Enrollment Guidelines
INDIVIDUAL MEMBERSHIP:
 Application Form
 Medical Requirements for 50 years old and above
 Photocopy of Alien Certification of Residency if foreign nationality
FAMILY MEMBERSHIP :
 Application Form
 Medical Requirements for 50 years old and above
 Photocopy of Alien Certification of Residency if foreign nationality
 Copy of Marriage Certificate
 Copy of Birth Certificate
*Incomplete requirements will not be accepted.

64. Enrollment Process
Step 1:
Fill out the IFG Application Form

65. Enrollment Process
Step 2:
Submit all necessary documents
for processing.
TAT : 3 – 5 working days for Clean Application)
TAT: 5 - 7 working days for apps with medical
requirements, BMI concern and previous member

66. Enrollment Process
Step 3:
Pay at any of these channels:
• Maxicare Head Office, 3rd Floor
• Banco de Oro branches
• Equicom Savings Bank branches
Statement of Account Billing Schedule:
For New Business : 1-2 days upon approval
For Renewal : 45 days before renewal date

67. Enrollment Process
Step 5:
Receive your Maxicare ID card
as proof of membership
Card will be sent within 10
working days after receipt of
payment

68. Cut – Off Dates
PAYMENT or EFFECTIVE DATE
O.R. DATE
11th to 25th of the month 1st of the following month
26th to 30/31st of the month 16th of the following month
1st to the 10th of the month 16th of the current month

69. Payment Provisions
CONDITIONS FOR
REINSTATEMENT
-Penalty fee of PhP 500
-Advance Payment for the next
period
-30-day non-coverage upon
45-day Reinstatement Period payment
During the reinstatement period, Maxicare
Healthcare coverage will be suspended

70.  Nationwide Access
- Access to all accredited facilities and
providers all over the country.

71.  Luzon Access
Access to all facilities and
providers within Luzon except NCR.
 Visayas Access
Access to all accredited facilities
and providers within Visayas
except Luzon, NCR and Mindanao.
 Mindanao Access
Access to all accredited facilities
and providers within Mindanao
except Luzon, NCR and Visayas.

73. Ineligible Industries
 Groups where other than a single
employer-employee relationship exists;
 Groups which involve special hazards;
 Groups which include more than 10%
of the group residing outside the
Philippines;
 Political Groups;
 Nuclear/Chemical/Natural Gas
plants
 Education (except Pre-schools only)
 Construction Companies;
 Oil Production;
*These industries will automatically be not accepted under Maxicare Plus; for
Corporate, it will be subject for approval.

74. Ineligible Industries
 Underground Mine workers & workers using
explosives;
 Drinking places except restaurants;
 Logging/Forestry
 Government Institution
 Pharmaceutical Groups
(Manufacturing/Distributing)
 Medical Groups
 NGOs and Cooperatives (except employees of
the organization)
*Account would still be asked to submit:
1. Answered questionnaire
2. Audited Financial Report
3. Masterlist with job classification

75. Ineligible Industries
 Group of Firemen
(Note: Minimum of 500 lives);
 Manufacturers of Ammunition or
explosives;
 Full Time Athletes;
 Drillers (oil/water/gas);
 Sauna, Turkish baths, massage parlors
or similar enterprises;
 Private households;
 Media
(newspaper, TV & Radio Broadcast);
 Law Firm
 Education (except Pre-Schools only)

76. Principal’s Participation
Requirements

77. Dependent’s Participation
Requirements

78. Dependent’s Participation
Requirements
 Escalation clause
 significant decrease of initial count to actual number of enrollees
 failure to comply to the 75% participation requirement
Participation Requirement* Applicable Rates
60% - 74.9% + 15% to standard rates
50% - 59.9% + 35% to standard rates
40% - 49.9% + 55% to standard rates
30% - 39.9% + 65% to standard rates
20% - 29.9% + 75% to standard rates
Below 20% Under Individual Program or
+100% to standard rates

79. Franchise Process
 Accounts with 5-19 heads;
Agents must use template
proposal with published rates.
 Accounts with 20- 50 heads
Email request of proposal to Account
Office.
( TURN AROUND TIME : 1 DAY)

80. Franchise Process
 Accounts with 51-99 heads
Submit the following:
1. Franchise Form
2. Prospective Corporate Account Form
(Same franchising requirements apply to
Corporate Accounts.)
( FRANCHISE APPROVAL TAT: 1 DAY)

81. Franchise Process
 INITIAL FRANCHISE VALIDITY
- 60 calendar days from date of
franchise approval
 FRANCHISE EXTENSION
FRESH ACCOUNTS
- up to 120 days
COMPETITOR ACCOUNTS
- effective date of HMO coverage
*same franchising validity applies to Corporate Accounts.

