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NOTE: THIS DOCUMENT IS PART OF A FORMAL SOLICITATION. DO NOT EDIT THE REQUIREMENT AND REQUIRED COVERAGE COLUMNS. OFFERORS MUST FILL IN ONLY THE "OFFERED COVERAGE" AND "COMPLIANT (YES/NO/EXCEEDS)" COLUMNS. ANY UNAUTHORIZED ALTERATIONS TO THE PRE-FILLED REQUIREMENTS MAY RENDER THE PROPOSAL NON-RESPONSIVE.
ANNEX C
BENEFITS COMPLIANCE MATRIX
The Benefits Compliance Matrix is a mandatory submittal and must be submitted as part of Volume 3 – Technical Proposal, Part 1 – Health Insurance Services. Failure to submit a complete Benefits Compliance Matrix shall render the proposal non-responsive.
Offerors must complete this matrix in full. For each benefit listed, indicate the exact coverage offered and assess compliance using the following ratings:
· YES - Offered coverage meets the stated requirement
· EXCEEDS - Offered coverage is higher than the stated requirement
· NO - Offered coverage does not meet the stated requirement
HOSPITAL-BASED PLAN - Direct Access in any Affiliated Network for Out-Patient Consultations and Simple Laboratory Procedures through Coordinator/Primary Physician/LOA Issuer.
| Requirement |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Daily Room & Board Limit |
| Open Room & Board |
| Maximum Limit for Non-Dreaded/Dreaded Diseases and/or Non-ICU/ICU Confinements |
| PhP300,000 per illness per year |
| Hospital Network Access |
| Asian Hospital & Medical Center, Makati Medical Center, The Medical City, Cardinal Santos Medical Center, St. Luke's Medical Center-Quezon City |
| Annual Physical Examination (APE) |
| Covered |
| Pre-Existing Conditions |
| Covered |
| COVID-19 Coverage – Covid-related illnesses |
| Guaranteed coverage up to MBL |
| COVID-19 Coverage – Outright RTPCR |
| Covered subject to existing guidelines and in designated facilities identified by the service provider |
| COVID-19 Coverage – Adverse effects of Covid vaccination |
| Covered subject to account benefits and limitations, especially pertaining to pre-existing and congenital conditions coverage |
A. ANNUAL PHYSICAL EXAMINATION
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Taking of Medical History |
| Covered |
| Physical Examination |
| Covered |
| Routine Urinalysis |
| Covered |
| Routine Fecalysis |
| Covered |
| Complete Blood Count (CBC) |
| Covered |
| Electrocardiogram (ECG) for members 35 years old and above or if indicated |
| Covered |
| Pap Smear for female members 35 years old and above or if indicated |
| Covered |
| Mammogram at the age of 25 years and older for female employees |
| Covered |
B. PREVENTIVE HEALTHCARE
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Health Education Counseling on diet or exercise |
| Covered |
| Periodic Monitoring of Health Problems |
| Covered |
| Family Planning Counseling |
| Covered |
| Passive and active vaccines for treatment of tetanus, rabies, venom, and animal bites |
| Covered |
| Diagnostic screenings as prescribed by the physician (Cancer Screening, Hepatitis Screening, Tuberculosis Screening, and others) |
| Covered |
| Immunizations (administration) |
| Covered |
C. OUT-PATIENT CARE
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Consultation during regular clinic hours, except prescribed medicines |
| Covered |
| Pre and Post Natal consultations |
| Covered including laboratory & diagnostic procedure |
| Eye, ear, nose and throat (EENT) treatment prescribed by an Affiliated Physician/Specialist |
| Covered |
| Treatment for minor injuries such as lacerations, mild burns, sprains and the like |
| Covered |
| Dressings, conventional casts (plaster of Paris) and sutures |
| Covered |
| Diagnostic tests, diagnostic screening and diagnostic imaging, X-ray, laboratory examinations, routine, diagnostic and therapeutic procedures prescribed by an accredited physician/specialist |
| Covered |
| Specialist consultations and treatment, including second surgical opinion |
| Covered |
| Immunizations recommended by local authorities and/or the World Health Organization |
| Covered |
| Minor surgery not requiring confinement prescribed by an Affiliated Physician/Specialist |
| Covered |
| Eye laser therapy for retinal tear, retinal holes, retinal detachment and glaucoma prescribed by an affiliated Physician/Specialist, excluding eye correction such as LASIK, PRK and the like |
| Covered up to PhP10,000/eye/member/year |
