Sykes Hmo Benefit Plan 2016
Sykes Hmo Benefit Plan 2016
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Sykes HMO Benefit Plan
Definition of Terms
Intellicare Coordinator/Assistant Coordinator — first contact doctor for primary consultation.
Issues referral slip to other affiliated physicians/specialists for consultation/treatment, for prescribed
out-patient diagnostic evaluations, and for hospital confinement
Out-patient Case — any condition which does not require hospital confinement
In-patient Case — continuous confinement in a hospital for at least six (6) hours except in an
emergency case
Elective Case — non-emergency case that needs no urgent treatment and may be deferred
without endangering the member’s life
Emergency Case — a condition where a trained medical professional diagnoses that the
member’s life or health would be put at serious risk if no immediate attention is provided. Examples:
heart attack, stroke, poisoning, loss of consciousness, convulsion, severe dehydration, etc.
Relative Value Scale (RVS) — schedule of charges as agreed upon between the Association of
Health Maintenance Organizations of the Philippines, Inc. (AHMOPI) and various Medical Societies
using the Philippine College of Surgeons book.
Maximum Benefit Limit (MBL) — the maximum amount payable per illness per member per year.
It shall include consultations, diagnostic procedures, and hospitalization
Dreaded Diseases- a generally chronic and irreversible condition requiring frequent and/or
prolonged hospitalization, including those requiring continuous confinement for fifteen (15) days or
more.
o Cerebrovascular Accident (CVA) or Stroke, Paralysis, Epilepsy
o Spinal Cord Injury, Major Head trauma
o Central Nervous System Lesions (e.g. poliomyelitis, meningitis, encephalitis, neurosurgical
conditions);
o Cardiovascular Diseases (Coronary/Valvular/Heart Disease, Hypertensive Heart Disorder,
Myocardial Infarction,Cardiomyopathies, Coronary Heart Disease)
o Chronic Pulmonary Disease (Asthma/Bronchitis/Emphysema)
o Chronic and Acute Liver Parenchymal Diseases (e.g. liver cirrhosis, hepatitis, new growth)
o Chronic Gastro Intestinal Diseases
o Collagen Immunologic Disease (e.g. rheumatoid arthritis, systematic lupus erythematosus)
o Endocrinologic Disease (e.g. diabetes mellitus, thyroid disorders, adrenal diseases);
o Cancer/Malignancies Blood Dyscrasia (e.g. Leukemia, Idiopathic Thrombocytopenic
Purpora)
o Coma requiring the use of a mechanical respirator
o Brain tumors (Benign or Malignant)
o Aneurysm of the Aorta
o Aorta Dissection or tear in the aortic wall
o Acute Respiratory Distress Syndrome (ARDS)
o Aplastic Anemia
Sykes HMO Benefit Plan
o Sepsis or infection of the blood Second degree burns or Partial Thickness Burns involving
10-20% TBSA (Total Body Surface Area), and Third Degree Burns or Full Thickness Burns
>10% TBSA;
o Any illness other than the above which would require intensive care unit confinement
Pre-Existing Condition (PEC) — an illness or disease the member already has (with or without
their knowledge) that has been diagnosed before enrollment or during the member’s first year of
coverage. These are illnesses or diseases that do not develop over 24 hours. PEC list includes but
is not limited to the following:
o Hypertension
o Thyroid disease, Goiter
o Cataracts/Glaucoma/Pterygium
o Eye, ear, nose, and/or throat conditions requiring surgery
o Hemorrhoids and anal fistulae
o Tumors
o Uterine myoma, ovarian cyst,endometriosis
o Buerger’s disease
o Asthma
o Tuberculosis
o Chronic cholecystitis/cholelithiasis and other forms of calcification
o Hernia
o Prostate disorders
o Varicose veins
o Scoliosis
o Arthritis
o Chronic allergies
o Gastric and Duodenal ulcers
o Dreaded diseases
Sykes HMO Benefit Plan
Membership Coverage
Principal member — full time probationary and regular employees at least 18 and up to 65 years
old
Dependents of the principal member - following the hierarchy rule, enrollment of dependents
shall strictly follow the order indicated below:
o Single Employees – employees who were never married, or legally annulled with no
children
Parents - up to 65 years old
Siblings - unmarried, unemployed; from 90 days - 21 years old. Enrollment of siblings
must be in order of age, starting with the eldest to the youngest
o Single Parent Employees – Employees who are legally annulled, or were never married
but have biological or legally adopted children
Children — biological, legitimate, or legally adopted; unmarried, unemployed; from 60
days - 21 years old. Enrollment of children must be in order of age, starting with the
eldest to the youngest
o Married Employees – Employees, who are legally married, widowed, divorced, annulled,
informally separated and legally separated.