83. Account’s Categories by Size
GROUP 5 to 19 principals (under Maxicareplus)
SMALL CORPORATE 20 to 99 members (under Maxicareplus)
MEDIUM CORPORATE 100 to 499 members (under Corporate)
LARGE CORPORATE 500 to 999 members (under Corporate)
JUMBO CORPORATE 1,000 to 4,999 (under Corporate)
SUPER JUMBO CORPORATE 5,000 and up (under Corporate)

84. Benefits Limits
MAXIMUM BENEFIT LIMIT ANNUAL BENEFIT LIMIT
(MBL) (ABL)
• Maximum amount that a member • Maximum accumulated amount
can avail of per illness or injury that a member can avail of for all
during the coverage year; types of illnesses during the
coverage year.
• Does not include ACU • Includes ACU’s, consultations and
routine procedures.
• Only applicable for Corporate
Plans

85. Funding Arrangements
Full Risk (Premium- based)
• Requires for the payment of membership fees.
Administrative Services Only (ASO)
• Requires an account to set up and maintain a fund [revolving fund]
• Is replenished to a certain minimum level [threshold limit]

86. Funding Arrangements
Administrative Services Only (ASO)
• Requires minimum number of enrollees = 200
• Revolving Fund (equivalent to 3 months claims)
• Threshold Limit (equivalent to 1 month claims)
• Standard Network Access Fee (NAF) = 450
• Standard Processing Fee (PF) = 100
• Standard Claims Handling Fee (CHF) = 13.5%

87. Contract Type
 Full HMO
– In-patient
– Out-patient
– Preventive care
– Annual Check-Up
– Emergency care
Above benefits are all subject to certain
exclusions, limitations and conditions.

88. Contract Type
 Unbundled In-patient (IP)
– Standard IP benefits under
the Full HMO product
– OP surgery
– OP radiotherapy
– OP chemotherapy
– OP dialysis
– Preventive care (except Passive and Active
Vaccines)
– Emergency treatment that leads/doesn’t lead
to confinement

89. Contract Type
 Unbundled Out-patient (OP)
– Standard OP benefits under the Full HMO
product except:
OP surgery
OP radiotherapy
OP chemotherapy
OP dialysis
– Preventive care
– OP emergency

90. Unbundled Products
 Requires at least 100 members
 Standard unbundled products will only be :
(a) Unbundled Inpatient
(b) Unbundled Out-Patient
Combination of these is subject to approval of Chief Actuary.

91. Availment Access

92. Maxicare EReady

93. The Maxicare Eready Card
 The first Maxicare Emergency Prepaid Card;
 Provides a one – time coverage for illnesses
or injuries during emergency cases or
conditions at a very low price;
 Open for both Maxicare members and non-
members aged 15 days old to 65 years old*;
Up to 2 enrollment is allowed per person per year with (3) months interval from the 1 st
enrolment.

94. The Maxicare Eready Card
PLAN TYPES
Plan 788: Plan 988:
Without access to 6 Major Hospitals With access to 6 Major Hospitals
1.Asian Hospital
2.Cardinal Santos Medical Center
3.Makati Medical Center
4.St. Luke’s Quezon City
5.St. Luke’s Global
6.The Medical City

95. The Maxicare Eready Card
 Coverage for Maxicare standard ER benefit (exclusion conditions shall apply)
 Coverage is limited to one (1) time availment only per membership card per year;
 Access to Maxicare accredited hospitals nationwide up to P15,000 for the first 24
hours;
 Life AD&D (Accidental Death and Dismemberment) up to P25,000 with Double
Indemnity Feature;
 20% discount from Metro Dental Services. (www.metrodental.com.ph)
 15% discount from My Health Services. (www.myhealth.ph)

97. It is the first prepaid Inpatient Benefit Card specifically designed to provide a
one-time coverage on the following confirmed coverable diseases -
 Dengue
 Malaria
 Cholera
 Typhoid and Paratyphoid
 Gastroenteritis
Pneumonia

