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A
Affiliated Hospital
A duly licensed hospital included in the list of affiliated hospitals of Maxicare with which Maxicare has an existing and valid service agreement where a Member can avail of Medical Services pursuant to this Agreement.
Affiliated Medical Clinic
A duly licensed medical healthcare facility included in the list of affiliated medical clinics of Maxicare which has an existing and valid affiliation agreement with Maxicare where a Member can avail of Medical Services pursuant to this Agreement.
Affiliated Medical Staff
A group of medical practitioners and other allied health professionals who are affiliated and authorized by Maxicare to deliver the required Medical Services to Members.
Affiliated Physician or Specialist
A duly licensed physician or specialist affiliated by Maxicare and named in the list of Maxicare’s affiliated physician with whom Maxicare has made arrangements to provide the required services under this Agreement.
Agreement
This Service Agreement, including all schedules, attachments, endorsements, addenda, Conforme Letter, Membership Application Form, and any other contracts or documents relevant to the relationship between the Member, Client and Maxicare.
Alternative Medicine
This is defined as therapeutic practices which are not currently considered an integral part of conventional allopathic medical practice. Alternative medicines include, but are not limited to the following disciplines: folk medicine, herbal medicine, diet fads, homeopathy, faith healing, new age healing, chiropractic, acupuncture, naturopathy, massage, and music therapy.
Annual Benefit Limit (ABL)
Annual Benefit Limit – the maximum liability that Maxicare shall assume for all covered services rendered to a Member within the term of this Agreement. The covered services include inpatient benefits, outpatient benefits, preventive healthcare benefits and emergency benefits but excluding Annual Check-up (ACU). ABL is replenished upon renewal of this Agreement but not during extension.
B
Balance Billing
It is the act of an Affiliated Physician and other health practitioners to charge Members for the difference between their desired higher professional fees and the agreed Maxicare standard professional fees for services rendered
C
Confinement/ Hospitalization
The state of being admitted in an Affiliated Hospital or Affiliated Medical Clinic.
Convalescent Care
The recovery of health and strength after an illness or injury.
Custodial or Maintenance Care
The degree of care furnished primarily to provide room and board, which may or may not include nursing care, training, personal hygiene, and other forms of self or supervisory care, to those persons who are physically or mentally disabled or both AND
Who are not under any specific medical, surgical or psychiatric treatment to reduce the existing disability to the extent medically necessary to enable the patient to live outside an institution providing such care; or
When despite such treatment, there is no reasonable possibility that the disability will be reduced or diminished.
D
Domiciliary Care
Degree of care provided in the patient’s home when in-patient care is not medically necessary.
E
Emergency Condition
A life threatening or accidental injury or a sudden and unexpected onset of a condition or illness which at the time of the occurrence reasonably appears to have the potential of causing immediate disability or death, or which requires the immediate action or alleviation of pain or discomfort. These illnesses or injuries require urgent medical or surgical care and attention which the Member secures immediately after the onset or as soon as the care may be made available but in any case not later than twenty four (24) hours after the onset. Heart attacks, cardiovascular accidents, poisonings, loss of consciousness or respiration and convulsions are some examples of emergency conditions.
Experimental Medical Procedure
Are any device, medical treatment, supply or procedure which is not established or unproven, whose safety and efficacy is considered investigational. These tests/procedures shall be classified under the category of Experimental Medical Procedures in the Maxicare Service Agreement, Benefits and Coverage.
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H
I
ID Card
The identification card issued by Maxicare to a Member containing the latter's name and signature, ID reference number, and other matters pertaining to his Membership
In-Patient Medical Services
The hospitalization services which include accommodations, medicines and supplies, procedures and/or surgery whenever medically necessary, furnished to a patient admitted in an Affiliated Hospital.
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M
Maxicare Coordinator
A duly licensed medical practitioner designated by Maxicare in an Affiliated Hospital or Affiliated Medical Clinic to direct and supervise the extension of Medical Services to Members, and who may render medical advice, prescribe medication or treatment, issue referrals to Affiliated Specialists, and request for laboratory examination and hospitalization, upon consultation by Members.