Legal Spouse — up to 65 years old
Children — biological, legitimate, or legally adopted; unmarried, unemployed; from 60
days t-21 years old. Enrollment of children must be in order of age, starting with the
eldest to the youngest
For exceptions to the hierarchy rule, employee needs to indicate reason in their enrollment for not
following the hierarchy and provide supporting documents:
o Dependent is deceased - Death Certificate of Dependent
o Dependent is overage - Birth Certificate of Dependent
o Dependent is enrolled in another HMO - Photocopy of HMO Card with effective date of
coverage
o Dependent is living abroad - Any valid document that will prove that dependent is living
abroad
o Dependent is a Sykes Employee - Photocopy of Sykes ID with Employee Number
o Others - Notarized affidavit stating the reason
Sykes HMO Benefit Plan
Dependent's Premium
No. of Dependents
Hire Date Status
Allowed to Enroll Company Paid Employee Paid
***For employees hired starting January 1, 2012, premium for first two dependents of Single
Parents/Married employees is FREE but subject to compensation tax which will be shouldered by employees.
Corresponding tax is payable within the year.
Terms of Payment: The cost of employee share premiums shall be paid within the year via salary
deductions over a period of eleven (11) months (22 payrolls for staff and 11 payrolls for managers).
Sykes reserves the right to adjust the amount of amortization as necessary to complete the annual
premium payments by December 31 payroll.
Dependent of Newly Hired Employee – enrollment should be completed within 15 days from
effective date of coverage of the principal member. Enrollment should be completed online
via Intellicare Web Tool. Submission of supporting documents should also be completed
within 45 days from effective date of coverage.
New members approaching age of ineligibility (65 for parents and spouses, 21 for children and
siblings) must be enrolled at least 6 months prior to reaching ineligibility age.
Life Events
o New born child – enrollment should be made within 90 days from child’s date of
birth. Enrollment should be completed online via Intellicare Web Tool
o New born siblings – enrollment should be made within 90 days from child’s date of
birth. Enrollment should be completed online via Intellicare Web Tool
Sykes HMO Benefit Plan
Dependents coverage is co-terminus with the principal. Once enrolled, cancellation of dependents will
only be allowed on the following instances:
o Single employee change in marital status. Existing dependents parents coverage will
automatically revoked.
o Death of a dependents
o Dependents migrated abroad or OFW
o For other reasons, employee will be allowed to cancel on the next renewal period.
In the event of employee separation from the company (whether voluntary or involuntary) or cases
enumerated above, employee shall remain liable for the applicable pro-rated premium. Amount will be
computed based on below formula but the HMO will be cancelled.
Annual Premium- total paid by the employee via salary deduction = payable by the employee
Example: 9,819.38 – 5000 = 4,819.38 to be deducted to the employee
If your total paid premium for your dependent at the time of separation is only 3,000, then the
difference between the 4,868.78 and 3,000 plus the administration cost shall be deducted from your
final pay.
Sykes HMO Benefit Plan
Health Coverage
Non-Managers 110000/illness/yr
Up to MBL Up to MBL Up to MBL
Managers & Above 120000/illness/yr
Sykes HMO Benefit Plan
Dependent of Married/Single
Parent Em ployees
= Covered up to DDL
Below Supervisosrs
Up to MBL (Subject to
120000/illness/yr Up to MBL Up to MBL
PEC Limit)
Supervisors & Above
Renewing members who will become ineligible within the year will have pro-rated PEC based
on remaining eligible period only.