98. PLAN ROOM AND LIMIT NETWORK MEMBERSHIP
TYPE BOARD ACCESS FEE
Gold 1 Regular Private Php 25,000 Without Access to Php 1,599
6 Major Hospitals
Gold 2 Regular Private Php 25,000 With Access to 6 Php 2,199
Major Hospitals
6 MAJOR HOSPITALS:
Asian Hospital
 Cardinal Santos Medical Center
 Makati Medical Center
 St. Luke’s Medical Center Quezon City
 St. Luke’s Medical Center Taguig
 The Medical City

99.  Room and Board Accommodation
 Use of Operating Room, Intensive Care Unit (ICU), Isolation Room (if
prescribed by the Attending Accredited Physician) and Recovery Room
 Professional Fees of Accredited Attending Physicians in accordance with
Maxicare Schedule of Rates
 Standard Nursing Services
 Medicines while in confinement
 Blood products, transfusions and intravenous fluids, including blood and
screening and cross matching for member only as recipient

100. Preventive Care Individual
Outpatient Care
Inpatient Care
Family
Emergency Care
Benefit Enhancers
Optional Riders Maxicareplus
 Life Insurance and AD&D
 Maternity Care
 Dental Care
Corporate
 Cancer Insurance
Benefits

101. Plan Types and
Maximum Benefit
R&B Entitlement
Plan Room & Board Annual Check Up
Limit
Platinum / 150,000 /
Large Private Executive (OP)
Platinum Plus 200,000
Gold Regular Private 75,000 Semi-executive (OP)
Silver Semi-Private 60,000 Routine
Bronze Ward 50,000 Routine
For Corporate Product lines, limits of each plan type may be customized.

102. Preventive Care

103. Annual Check -up
 Physical Examination
 Urinalysis
 Fecalysis
 Chest X-ray
 Complete Blood Count
 ECG for members 35 yrs old and above
 Pap Smear for female members 35 YO & above
Note: Extensive Coverage varies per plan type.

104. Outpatient Care
Consists of coverage for regular consultations/ check ups.

105. Outpatient Care

106. Availment Procedure
for Outpatient Services
OPTION 1 Maxicare Primary
Care Center (PCC)
Maxicare Centers
OPTION 2
or Accredited
Clinics
Coordinators at
OPTION 3
Accredited
Hospitals

107. Step 1:
Proceed to a Maxicare Accredited
facility

108. Step 2:
Present your Maxicare card for
membership verification

109. Step 3:
Avail of the consultation

110. Step 4:
Secure laboratory slip if there is a
need to undergo any laboratory
procedure
Laboratory procedure amounting to more than
P1000.00 will need a Head Office approval.

111. Step 6:
Secure your test results from the
coordinator of the clinic/hospital

112. STEP 2 STEP 3 If required to
STEP 1
PM goes to the Medilink POS PM presents his LOE, undergo
Plan Member (PM)
terminal and swipes the card Maxicare card & 1 valid laboratory exam,
goes to Maxicare
for membership verification ID to Plan Coordinator secure Laboratory
accredited facilities
(LOE) and consultation takes Slip from the
place; Coordinator
*LOE is only valid on the day it
was swiped
STEP 5 STEP 4
For laboratory tests at P1000 below,
For tests not available at the clinic, PM may no need to secure confirmation from
proceed to Maxicare accredited hospitals. Maxicare; otherwise Hospital will get
Members should go back to the doctors at confirmation from Maxicare if cost is
the clinic/primary care center for follow-up. more than P1000

113. Inpatient Care
Consists of coverage for hospitalization expenses.

114. Inpatient Care

115. Inpatient Care
Availment Procedure

116. Availment Procedure
For In- Patient Services
Step 1:
Secure admitting slip from
a Maxicare accredited physician

117. Step 2:
Call Maxicare Hotline at least 24
hours before the admission

118. Step 3:
Proceed to the Admitting Section
of the hospital on the
confinement day to secure the
LOE

119. Step 4:
File your PhilHealth on or before
discharge

120. Step 5:
Present your Maxicare card and
sign the hospital bill before
discharge

121. Step 6:
Settle charges not coverable by Maxicare

122. Secure Admitting Slip Call Maxicare Hotline al least 24 On Confinement day, go
from a Maxicare hours before admission for to the Admitting Section
Accredited Physician assistance in securing the entitled POS Terminal to secure
room assignment and other the LOE
verification MAXICARE will
issue LOA,
member proceeds
with confinement
Settle charges not coverable File Philhealth on or
by Maxicare at the Billing
Present Maxicare Card before discharge
Section once the discharge
order is issued by the and sign the
Attending Doctor hospital bills
Secure Follow up before discharge
Prescription from the attending
Physician