| Cauterization of Warts prescribed by an Accredited Physician/Specialist except genital warts and condyloma acuminatum (NECK DOWN) |
| Reimbursable up to PhP2,000/member/year |
| Blood products transfusions and intravenous fluids, including blood screening and cross matching |
| Covered subject to MBL if related to dread disease |
| Speech Therapy (secondary to Stroke/Myocardial Infarction) |
| Reimbursable up to PhP10,000/member/year |
| Allergy Testing/allergy screening and other related examinations prescribed by an Affiliated Physician |
| Covered up to PhP2,500/member/year |
| Tuberculin Test (including screening, as prescribed by the attending physician) |
| Covered up to PhP600/member/year |
| Sclerotherapy for varicose veins as prescribed by an Affiliated Physician, to be availed through accredited vascular surgeons |
| Up to PhP5,000/leg/member/year |
D. ROUTINE PROCEDURES
Routine procedures as prescribed by the physician to include, but not limited to:
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Blood Chemistries |
| Covered as prescribed by attending physician subject to MBL |
| Chest X-ray |
| Covered as prescribed by attending physician subject to MBL |
| Complete Blood Count (CBC) |
| Covered as prescribed by attending physician subject to MBL |
| Fecalysis |
| Covered as prescribed by attending physician subject to MBL |
| Urinalysis |
| Covered as prescribed by attending physician subject to MBL |
E. DIAGNOSTIC PROCEDURES
Diagnostic procedures as prescribed by the physician to include, but not limited to:
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| 24-Hour Holter Monitoring |
| Covered as prescribed by attending physician subject to MBL |
| Adrenocortical Function |
| Covered as prescribed by attending physician subject to MBL |
| Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam |
| Covered as prescribed by attending physician subject to MBL |
| Arterial Blood Gas |
| Covered as prescribed by attending physician subject to MBL |
| Arthroscopic Procedures, Orthopedic Arthroscopy |
| Covered as prescribed by attending physician subject to MBL |
| Audiograms and Tympanograms |
| Covered as prescribed by attending physician subject to MBL |
| Bone Densitometry Scan (Dexascan) |
| Covered as prescribed by attending physician subject to MBL |
| Bone Mineral Density Studies |
| Covered as prescribed by attending physician subject to MBL |
| Cardiac Stress Tests (Thalium and Dipyridamole Stress Tests) |
| Covered as prescribed by attending physician subject to MBL |
| Computed Tomography Scans |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Radiographs – Biliary tract: Cholecystogram and Cholangiogram |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Radiographs – Chest, ribs, sternum and clavicle |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Radiographs – Digestive: Plain film of the abdomen, Barium Enema, Upper GI Series, Lower GI Series, Small Bowel Series |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Radiographs – Face (including sinuses), Head and Neck |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Radiographs – Urinary: KUB, Pyelograms and Cystograms |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Radiographs – X-ray of the extremities and pelvis |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Radiographs – X-ray of the spine (cervical, thoracic, lumbo-sacral) |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Ultrasounds – 2D-Echo with Doppler |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Ultrasounds – Abdomen |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Ultrasounds – Duplex Scan |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Ultrasounds – Digestive and Urinary Systems |
| Covered as prescribed by attending physician subject to MBL |
| Diagnostic Ultrasounds – Ultrasound of the Lungs |
| Covered as prescribed by attending physician subject to MBL |
| Electroencephalogram |
| Covered as prescribed by attending physician subject to MBL |
| Electromyography and Nerve Conduction Studies |
| Covered as prescribed by attending physician subject to MBL |
| Endoscopic Procedures |
| Covered as prescribed by attending physician subject to MBL |
| Fluorescein Angiography |
| Covered as prescribed by attending physician subject to MBL |
| Impedance Plethysmography |
| Covered as prescribed by attending physician subject to MBL |
