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Procurement of HMO Medical and Dental Insurance Plan
AI Summary
The National Irrigation Administration is procuring a comprehensive HMO medical and dental insurance plan for its employees, covering both preventive and curative services through accredited service providers. The plan is designed to support the health needs of the workforce by providing coverage that begins after PhilHealth benefits are exhausted, with a maximum benefit limit of at least PHP 65,000 per illness or disease each year. Annual physical examinations are fully covered and include a wide array of diagnostic procedures such as complete blood count, comprehensive metabolic panels, advanced cardiovascular and gynecological screenings, and key imaging studies. Dental benefits allow unlimited consultations, twice‑annual prophylaxis, and a selection of restorative procedures, with special provisions for non‑accredited providers and quarterly coverage limits.
Outpatient and inpatient services are structured to ensure accessibility to primary care, diagnostics, and hospital care, including semi‑private room accommodations and coverage of professional fees, medicines, laboratory work, and anesthesia up to the plan’s limit. Emergency care is covered with a quarterly cap of PHP 10,000 for accredited hospitals and a specified reimbursement rate for non‑accredited institutions, alongside ambulance reimbursements for both Metro Manila and provincial locations. Pre‑existing conditions are waived for 60 % of enrollees and subject to a 6‑month waiting period otherwise, and predetermined maxima apply to dreaded disease coverage. The HMO must guarantee 24/7 customer support, deliver all documentation within twenty working days of policy commencement, and submit semi‑annual utilization reports, an annual physical examination summary, and a monthly utilization summary to the NIA Medical and Dental Unit. The plan is valid for one year and subject to annual renewal conditioned on utilization and claims. The plan requires PhilHealth benefit exhaustion before HMO benefits apply and an annual maximum benefit limit of at least PHP 65,000 per illness.
Description
TECHNICAL SPECIFICATIONS
I. PhilHealth Coverage: The plan pays benefits up to its limits after PhilHealth Benefits have been exhausted
II. Maximum Benefit Limit (MBL) for each illness/disease/year
Atleast P65,000/illness
III. Annual Physical Examination (APE) not deductible to MBL
The APE coverage shall include the following procedures:
-Medical History taking including Anthropometric MEasurements and Vital Signs
-Comprehensive Physical Examination
-Chest X-ray
-Routine Urinalysis
-Complete Blood Count
-Blood Chemistry Tests: Blood Ureana Nitrogen (BUN) Creatinine, Fasting, Blood Sugar, Hemoglobin A1C (HBa1C), Lipid Profile, SGPT, SGOT, Blood Uric Acid, HSCRP (high sensitivy C reactive Protein test) for male and femaile 30 years old and above.
-Electrocardiogram (EG) for members aged 30 years and above or when medically indicated
-Serum PSA for males 40 and above
-Papsmear for females
-Plain Whole Abdominal Ultrasound for males and females
IV. Dental Care Benefits
The following dental services shall be included for accredited service providers:
-Unlimited dental consultations annually, including health education, nutritional counselling, and pain prescriptions
-Oral prophylaxis twice annually beginning on the fourth month of coverage
-Simple tooth extractions uo to three (3) annually, excluding impacted teeth and rooth canal surgeries- subject to MBL
-Temporary filling and permanent restoration up to three (3) annually, subject to MBL
-Summary report on dental procedures and treatmenrs renders per employee
-Semi-annual report on utilization of dental services
*For non-acrredited services providers:
-P 3,000/quarter-deductible from MBL
-Will only cater to dental emergency cases (consultation, tooth ache and/or simple tooth extraction)
V. Out-Patient Services
The following outpatient services shall be available:
-Integrated/Stand Alone Primary Care Clinics (if Available)
>Unlimited and Free Consultation
>Laboratory/ Diagnostic Procedures-deductible from MBL
-Accredited Service Providers:
>Consultation, laboratory/diagnostic procedures: P3,000/quarter (Deductible from MBL)
-Non-Accredited Service Providers:
>80% Reimbursement of total clinic/hospital charge but not to exceeds plan's quarterly allocation
VI. In-Patient/Hospitalization