123. Emergency Care
 Doctor’s Services
 Emergency room fees
 Medicines used for immediate relief and during
treatment
 Oxygen, I.V. fluids, whole blood, and human
blood products
 Dressings, casts, and sutures
 X-ray, laboratory, and diagnostic exams

124. Emergency Care
 Passive & active vaccines for treatment of
tetanus, animal bites & snake bites
 Ambulance Services up to MBL if within the
network, and up to Php2,500/member/case
if outside the network

125. Availment Procedure for
Emergency Coverage
Step 1:
Procced to the Emergency Room
of Maxicare accredited hospital

126. Step 2:
Present your Maxicare card for
membership verification

127. Step 3:
Avail of the emergency
treatment

128. Step 4:
Call Maxicare for further
assistance in case of
confinement

129. Step 5:
File PhilHealth on or before
discharge

130. Step 6:
Present your Maxicare card and
sign the hospital bill before
discharge

131. Step 7:
Settle charges not coverable by
Maxicare

132. Emergency Availment
in a
Non-Accredited
Availment in Non-accredited hospital within the Philippines Facility
Maxicare shall reimburse 80% of the Hospital Bills and Professional Fees, based on
Maxicare standard rates up to 30,000 per case for the 1 st 24hrs
Outside the Philippines
Maxicare shall reimburse 80% of the Hospital Bills and Professional Fees, based on
Maxicare standard rates up to 30,000 per case for the 1 st 24hrs
Areas without affiliated hospitals within the Philippines
Maxicare shall reimburse 100% of the Hospital Bills and Professional Fees, based on
Maxicare Standard Rates up to MBL

133. Member
Emergency Room of nearest Present Maxicare Card at the
Accredited Hospital/Clinic Emergency Section
If for Confinement Avail of treatment
at the Emergency Room
File Philhealth on or
Settle charges not covered by before discharge
Avail of entitled room plan and
Maxicare at the Billing Section notify MAXICARE within 24
once the Discharge Order is issued hours for proper assistance
by the Attending Doctor

134. Claims Reimbursement Procedure
Check Reimbursement
All claims must be submitted to the Maxicare Head Office within 30 days from date of discharge from
the hospital. The following are the required documents for reimbursement:
 Claim Reimbursement Form (CFR);
 Original Receipts of all Hospital Bills & Professional Fee of the Doctor;
 Original Charge Slips (with itemized breakdown of charges);
 Clinical Abstract, Admitting History and Medical Certificate;
 Histopath/Surgical Report (if surgical operation was done);
 Police Report in case of accident and medico legal cases:
•Processing of claims will be 30 calendar days upon receipt of the complete documents
•Checks payable to the principal will be issued by Maxicare once the reimbursement is approved

135. Claims Reimbursement Procedure
Maxicare Reimbursement Card
All claims must be submitted to the Maxicare Head Office within 30 days from date of discharge
from the hospital. The following are the required documents for reimbursement:
 Claim Reimbursement Form for MRC (with filled out SMS number and email);
 Original Receipts of all Hospital Bills & Professional Fee of the Doctor;
 Original Charge Slips (with itemized breakdown of charges);
 Clinical Abstract, Admitting History and Medical Certificate;
 Histopath/Surgical Report (if surgical operation was done);
 Police Report in case of accident and medico legal cases:
Processing of Claims will be 7-15 days from receipt of complete documents.
Approved reimbursement shall be credited to your Maxicare Card.

136. Claims Reimbursement Procedure
Maxicare Reimbursement Card
Once your reimbursement has been approved:
Your card will be activated to cash
card and you will receive
notification thru SMS of your PIN Member may withdraw the OR member may use the amount
and approved reimbursement amount to Equicom ATMs or to purchase from any of the
amount. Bancnet, Expressnet or Megalink Bancnet accredited merchants
ATMs
*Your SMS number must be
correctly reflected in the Claims
Reimbursement Form.