| Lead Electrocardiogram |
| Covered as prescribed by attending physician subject to MBL |
| Magnetic Resonance Angiography (MRA) |
| Covered as prescribed by attending physician subject to MBL |
| Mammography and Sonomammogram |
| Covered as prescribed by attending physician subject to MBL |
| Myelogram |
| Covered as prescribed by attending physician subject to MBL |
| Pap's Smear |
| Covered as prescribed by attending physician subject to MBL |
| Perfusion Scan |
| Covered as prescribed by attending physician subject to MBL |
| Plasma Urinary Cortisol, Plasma Aldosterone |
| Covered as prescribed by attending physician subject to MBL |
| Polysomnograms (Sleep Recording) |
| Covered as prescribed by attending physician subject to MBL |
| Pulmonary Function Tests |
| Covered as prescribed by attending physician subject to MBL |
| Radioisotope Scans and Function Studies – Cardiac |
| Covered as prescribed by attending physician subject to MBL |
| Radioisotope Scans and Function Studies – Gastrointestinal |
| Covered as prescribed by attending physician subject to MBL |
| Radioisotope Scans and Function Studies – Liver |
| Covered as prescribed by attending physician subject to MBL |
| Radioisotope Scans and Function Studies – Parathyroid Bone, Pulmonary (Perfusion/Ventilation Lung Scans) |
| Covered as prescribed by attending physician subject to MBL |
| Radioisotope Scans and Function Studies – Renal |
| Covered as prescribed by attending physician subject to MBL |
| Radioisotope Scans and Function Studies – Thyroid Scans |
| Covered as prescribed by attending physician subject to MBL |
| Radioisotope Scans and Function Studies – Total Body Scans |
| Covered as prescribed by attending physician subject to MBL |
| Radionuclide Ventriculography |
| Covered as prescribed by attending physician subject to MBL |
| Surface Electromyography (SEMG) |
| Covered as prescribed by attending physician subject to MBL |
| Thallium Scintigraphy |
| Covered as prescribed by attending physician subject to MBL |
| TMST-Treadmill Stress Test |
| Covered as prescribed by attending physician subject to MBL |
| Cataract Extraction except cost of lens |
| Covered as prescribed by attending physician subject to MBL |
F. THERAPEUTIC PROCEDURES
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Dialysis |
| Covered subject to MBL |
| Intravenous Chemotherapy |
| Covered subject to MBL |
| Physical therapy including subspecialties such as cardiac rehabilitation, pulmonary rehabilitation and the like (Therapy of one (1) body area shall be considered as one (1) session) |
| Covered subject to MBL |
| Therapeutic Radiology – Brachytherapy |
| Covered subject to MBL |
| Therapeutic Radiology – Cobalt |
| Covered subject to MBL |
| Therapeutic Radiology – Linear Accelerator Therapy |
| Covered subject to MBL |
| Therapeutic Radiology – Radioactive Cesium |
| Covered subject to MBL |
| Therapeutic Radiology – Radioactive Iodine |
| Covered subject to MBL |
G. IN-PATIENT SERVICES
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Room and Board according to the Member's Room and Board Accommodation and subject to the maximum rate of Daily Room and Board, if any, of the plan under which the Member is enrolled |
| Covered |
| Use of operating room, Intensive Care Unit (ICU), isolation room (if prescribed by attending Accredited Physician) and recovery room |
| Covered subject to MBL |
| Professional fees – Attending Physicians |
| Covered subject to MBL if related to dread disease |
| Professional fees – Surgeons |
| Covered subject to MBL if related to dread disease |
| Professional fees – Anesthesiologists |
| Covered subject to MBL if related to dread disease |
| Professional fees – Cardio-pulmonary clearance before surgery and cardiac monitoring during surgery |
| Covered subject to MBL if related to dread disease |
| Standard Nursing Services |
| Covered |
| Medicines for in-patient services |
| Covered, charged subject to MBL if related to dread disease |
| Blood products transfusions and intravenous fluids, including blood screening and cross matching |
| Covered, charged subject to MBL if related to dread disease |
| X-ray, laboratory examinations, diagnostic tests and therapeutic procedures incidental to confinement |
| Covered, charged subject to MBL if related to dread disease |
| Dressings, conventional casts (plaster of Paris) and sutures |
