Health Care Service Coverage Proposal

for

CUTA FARMERS MULTI-PURPOSE COOPERATIVE

by

COOPERATIVE HEALTH MANAGEMENT FEDERATION

 COOPERATIVE HEALTH MANAGEMENT FEDERATION
2nd Floor Unit 208-209 Malakas Suites Bldg.,No. 88 Malakas St., Brgy. Pinayahan, Diliman, Q.C
Tel. Nos.: (02) 283-2321 * Fax No.: (02) 931-0387 Email Address: onecoophealth@gmail.com

November 29, 2019

FLORA D. BUENA
BOD Chairperson
CUTA FARMERS MULTI-PURPOSE COOPERATIVE
Brgy. Cuta, Barugo, Leyte

Dear Ms. Buena:

The Cooperative Health Management Federation (CHMF), a health maintenance organization

(HMO), has designed a healthcare program proposal to the individual members of your co-
operative with breakdown as follows:
ANNUAL ANNUAL PREMIUM MAXIMUM BENEFIT
ROOM AND
AGE PREMIUM (per head) LIMIT (MBL)
BOARD
(per head) w/ HIB P500 /ILLNESS
12-65 WARD P 3,600.00 P 4,100.00 P 60,000.00 / ILLNESS

66-70 WARD P 7,200.00 P 7,700.00 P 60,000.00 / ILLNESS

71-75 WARD P 10,800.00 P 11,300.00 P 60,000.00 / ILLNESS

HIB – HOSPITAL INCOME BENEFIT (applicable for In-Patient only)

A. COVERAGE : Cooperative Officers, Staff, Dependents

and Members

B. NUMBER OF ENROLEES : 300

Officers: ____ Staff: ____
Dependents: ____ Members: ____

C. CONTRACT PLAN : WARD

D. MEMBERSHIP ELIGIBILITY :

 Officers, Staff and Members : 18 to 75 years old

 Dependents : 12 to 75 years old

E. CLASIFICATION OF DEPENDENTS:

1. For married cooperative officers, staff and members:

 Legitimate Spouse : 18 to 75 years old

 Child/Children (Single) : 12 to 45 years old

2. For single cooperative officers, staff and members:

 Parents : up to 75 years old

 Siblings (Single) : 12 to 45 years old

3. For single parents:

 Child/Children (Single) : 12 to 45 years old

 Parents : up to 75 years old
 F. Health Plan features and advantages:

a. Open to all cooperative members. No medical screening required;

b. Pocket friendly and you can get full 24 hour coverage;
c. Premium payment can be facilitated through cooperatives;
d. Zero or minimal out of pocket expense;
e. Comprehensive coverage benefits: consultation, treatment, annual P.E., dental
service, death benefit, accident insurance, etc;
f. Prompt payment of bills;
g. Immediate attention from admission to discharge especially in emergency and
critical cases;
h. Open door policy: all hospitals fully accredited in case of emergencies;
i. 24/7 coverage, 24/7 hotline;
j. Custom-tailored membership orientation programs & periodic service quality
forums.

Membership in CHMF is open to all types of cooperatives by subscribing to and paying for
100 shares with par value of Php 1,000 per share or Php 100,000.00 with minimum enrol-
lees of 300 members.

If our program fits the healthcare needs of your cooperative, simply sign the conforme space
below along with the attached documents and we will organize orientation sessions for your
members. Contact us at 0917-5067809 / 0998-9668501 / 0943-1327628 / TOLL FREE NO.
180010-9310387.