137. Benefit Enhancers

138. Benefit Enhancers

139. Benefit Enhancers
* Member must be an active member for 12 months

140. Optional Riders

141. Optional Riders

143. Injuries arising / resulting from;
War or any combat-related activities
while in military service

144. Injuries arising / resulting from;
Self infliction as a result of functional
disorders of the mind, alcoholism and drug
addiction or abuse

145. Member’s own
misconduct which may be
a cause of;
Gross Negligence;
Vicious or immoral habits;
Direct of Indirect participation
in the commission of a crime
whether consummated or not;
 Violation of a law or ordinance;
Unnecessary exposure to imminent
danger or hazard to health

146. Beautification Purposes:
 Cosmetic surgery, reconstructive
surgery to treat a functional defect
due to accidental injury within the
initial confinement
 Oral surgery following accidental injury
to teeth for purposes of beautification
 Weight reduction programs, surgical
operation or procedure for treatment
of obesity, including gastric stapling or
balloon procedures and liposuctions.

147. Chronic Dermatoses
except consultations
Psoriasis / Skin Asthma)

148. Government funded
healthcare entitlements
 All other government funded health-
care entitlements as
provided for by law.
 Infectious diseases (according to the
local epidemiologic patterns) that may
arise in times of epidemic (i.e. Avian
Flu, Meningococcemia, etc.) as
declared by the Department of Health

149. Personal Medical Requirements
Routine physical examinations required
for obtaining or continuing employment,
requirement in school, insurance or
government licensing

150. Involvement in the Hazardous Sport
Treatment of injuries/illnesses the
direct and immediate cause of which
is the engagement and participation of
the Member in any (a) hazardous sport
or activity i.e. scuba diving, mountain
climbing, parachuting et. al. ,

151. Any Additional or Extra Charges
Additional charges resulting from room
upgrading, or additional personal comfort
items not included in the room & board
accommodation ( T.V., telephone, etc.)

152. Any Additional or Extra Charges
 Corrective appliances, artificial aids,
prosthetic appliances
 Take home medicine
 Services obtained from Non-
Accredited Physicians and Hospitals or
other provider of care, except under
emergency care.

153. Any Additional or Extra Charges
Purchase or lease of durable medical
equipment, oxygen dispensing
equipment, and oxygen except during
covered in-patient care.

154. Other Non- Insurable Condition
• Custodial, domiciliary and convalescent care.
• Long-term rehabilitation and Psychiatric care.
• Dental and Maternity cases
• Circumcision, sex transformation, diagnosis and treatment of fertility or
infertility, artificial insemination, sterilization or reversal of such.

155. Other Non- Insurable Conditions
• All expenses incurred in the process of organ donation and
transplantation, unless the Member thereof is the recipient of such
donation or transplantation.
• All physical deformities prior to enrolment
• Experimental medical procedures, acupuncture
• Hepatitis B screening and all diagnostic examinations for Members
who have pre-existing Hepatitis B.

157. Travel Package
up to Php 25,000
HBA/ Independent Agent
for IF and Maxicareplus
 Php 3.5M minimum production
 Cut – off Period : November
 Regardless of contract date of Accreditation

158. Free 1 year HMO
Coverage
HBA/ Independent Agent
for IF and Maxicareplus
 Php 3.5M minimum production
 Cut – off Period : November
 Regardless of contract date of Accreditation
* Silver Plan; Semi – Private, up to Php 60,000 MBL ( may be upgraded)

159. Race to 5 on 25
 Php 25,000 cash incentive for a
minimum of Php 5,000,000 TCV
* 20 % paid TCV

160. Recruitment Incentive
and Referral Fee
Receive the following cash incentive for every
successful referral of agents:
 Php 2,500 – AUH
 PHP 1,500 – AUM
 Php 500 – HBA &AIA
*referred agent/s must have at least achieved
10% of their annual quota.