| Covered, charged subject to MBL if related to dread disease |
| Anesthesia and its administration |
| Covered, charged subject to MBL if related to dread disease |
| Oxygen and its administration |
| Covered, charged subject to MBL if related to dread disease |
| Standard Admission Kit |
| Covered |
| All other items directly related to the medical management of the patient, as deemed medically necessary by the attending Accredited Physician |
| Covered subject to MBL if related to dread disease |
| Assistance in administrative requirements through a Liaison Officer |
| Covered |
H. ADDITIONAL SPECIAL PROCEDURES
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Angiogram and/or Angioplasty/Coronary Artery Bypass Graft |
| Covered as prescribed by attending physician subject to MBL |
| Gamma Knife Surgery |
| Covered as prescribed by attending physician subject to MBL |
| Laparoscopy |
| Covered as prescribed by attending physician subject to MBL |
| Conventional Hemorrhoidectomy |
| Covered as prescribed by attending physician subject to MBL |
| Scalpel Hemorrhoidectomy |
| Covered as prescribed by attending physician subject to MBL |
| Stapled Hemorrhoidectomy |
| Covered up to PhP5,000/member/year |
| Mammotone |
| Covered up to PhP5,000/member/year |
| 4D Ultrasound except for maternity-related cases |
| Covered up to PhP5,000/member/year |
| 24 Hour EEG Monitoring |
| Covered up to PhP5,000/member/year |
| Esophageal Manometry |
| Covered up to PhP5,000/member/year |
| Intensified Modulated Radiotherapy |
| Covered up to PhP5,000/member/year |
| Botox which is not cosmetic in nature nor for beautification purpose |
| Covered up to PhP5,000/member/year |
| Positron Emission Tomography |
| Covered up to PhP5,000/member/year |
| CT Pulmonary Angiography |
| Covered up to PhP5,000/member/year |
| Photodynamic Therapy |
| Covered up to PhP5,000/member/year |
I. SPECIAL MODALITIES OF TREATMENT
Note: The availment of Laparoscopic Cholecystectomy, Lithotripsy, Transurethral Microwave Therapy of Prostate, Percutaneous Ultrasonic Nephrolithotomy, Ureter lithotripsy, or Cryosurgery procedure is limited only to once per contract year.
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Laparoscopic Cholecystectomy (once per contract year) |
| Covered as charged subject to MBL |
| Lithotripsy (once per contract year) |
| Covered as charged subject to MBL |
| Magnetic Resonance Imaging (MRI) |
| Covered as charged subject to MBL |
| Nuclear Radioactive Isotope Scan |
| Covered as charged subject to MBL |
| Hysteroscopic Myoma Resection |
| Covered as charged subject to MBL |
| Laparoscopic Adrenalectomy (Unilateral) |
| Covered as charged subject to MBL |
| Laparoscopic Adrenalectomy (Bilateral) |
| Covered as charged subject to MBL |
| Transurethral Microwave Therapy of Prostate (once per contract year) |
| Covered as charged subject to MBL |
| Hysteroscopically-guided D&C |
| Covered as charged subject to MBL |
| Percutaneous Ultrasonic Nephrolithotomy (once per contract year) |
| Covered as charged subject to MBL |
| Ureterolithotripsy (once per contract year) |
| Covered as charged subject to MBL |
| Stereotactic Brain Biopsy |
| Covered as charged subject to MBL |
| Cryosurgery (once per contract year) |
| Covered as charged subject to MBL |
| Sleep Study |
| Covered as charged subject to MBL |
| Neuroscan |
| Covered as charged subject to MBL |
| Pelvic Laparoscopy (for endometriosis) |
| Covered as charged subject to MBL |
| All Special Modalities of Treatment and/or diagnostic procedures for which there are no comparable conventional or traditional equivalent or counterparts |
| Covered up to PhP5,000/procedure/member/year |
J. EMERGENCY CARE
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| In Accredited Hospitals – Doctor's services |
| Covered subject to MBL |
| In Accredited Hospitals – Emergency Room fees |
| Covered subject to MBL |
| In Accredited Hospitals – Medicines used for immediate relief during treatment |
| Covered subject to MBL |
| In Accredited Hospitals – Oxygen, intravenous fluids, and blood products |
| Covered subject to MBL |
| In Accredited Hospitals – Dressings, conventional casts (plaster of Paris) and sutures |
| Covered subject to MBL |
| In Accredited Hospitals – X-ray, laboratory and diagnostic examinations, and other medical services related to the emergency treatment of the patient |
| Covered subject to MBL |