Maxicare Multifunction Card
The membership card issued by Maxicare to a Member which serves as the gateway for the Member to avail of his / her benefits.
The Maxicare Multifunction Card has three (3) functions:
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- Health Card – for the needed medical services
- Privilege Card – for the special privileges offered by Maxicare Lifestyle Partners
- Cash Card – for approved reimbursements
Maximum Benefit Limit (MBL)
The maximum liability that Maxicare shall cover and assume per covered illness or injury of a Member within the one-year term of this Agreement, including all Out-patient, In-patient and Emergency Care Benefits for any one-year period with respect to any particular disease/condition and their complications, but excluding ACU. MBL is replenished upon renewal of the Agreement by Client but during any extension thereof.
Medically Necessary
A Medical Service, as determined by Maxicare, which is (a) consistent with the diagnosis and customary medical treatment of the condition, (b) in accordance with the standards of managed care and good medical practice, (c) not for the convenience of the Member or the Affiliated Physician or Specialist, (d) performed in the most cost effective manner required by the medical condition and (e) consistent with the terms and conditions of this Agreement.
Member
A Principal and/or Dependent who is eligible, has been accepted for Membership by Maxicare after complying with the Membership Eligibility, and is currently enrolled under this Agreement.
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Reasonable Charges
Professional fees of non-Affiliated Physicians for services rendered to Members which do not exceed the standardized professional fees/terms of the Affiliated Physicians/Specialists. In cases where Maxicare does not have a standard professional fee for the professional service rendered, Maxicare reserves the right to determine the amount of reasonable charges for the said service.
Related Condition
An illness, condition, or disease which is associated with the particular diagnosis in question either as a direct symptom or sign, a risk factor, an underlying cause, a part of a syndrome, or a complication including complications of diagnostics and treatment.
Room and Board Accommodation
The pre-assigned type of hospital room and board by Maxicare to the Member based on the benefit and coverage of the health care plan under this Agreement.
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A
Affiliated Hospital
A duly licensed hospital included in the list of affiliated hospitals of Maxicare with which Maxicare has an existing and valid service agreement where a Member can avail of Medical Services pursuant to this Agreement.
Affiliated Medical Clinic
A duly licensed medical healthcare facility included in the list of affiliated medical clinics of Maxicare which has an existing and valid affiliation agreement with Maxicare where a Member can avail of Medical Services pursuant to this Agreement.
Affiliated Medical Staff
A group of medical practitioners and other allied health professionals who are affiliated and authorized by Maxicare to deliver the required Medical Services to Members.
Affiliated Physician or Specialist
A duly licensed physician or specialist affiliated by Maxicare and named in the list of Maxicare’s affiliated physician with whom Maxicare has made arrangements to provide the required services under this Agreement.
Agreement
This Service Agreement, including all schedules, attachments, endorsements, addenda, Conforme Letter, Membership Application Form, and any other contracts or documents relevant to the relationship between the Member, Client and Maxicare.
Alternative Medicine
This is defined as therapeutic practices which are not currently considered an integral part of conventional allopathic medical practice. Alternative medicines include, but are not limited to the following disciplines: folk medicine, herbal medicine, diet fads, homeopathy, faith healing, new age healing, chiropractic, acupuncture, naturopathy, massage, and music therapy.
Annual Benefit Limit (ABL)
Annual Benefit Limit – the maximum liability that Maxicare shall assume for all covered services rendered to a Member within the term of this Agreement. The covered services include inpatient benefits, outpatient benefits, preventive healthcare benefits and emergency benefits but excluding Annual Check-up (ACU). ABL is replenished upon renewal of this Agreement but not during extension.
B
Balance Billing
It is the act of an Affiliated Physician and other health practitioners to charge Members for the difference between their desired higher professional fees and the agreed Maxicare standard professional fees for services rendered