Cooperatively yours,

CHONA F. AMPARO
Regional Agency Manager

Noted by: Conforme:

NAYDA T. CANITA FLORA D. BUENA

Chief Operating Officer BOD Chairperson
 Health Care Program Benefits
IN PATIENT BENEFITS
(Hospital Confinement)
A. Confinement in a COOP HEALTH accredited Hospital
(MBL-Maximum Benefit Limit up to P 60,000.00 per illness)
1. A member confined at our accredited hospitals may avail of the following services (up
to a maximum of P 30,000 for the first single period of confinement.)
2. Confinement for Non-Accredited Hospital (In areas with no provider network) covered
100% for reimbursement.
3. Confinement for Non-Accredited Hospital covered 80% for reimbursement.
- Room & Board
- Operating Room, Anesthesia and Recovery Room
- Professional services of specialists
- Blood transfusions and Intravenous fluids
- X-ray, laboratory and other, diagnostic examinations
- Administered medicines
- Dressings, plaster casts, sutures and other items related to the management of
the patient
- Other coverable hospital services, when deemed necessary by designated attend-
ing physician
- ICU confinement ( Intensive Care Unit )
- CT Scan & Ultrasound ( Computed Tomography )
- MRI ( Magnetic Resonance Imaging )

B. Confinement in non-accredited hospitals in Emergency cases

Reimbursement of 100% of the member’s covered benefits for confinement in a non-
accredited hospital, inclusive of professional fee but shall not in any case be more than
P 30,000 for the first single period of confinement.

- Room and Board

- Operating Room, Anesthesia and Recovery Room
- Professional services of specialists
- Blood transfusions and Intravenous fluids
- X-ray, laboratory & other, diagnostic examinations
- Administered medicines
- Dressings, plaster casts, sutures & other items related to the management of the
patient
- Other hospital services, when deemed necessary by designated attending
- physician
- ICU confinement ( Intensive Care Unit )
- CT Scan & Ultrasound ( Computed Tomography )
- MRI (Magnetic Resonance Imaging )

OUT PATIENT BENEFITS

A. Outpatient Services
Outpatient services shall be made available to members in accredited Clinics (unlimited
consultations for the whole year and a Maximum Limit of P 10,000.00 for all minor OPD
Laboratories).

1. Medical consultations during regular clinic hours, excluding prescribed medicines

2. Treatment of minor injuries or illness
3. Laboratory, X-ray and other diagnostic examinations prescribed by physician on
duty
4. Referral to specialists

B. Emergency Care Services

Emergency care services without confinement shall be made available at accredited and
non- accredited hospitals / clinics (up to a maximum amount of P 10,000 per incident
but not to exceed P 30,000 per year)

- Doctor's services
- Medicine, X-ray, laboratory examinations and blood transfusions during the
emergency.
- Oxygen and intravenous fluids
- Dressing, casts, and sutures
- Other emergency services and treatment deemed necessary by the attending
Physician.
C. Preventive Health Care Benefits
The following preventive and wellness program shall be made available for free:

1. Counseling on health habits, diet, family planning

2. Recording and review of medical history

D. Annual Physical Examination (Basic 5)

The following basic annual physical examination can be availed after 3 months of
membership:

1. Chest X-ray
2. Urine Test
3. Fecalysis
4. Complete Blood Count
5. Physical Examination

E. Dental Care Services

The following Dental Care Services shall be made available at COOP HEALTH accredited
dental clinics:

1. Annual Prophylaxis
2. Simple tooth extractions up to two (2) extractions per day
3. Temporary fillings up to two (2) procedures per day
4. Consultation & Oral examinations

NOTE: Reimbursement of Php 250.00 per procedure for all non-accredited dental clinics.
Dental services for members aged 66-75 years old are not covered.

Financial Assistance or Death Benefit

COOP HEALTH provides financial assistance to the heir and / or assign of a member
validly enrolled in COOP HEALTH’s Health Care Program in case of death through natural
or accidental.

A. Death Benefit

1. Natural Cause of Death ( P 10,000.00 )

2. Accidental Cause of Death ( P 20,000.00 )
(excluding motorcycle accident/death for 66-75 years old)
3. Unprovoked murder and assault ( P 20,000.00 )

Additional Features
1. Open Door
- All cooperative members with ages between 18 to 65 years old, may qualify for
membership with COOP HEALTH, there is no need for medical examination for
enrollment except when required by the COOP HEALTH medical staff. COOP
HEALTH, however, reserves the right to reject any membership application for
whatever reason at any time.

2. Convenient Payment System

- Payment of membership fees for plans may be facilitated through cooperatives.