Sykes HMO Benefit Plan
Schedule of Benefits
Out-Patient Care Benefits : Without Access to Healthway Clinics & St. Luke’s Global City
In-Patient Care Benefits : Without Access to Healthway Clinics & St. Luke’s Global City
Emergency Care Services : Without Access to Healthway Clinics & St. Luke’s Global City
o A foreign territory - Intellicare shall reimburse the member on what should have been
paid had the member been confined in an accredited hospital in the Philippines (based
on Intellicare’s Relative value scale), but not to exceed MBL
Sykes HMO Benefit Plan
Additional Benefits
Maximum
Treatments/Procedure
PEC Limit
Heart Surgery/Angiography/Angiogram 50000.00
Transurethral Microwave Therapy 35000.00
Percutaneous Ultrasonic Nephrolithotomy 35000.00
Lithotripsy 30000.00
Laparoscopic Procedure 30000.00
Arthroscopic Procedure 30000.00
Magnetic Resonance Imaging (MRI) 6000.00
Nuclear Radioactive Isotope Scan 5000.00
Neuroscan 7000.00
Perfusion Scan 5000.00
Dialysis PEC Limit
Chemotherapy/Radiotherapy PEC Limit
Gamma Knife Surgery(based on cobalt/radiotherapy) PEC Limit
CT Scan PEC Limit
Ultrasound(except for maternity cases) PEC Limit
Thallium Scintigraphy PEC Limit
Benign Prostatic Hypertrophy PEC Limit
2D-echo with Doppler PEC Limit
24-hour Holter Monitoring PEC Limit
Herniorraphy PEC Limit
Electromyography PEC Limit
Treadmill Stress PEC Limit
Myelogram PEC Limit
Video Gastroscopy PEC Limit
Mammography/Sonomammogram PEC Limit
Bone Densitometry Scan(Dexascan) PEC Limit
Sykes HMO Benefit Plan
Financial Assistance
Important Provisions
Co-Payment
Applicable to dependents of Legacy SMSI employees hired before July 1, 2010 onwards & SAI
employees hired January 1, 2011 onwards.
Php1,500.00 – Makati Medical Center, St. Luke’s Medical Center, Cardinal Santos Medical
Center, The Medical City, Asian Hospital Medical Center
Philhealth/ECC Provision
Sykes company/clinic doctor is authorized to issue out-patient referral forms and laboratory
request forms for simple laboratory exams (urinalysis, stool exam, chest x-ray, FBS, CBC, ECG)
to be done at accredited clinics
Services rendered by non-affiliated doctors except with the prior written authorization of an
Intellicare Coordinator or in emergency cases
Hospital charges for special or private nursing services, supplemental foods and medicines
like vitamins and minerals (unless prescribed), extra accommodation and non-medical
personal appliances such as radio, television, telephone, computer, and refrigerator
Medical certificates
Procurement or use of eye glasses, special braces, steel implants, wheelchairs, or prosthetic
appliances including but not limited to items such as artificial limbs, hearing aids, crutches,
intra-ocular lens, contact lenses, artificial hips or joints, pacemakers, mesh (for hernia), stents,
and ventilating tubes
Determining/ruling out PEC during the first 12 months of membership if result is positive
Sleep study (unless directly related to an organic illness covered up to Php 5,000)
Blood screening
Participation in hazardous activities such as skydiving, motor sports, judo, karate, boxing,
taekwondo, wrestling, bungee jumping, scuba diving, snorkeling, horseback riding, polo,
Sykes HMO Benefit Plan
hunting, mountain climbing, rock climbing, hang gliding, spelunking, ballooning, gymnastics, or
partaking as a paid professional or semi-professional in any sport
Aviation or aeronautics use or sea travel other than as a fare-paying passenger on a licensed
aircraft/vessel operated by a recognized airline/operator
Substance addiction or reaction to use of prohibited drugs, alcoholism, alcohol intake, anxiety
reaction, psychiatric and psychological illnesses, neurotic and psychiatric behavior disorders,
or accidents arising from these conditions
Guillain-Barre syndrome
Developmental delay
Any illness or disability which may have affected a dependent prior to the 30th day after birth
Philhealth/ECC Provision