161. Chairman’s Challenge
Top Three agents with the highest number
of sales based on TCV will receive the following;
1st Place
- PLAQUE
- Php 40,000
2nd Place
- PLAQUE
- Php 20,000
3rd place
- PLAQUE
- Php 10,000

162. Review
Activity

163. A prospective client asks,
“What is the nature of business of Maxicare?”
The correct answer would be:
a. Non- life insurance
b. Life insurance
c. Healthcare Maintenance Organization
d. Health insurance

164. A member calls you to report that her son’s
Maxicare Intelligent Card has been lost. What
website would you recommend to process the ID
replacement?
a. Maxicare Member Gateway
b. Maxicare Portal
c. Maxicare Link
d. Maxicare Get Away

165. Which of the following best describes Maxicare’s
Primary Care Centers?
a. These are Maxicare owned healthcare facilities that offer unlimited free
consultations to Maxicare cardholders and provide medical services and
laboratory procedures at a least possible cost.
b. Maxicare’s affiliated clinics which offer consultations to all patient both
members and non – members.
c. Tertiary hospitals that offers in – patient and outpatient services.
d. None of these

166. A client asks you, “What number shall I call for
my general inquiries about eligibility and
benefits?
The correct answer would be:
a. 582-1900
b. 582-1990
c. 582-9000
d. 582-1999

167. A client asks you;
“When was Maxicare founded?”,
Your response would be;
a. 1985
b. 1990
c. 1987
d. 1984

168. You are about to present Maxicare’s products to a
client. He/she is interested to a product with only 1
enrollee. What is the best Maxicare product for the
client?
a. Family
b. Group
c. Individual
d. Maxicare Plus

169. A client with 1 enrollee asked you,” What is
the age eligibility for an Individual Plan?”
The correct answer would be;
a. 2 – 60 years old
b. 1 month old – 70 years old
c. 2 years old and up
d. 2 years old, renewable up to 65 years old

170. A client who wants to avail an Individual and
Family plan ask ,”How many prophylaxes are
allowed per member per year?”
The correct answer would be;
a. 1 c. 2
b. 3 d. 5

171. Rule of Hierarchy refers to;
a.non-selection of dependents to be enrolled for a Maxicare
plan
b.selection of dependents to be enrolled for Maxicare plan
c.pre - selection of dependents to be enrolled for Maxicare plan.
d.None of these.

172. You are discussing platinum plan for Family and
individual program when a client asked you;
“How much is the coverage for Acquired Dreaded and
Non Dreaded condition on the first year of
membership under Platinum Plus?”
Your answer would be;
a.Php 20,000 b. Up to MBL
c. Php 15,000 d. Up to ABL

173. Situation
Nick, a company manager called you to inquire
about Maxicare Plus.

174. Nick asked; “What is the minimum number of the
principal enrollees in order for the company to be
accepted in a Maxicare Plus program?” Your answer
would be;
a. 5 b. 99 c. 50 d. 10

175. Nick asked you about the different modes of
payment for Maxicare Plus. Which of the following
modal payment is applicable to Maxicare Plus?
a. Per payout cut-off
b. Annual mode of payment
c. Monthly mode of payment
d. Weekly mode of payment

176. Nick’s company is located in Mindanao and they
would like that their medical network access be in
that region only. What Maxicare Plus variant will
you offer?
a.Maxicare Plus Provicial – Mindanao access
b.Maxicare Plus Nationwide access
c. Maxicare Plus Luzon – Access
d.Maxicare Plus – Visayas Access

177. A client asks you; “When will the coverage for
acquired dreaded condition commence?”
a.Right after the effectively of the contract.
b.On the 2nd year of a continuous contract.
c.On the 3rd year of a continuous contract
d.It will never be covered

178. The following belongs to the ineligible
group/industries under a Maxicare Plus program
except:
a. Law Firm
b. Full Time Athletes
c. Construction Companies
d. Religious Group/Sector

179. Situation
Ralph an HR manager of a multi- national
company with 2000 employee.

180. He asks you,” What are the standard benefits
coverage for corporate plan?”. Your best answer
would be;
a.Inpatient, Outpatient, Emergency ,Preventive, & Annual Checkup
b.Inpatient only
c.Emergency, Outpatient and Preventive
d.Emergency and Preventive

181. A client asks if they can still change the benefits
under a corporate plan, your answer would be:
a.Yes, because corporate account can be customized depending
on the corporation’s needs.
b. No, because in order to have a corporate account, the
company needs to avail all the health program of Maxicare.
c. Both answers are correct.
d. None of these.