| In Accredited Hospitals – Room Upgrade in case of room unavailability |
| Up to 24-hours except Suite room |
| In Non-Accredited Hospitals |
| 80% of hospital bills & professionals fees based on insurance provider rates up to PhP30,000/case/member/year (Reimbursement Basis) |
| Outside the Philippines |
| 80% of hospital bills & professionals fees based on insurance provider rates up to PhP30,000/case/member/year (Reimbursement Basis) |
| Areas without Accredited Hospital (50-km radius rule) |
| Covered subject to insurance provider rates up to MBL |
| Ambulance Service (accredited to accredited) |
| Covered up to MBL |
| Ambulance Service (non-accredited to accredited, fully coordinated with insurance provider, within Metro Manila only) |
| Covered up to PhP2,000 per conduction |
K. PRE-EXISTING CONDITIONS
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Pre-Existing Conditions |
| Covered |
L. OTHER BENEFITS/SPECIAL PROCEDURES
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Work Related Conditions based on conditions covered by ECC |
| Covered (for employees only) |
| Motor Vehicular Accidents |
| Covered subject to MBL |
| Unprovoked Assault, including domestic violence, whether initiated by the Member or by a known or unknown third party |
| Covered subject to MBL |
| Scoliosis (whether pre-existing, congenital or acquired) including necessary procedures, except physical therapy sessions |
| Covered up to PhP40,000/member/year |
| Congenital diseases, including physical therapy sessions |
| Covered up to PhP40,000/member/year |
| Congenital Hernia |
| Covered subject to MBL |
M. DENTAL CARE
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Annual Dental examination and consultation including x-rays and dentist's fees |
| Covered |
| Emergency Out-patient Dental Treatment |
| Covered |
| Oral Prophylaxis |
| Covered – Twice a year |
| Tooth extractions |
| Covered |
| Restorative and prosthodontic treatment planning |
| Covered |
| Temporary fillings |
| Unlimited, as needed |
| Permanent light cure fillings |
| Unlimited, as needed |
| Desensitization of hypersensitive teeth |
| Covered |
| Simple adjustment of dentures |
| Covered |
| Re-cementation of loose crowns, inlays and on lays |
| Covered |
| Dentures, bridges, root canal |
| Covered |
| Crowns (Plastic & Acrylic) |
| Covered, PhP10,000 per member per year |
| Dental Nutrition and Dietary Counseling |
| Covered |
| Dental Health Education |
| Covered |
| Pre-natal check of teeth and gums |
| Covered |
| Temporo Mandibular Joint Consultation |
| Covered |
| Gum Treatment for cases like inflammation or bleeding |
| Covered |
N. MEMBERSHIP GUIDELINES
| Requirement |
| Required |
| Offered |
| Compliant (Yes/No/Exceeds) |
| Age Eligibility – Principals |
| 18 up to 71 years old |
O. STANDARD PACKAGE – ADDITIONAL BENEFITS
| Benefit |
| Required Coverage |
| Offered Coverage |
| Compliant (Yes/No/Exceeds) |
| Reimbursement for services availed from a non-accredited provider |
| Subject to standard rates offered by the medical insurance provider |
| Reimbursement for eyeglasses and contact lenses from doctors, hospitals or clinics of employee's choice |
| Up to PhP5,000.00 |
| Outpatient medicine reimbursement |
| Up to PhP15,000 |
| Maternity Benefits – Normal Delivery |
| PhP20,000.00 |
| Maternity Benefits – Caesarian |
| PhP41,200.00 |
| Maternity Benefits – Others |
| PhP15,600.00 |
| Hearing Aids – Examinations and Treatments, Apparatus limited to one per ear |
| Up to PhP40,000.00 per covered individual |
| Hospital Network Access |
| Asian Hospital & Medical Center, Makati Medical Center, The Medical City, Cardinal Santos Medical Center, and St. Luke's Medical Center-Quezon City |
| COVID-19 Coverage – Covid-related illnesses |
| Guaranteed coverage up to MBL |
| COVID-19 Coverage – Outright RTPCR |
| Covered subject to existing guidelines and in designated facilities identified by the service provider |
| COVID-19 Coverage – Adverse effects of Covid vaccination |
| Covered subject to account benefits and limitations, especially pertaining to pre-existing and congenital conditions coverage |
Note: By submitting this Benefits Compliance Matrix, the offeror certifies that all information provided is accurate, complete, and verifiable. Any misrepresentation may result in disqualification of the proposal.
RFQ NO. 19RP3826Q0071
[2]
Department of State