In-patient services shall include, but are not limited to:
Accredited Service Providers
-Room and board per the NIA Employee member's entitled category and plan limits
-50% of professional fee of attending physician- subject to MBL
-Medicines, blood transfusions (including screening and cross matching), and IV Fluids- subject to MBL
-Diagnostics, therapeutic, laboratory procedures, and X-ray incidental to confinement- subject to MBL
Dressings, conventional casts (plastyer of Parts) and structures- subject to MBL
-Anesthesia and its administration- subject to MBL
-Oxygen and its administration- subject to MBL
-Other medically necessary supplies or services as determined by the Attending Affiliated Physician
-Administrative assistance via HMO Liason Office
ROOM TYPE: SEMI-PRIVATE
Non-Accredited Service Providers:
80% Reimbursement of total hospital charges but not to exceed the plan's per illness confinement allocation/year
VII. Emergency Care Services:
Emergency services coverage shall include:
-Emergency room services in accredited hospitals:
> up to P10,000/quarter (inclusive of doctor's fees, ER Charges, medications, oxygen, intravenous fluids, blood products, dressings, conventional casts (plaster of Parts), structures, diagnostics)
-Emergency room services in non-accredited hospitals:
>80% reimbursement of hospital bills and professional fees not to exceed plan's quarterly allocation, subject to MBL
-Ambulance Services: (from workplace/affiliated/non-affiliated institution to affiliated institution)
>Metro Manila- up to P 500.00 per condition (reimbursable)
>Province areas- up tp P1,000.00 per condition (reimbursable)
VIII. Pre-existing Conditions (PEC)
-Pre existing Conditions (PEC) shall be waived provided 60% of the total employees are enrolled to the program. Otherwise, PEC will be covered after Six (6) months of membership
-Coverage for dreaded diseases is provided up to a maximum limit of P10,000.00 subject to the terms and conditions of the Master Policy Contract
IX. Other Requirements:
1. Customer Support and Medical Assistance Availability
- The HMO shall maintain a responsive multi-channel customer service and medical support unit available 24/7, NIA employee members may contact the HMO through landline, mobile, Viber of designated liason officer, email and the HMO's official website or online application
2. Room & Board Incremental Charges
-HMO Coverage for hospitalization shall be limited to the NIA employee-members' MBL and prescribed room and board accommodation. Should the member opt for accommodation above the standard entitlement, all costs or incremental charges shall be shouldered by the NIA employee-member out of pocket.
3. Timeline of Deliverables
-The HMO shall deliver all relevant materials (e.g HMO cards, Statement of Account, contract documents) within twenty (20) working days from the policy inception date, provided that all required documents have been duly submitted and verified.
4. Reporting Requirements
- The HMO shall submit the following reports to the NIA Medical and Dental Unit:
> A semi-annual utilization report detailing the disbursement and usage of medical funds
> A summary report of Annual Physical Examination (APE), categorized by group or port, providing complrehensive profile of each NIA employee member
5. Plan Validity
-The corporate health plan shall be valid for (1) year and subject to annual renewal
6. Renewal Terms
- Policy renewal shall be based on the actual utilization and claims but must not exceed the specified medical allowance of P 7,000.00
7. Scope of Benefits Limits
-The MBL is inclusive of room rates, professional fees, diagnostic and therapeutic procedures, incidental expenses, consultations, and hospitalizations. All availment are subject to the applicable limits, exclusions and pre-existing condition provisions as set forth in the policy.
8. Complimentary
- Provision for Ten (10) free buffers for policy holders who will exhaust their MBL for particular preexisting condition.
Line Items
Item No. : 1
Product/Service Name : HMO Medical and Dental Insurance Plan
Description : Procurement of HMO Medical and Dental Insurance Plan
Quantity : 55
UOM : Pack
Budget (PHP) : 385,000.00
Reference Number: 13261265
Area of Delivery: Isabela
Trade Agreement: Implementing Rules and Regulations
Procurement Mode: Negotiated Procurement - Small Value Procurement (Sec. 34)
Classification: Goods
Category: Diagnostic and Laboratory Services
Bid Supplements: 0
Document Request List: 5