182. What are the covered benefits under an
OutPatient Unbundled program ;
a. Standard out – patient benefit under the full HMO benefit
except out – patient benefits that are offered in in-patient
unbundled program.
b. Out – patient radiotherapy, out – patient dialysis and
preventive care
c. Out – patient surgery, consultations and Emergency care
d. All of the above

183. Ralph asks; “What are the different availment
modes that can be offered in a Corporate Plan?”
a. Hospital –based and Clinic based.
b. Hospital only
c. Clinic only
d. None of these

184. A client asks you; “What are the different riders for
a corporate plan?” The correct answer would be;
a.Maternity benefits, dental, cancer benefit and group life insurance.
b. Annual physical examination, maternity
benefit and group life insurance.
c. Cancer benefit, emergency benefit and dental.
d. None of these

185. The client wants to know the price of Maxicare
EReady card. The answer would be;
•788 and 988 c. 799 and 899
•750 and 950 d. 699 and 799

186. The client asks you; “How much is the maximum
emergency coverage of the EReady card?”
a. Php 15,000 c. Php 10, 000
b. Php 20, 000 d. Php 5, 000

187. The client asks; “How many times can I use the
EReady card?
a. Once b. twice
c. trice d. unlimited

188. The client wants to know when the card will be
ready for use once registered. Your answer would
be;
a. After 7 calendar days
b. Within 7 business days
c. After 3 calendar days
d. Within 3 business days

189. What is the expiration date of Maxicare EReady
Card if registered and activated?
a.1 year after the activation day.
b. 6 months after the purchase
c. 1 year after the purchase
d.6 months after the activation day

190. A client asks you; “what is the initial availment
process for emergency cases.
a. Proceed directly to ER and show your Maxicare Card.
b. Go to Maxicare’s medical coordinator and secure LOA
c. Call Maxicare’s call center and ask for assistance.
d. None of these

191. A Maxicare member asks; “How much will you cover
for a consultation to a non - accredited doctor? The
correct answer would be;
a. 80 percent of the actual cost
b. Maxicare Rate
c. 100 % of the actual cost
d. Not covered

192. How many days will Maxicare allow a member to
file for a reimbursement claim?
a. within 30 calendar days from date of availment
b. 20 calendar days from date of LOA issuance
c. within 30 calendar days from date of discharge
d. 30 calendar days from date of LOE issuance

193. Within how many days can an IF (individual/family)
member file for a reinstatement of policy?
a. within 30 calendar days from effective date
b. within 45 calendar days from policy lapsation date
c. within 30 calendar days from policy lapsation date
d. within 45 calendar days from effective date

194. What is a pre – existing condition?
a. It is a condition or a disease that is present or diagnosed
before the enrollment of the member to Maxicare .
b. It is a condition or a disease where in there is no cure.
c. It a condition or a disease that is present after the
enrollment
d. None of the above

195. A client is asking if a personal nurse will be covered
by Maxicare; The correct answer would be;
a. Yes, because it is a part of in – patient coverage.
b. Yes, because since, you are a customer you can request
what you want
c. No, because a private duty nurse has a very expensive rate.
d. No, because personal nurse, other additional hospital
charges such as telephone and TV, etc.,

196. A client called you complaining that the medical
coordinator told her that take home medicines are not
covered by Maxicare. Your best response would be;
a. “Please be informed that take home medications are part of
the exclusion of the plan.”
b. “Only medications used inside the emergency room for
treatment and medication administered within confinement
will be covered by Maxicare.”
c. “That should be covered, wait I’ll call the medical coordinator.”
d. Both a and b

197. A member is inside the Emergency room due to a
vehicular accident. In order for Maxicare to cover
the medical expenses, what initial document does
the member need to secure.
A.Medical abstract
B.Police report
C.Admitting History
D.Driver’s License

198. Maxicare will not cover any medical expenses
for a vehicular accident of the member if;
a. There is any violation of the law or ordinance
b. Cannot present a police report
c. The driver is drunk
d. All of the above

199. A member who will undergo a kidney transplant
asked you if both the donor and recipient will be
covered by Maxicare. Your response would by;
a. Yes, it will be covered since the members will be the recipient
of the organ.
b. Yes, it will be covered, as long as the purpose of the donation
is not for organ selling or buying,
c. No, because, all expenses incurred in the process of organ
donation and transplantation if the Member is the donor of
such donation or transplantation is part of the exclusion.
d. Both A and B