COVID-19: Avega and PhilHealth Coverage
February 4, 2021
The Philippine Health Insurance Corporation (PhilHealth) will shoulder the cost of treatment for patients with COVID-19 based on a case-rate package. The state-run insurance agency has also clarified that patients may use their health insurance coverage and mandatory discounts, such as senior citizen and PWD discounts, to help substantially cover the cost of treatment.
As your partner in healthcare management, ActiveLink reached out to Intellicare on how the HMO policy will apply for the duration of the community quarantine period. For your guidance, please refer to the information below:
1. Will Avega cover availments for COVID-19?
Avega will continue to provide coverage for COVID-19 provided that the patient availed the services within the Avega-accredited network. Medical benefits will be deducted first before applying the PhilHealth benefits for medical expenses related to Probable and Confirmed COVID-19 cases inpatient care. This is in compliance with PhilHealth Circulars 2020-009 and 2020-011. However, most facilities apply the HMO coverage net of PhilHealth. Avega will follow the hospital's protocol given this case. Please take note that Avega’s coverage will be based on the final diagnosis and the member’s maximum benefit limit.
2. Will Avega cover testing costs?
Meanwhile, RT-PCR test to be conducted for patients who are not manifesting signs and symptoms of COVID-19 as a screening test will not be covered. The following are also
not covered:
- Any rapid antibody tests
- Patient is asymptomatic
- Even if recommended by a doctor to undergo swab test after testing positive in a rapid antibody test conducted in the company
- Even if exposed to a COVID-19 positive patient
- Initial test is negative, unless symptomatic
- Test is for pre-surgery, maternity delivery and other gynecological procedures
-
· Prescribed by doctor to undergo swab test after testing positive in a company-conducted antibody test.
3. If the treatment was done in a government hospital, will Intellicare allow reimbursement?
No. Avega will not cover treatment availed in government hospitals. Avega will only cover reimbursements for emergency availments in non-affiliated private hospitals, subject to:
- Avega’s Relative Value Scale;
- Member’s maximum benefit limit; and
- Evaluation and approval of Intellicare.
- Outright coverage applies if member availed in an Intellicare-accredited facility.
4. How much will PhilHealth cover for COVID-19 treatment? And how does this apply with Intellicare’s coverage?
For patients who were admitted starting April 15 2020, PhilHealth will cover the admission cost based on a case rate package:
SEVERITY
|
PACKAGE AMOUNT (PHP)
|
HOSPITAL CATEGORY
|
Mild pneumonia in the elderly or with comorbidities
|
43,997
|
Levels 1-3 hospital, private room
|
Moderate pneumonia
|
143,267
|
Levels 1-3 hospital, private room
|
Severe pneumonia
|
333,519
|
Levels 2-3 hospital, private room, ICU
|
Critical pneumonia
|
786,384
|
Levels 2-3 hospital, private room, ICU (capable of ECMO, RRT)
|
5. Will there be additional fees charged to HMO patients?
Effective June 1 to September 1, 2020, Avega agreed to increase the professional fees of major medical societies such as Philippine College of Physicians (PCP). Philippine College of Surgeons (PCS), Philippine Obstetrical and Gynecological Society (POGS), and Philippine Pediatric Society (PPS).
Avega will also cover charges for the use of Personal Protective Equipment (PPE) for inpatient and emergency room availments (except for outpatient availments), subjects to the limits established by the AHMOPI.
6. I have other questions regarding COVID-19. Whom can I contact?
Should you have further concerns or clarifications, you may get in touch with:
-
Avega:
- Customer Care Support: (02) 7902-3400 or (02) 8789-4000
- Medgate for phone consultations:
- Hotline: (02) 8705-0700
- Globe: 0917 536 2156
- Smart: 0998 990 7540
- Sun: 0925 714 7794
-
ActiveLink:
You may also call the following COVID-19 dedicated hotlines:
- Department of Health: (02) 894-26843 or dial 1555
- Philippine National Police:
- Globe: 0917 312 5626
- Smart: 0998 894 0013
- Philippine General Hospital (Telemedicine Hotline): Dial 155200
- Philippine Red Cross: Dial 1158
Note: The above provisions are based on the notification sent by HMO providers, which are subject to change without prior notice. For more details about your HMO coverage, you may log in to your Benefits Made Better account, ActiveLink mobile application or email us at [email protected].