3. Open Door Policy in Emergency cases

- Members needing emergency treatment, with or without confinement, may avail of
the services of the nearest available hospital or clinic, accredited or non-
accredited. For emergency cases treated without need for confinement, COOP
HEALTH will facilitate prompt reimbursement and or actual payment of coverable
hospital bills even if the hospital is a non-accredited.

4. 24/7 membership assistance

- Members in need of medical services may call COOP HEALTH hotline that are
manned on a 24 hour basis.
 HEALTH CARE PROGRAM

CUTA FARMERS MULTI-PURPOSE COOPERATIVE

SCHEDULE OF COOP HEALTH BENEFIT AND FEES
WARD WARD (WITH HIB)
PREMIUM / BENEFIT SCHEDULE
(12-65 years old) (12-65 years old)
Annual Premium P 3,600.00 P 3,600.00 + P 500 (HIB)
Number of Enrollees 300 300
Room & Board Ward Ward
Out-Patient:
1. Consultation
1.1 Accredited Clinic Covered Covered
1.2 Non-Accredited Clinic Covered – 80% reimbursement Covered – 80% reimbursement
1.3 Areas with no provider Covered – 100% reimbursement Covered – 100% reimbursement
2. OPD Laboratories Maximum of P 10,000 / year Maximum of P 10,000 / year
Out-Patient Emergency Treatment of ill- Maximum of P 30,000 / year Maximum of P 30,000 / year
ness and injury:
1. Accredited Hospital Covered Covered
2. Non-accredited hospital Covered Covered
3. Medicolegal cases Reimbursement only Reimbursement only
4. Anti-rabies and anti-venom Covered (first dose only) Covered (first dose only)
In-Patient Hospital Confinement: P 30,000 / illness for the first P 30,000 / illness for the first
single confinement single confinement
1. Non-emergency Covered – up to MBL Covered – up to MBL
(Accredited hospital)
2. Non-emergency Covered – 80% reimbursement Covered – 80% reimbursement
(Non-accredited hospital)
3. Emergency confinement Covered – up to MBL Covered – up to MBL
Hospital Income Benefit (HIB)
1. Hospital Income Benefit N/A P 200/day max 30 days
2. Medicine subsidy N/A P 4,500.00
3. Ambulance transfer N/A P 2,500.00
Maximum Benefit Limit P 60,000 / illness P 60,000 / illness
Prescribed Take Home Medicines Not covered and other standard Not covered and other standard
(Out-Patient) exclusion exclusion
Dental Services:
(not covered for 66-75 yrs old)
1. Simple tooth extraction Covered – two (2) per day Covered – two (2) per day
2. Temporary filling Covered – two (2) surface per day Covered – two (2) surface per day
3. Permanent filling Not covered Not covered
4. Prophylaxis Covered – one (1) per year Covered – one (1) per year
Annual Physical Examination X-ray, CBC, Urine test, Stool test & X-ray, CBC, Urine test, Stool test &
(can be availed after 3 months of membership) Physical Exam Physical Exam
Pre-existing Illness Covered after 1 year of Covered after 1 year of
membership membership
Financial Assistance: Death Benefit
1. Natural Death P 10,000.00 P 10,000.00
2. Accidental Death P 20,000.00 P 20,000.00
(excluding motorcycle accident/death
for 66-75 yrs old)
3. Unprovoked murder and assault P 20,000.00 P 20,000.00
Physical Therapy Session Not covered Not covered
ELIGIBILITY:
 Special accommodation for over-aged enrollees
The following rates shall apply but not to exceed 10% of the total eligible enrollees:
** 66 to 70 years old – twice (2x) the premium rates,
** 71 to 75 years old – thrice (3x) the premium rates.
 All Enrollees must be a member of PhilHealth. In case an enrollee is not a PhilHealth member, the PhilHealth
portion must be paid by the member directly to the hospital at the point of availment (upon discharge).

Prepared by: Checked by: Endorsed by: Approved by:

LUCY MARIE L. RAMIREZ SHARON M. SANTOS ANDREA MILES B. VARGAS NAYDA T. CANITA
Marketing Staff Marketing Assistant Actuarial Assistant Chief Operating Officer