As an HR professional in the Philippines, you play a vital role in helping employees understand their company-provided health insurance benefits. Here’s a breakdown of HMOs (Health Maintenance Organizations) with a focus on Maximum Benefit Limits (MBL), a crucial concept for both you and your employees.
What is an MBL?
An MBL is the maximum amount your employee’s HMO plan will cover for a specific illness or injury within a year. Imagine it as a set budget for each medical condition. Employees can receive multiple treatments for the same illness, but the total cost cannot exceed their MBL. Once that limit is reached, they’ll shoulder any additional expenses.
Key Points about MBLs for HR Professionals:
- Per Illness/Injury: The MBL applies to each separate medical condition, not overall yearly healthcare needs.
- Yearly Reset: Any unused portion of an MBL for a particular illness does not carry over to the next year.
- HMO Approval Still Needed: Even if costs stay within the MBL, the HMO may require approval for specific treatments.
Understanding MBLs with Scenarios:
- Scenario 1: Dengue Fever
- Employee John gets Dengue Fever. His MBL for Dengue is Php 50,000.
- Hospitalization and medication cost Php 35,000 (covered by HMO).
- John recovers and doesn’t need further treatment within the year. The remaining Php 15,000 of his MBL for Dengue is unused and doesn’t roll over.
- Scenario 2: Heart Disease
- Employee Mary has a pre-existing heart condition. Her MBL for heart disease is Php 100,000.
- Throughout the year, Mary undergoes regular checkups (covered by HMO) and has a medication cost of Php 80,000 (covered by HMO).
- Unfortunately, Mary suffers a heart attack requiring surgery. The cost is Php 150,000.
- The HMO covers Php 100,000 (MBL limit), and Mary is responsible for the remaining Php 50,000.
Who can benefit from an MBL plan?
MBL plans can be suitable for:
Generally Healthy Employees: If your employees are young and healthy with a low risk of needing extensive medical care, an MBL plan with a higher limit might be sufficient.
Employees with Manageable Chronic Conditions: For employees managing predictable chronic conditions with known costs (e.g., controlled diabetes), an MBL can offer coverage as long as treatment stays within the limit.
Things to Consider for MBL Plans:
- Cost vs. Coverage: MBL plans may have lower premiums. However, exceeding the limit for a serious illness can be financially burdensome for employees.
- Employee Needs Assessment: Consider offering resources or workshops to help employees assess their health history and potential healthcare needs before choosing an MBL plan.
- Alternatives: HMO plans can also have Annual Benefit Limits (ABL) which pool coverage for all medical expenses in a year. This might be a better option for employees who anticipate needing broader coverage.
Your Role in Empowering Employees:
- Clear Communication: Ensure employees have clear and accessible information about the MBL within their HMO plan, including any exclusions.
- Guidance and Resources: Direct employees to HMO resources or organize informational sessions to help them understand MBLs and make informed decisions.
By understanding MBLs, you can empower your employees to choose the right HMO plan for their healthcare needs. This promotes a healthier and financially secure workforce. Do you want to learn more about MBL and other information about your company’s HMO? Feel free to get in touch with us and book a FREE consultation!