MAXICARE EMPLOYEE DEPENDENTS

Please find below Premium Rates for the period December 1, 2017 – November 30, 2018:

MAXICARE FULL HMO Program - Premium Based rates:

TOTAL DEDUCTION
MONTHLY
PLAN ROOM MBL ANNUAL PER
PREMIUM
PREMIUM PAYDAY
OPEN
PLATINUM 100K 22,704.00 1,892.00 946.00
PRIVATE
REGULAR
GOLD 75K 18,856.00 1,571.33 785.67
PRIVATE
SEMI-
SILVER 50K 14,001.00 1,166.75 583.38
PRIVATE

ENROLLMENT GUIDELINES: Hierarchy of dependents must be followed.

For single employees

 Parents (anyone ahead of the other) up to 65 years old

 Brothers and Sisters from 15 days old up to 21 years old (eldest to youngest in that order)

For Married employees

 Legitimate spouse up to 65 years old

 Children residing from the principal member 15 days old up to 21 years old (eldest to youngest
in that order)
For Single Parents

 His or Her own children from 15 days old up to 21 years old (eldest to youngest in that order)
 Parents (anyone ahead of the other) up to 65 years old
 Brothers and Sisters from 15 days old up to 21 years old (eldest to youngest in that order)

Provided, That the child is not confined on the date of attaining the minimum eligibility age (15 days
old). Coverage of the child shall commence after seven (7) consecutive days that the child is not
confined in a hospital. Provided further, that the spouse, children, parents, siblings are in good health;
provided lastly, that the children and the brothers and sisters are not gainfully employed and have no
children of their own.

VALID REASONS TO SKIP HIERARCHY:

1. Over-aged dependents – please provide copy of birth certificate

 Minor dependents: over 21 years old
 Adult Dependents: over 65 years old
2. Deceased – please provide copy of death certificate
3. No longer residing in the Philippines/abroad – please provide necessary documents certifying it
4. Has another HMO provider – please provide copy of HMO Card
5. Separation – please provide necessary documents certifying it

For further inquiries, please email bevearly.chan@foodgroup.ph or call 371-7806 / 0917-889-9088.

Deadline of Submission: November 15, 2017 (Wednesday)

 MAXICARE EMPLOYEE DEPENDENTS’
Coverage Period: December 1, 2017 to November 30, 2018

ENROLLMENT FORM

NAME: ____________________________________________ EMP NO. ________________________

DEPARTMENT: __________________CIVIL STATUS: ____________ CONTACT NO: ___________________

TO : PAYROLL

This is to authorize you to deduct from my salary the amount of PHP ______________ in twenty-four (24) equal
semi-monthly installments representing the annual premium coverage of my dependent/s listed below.

Annual
Name of Dependent Birthday
Premium
(Last Name, First Name, Middle Name) Relationship (mm/dd/year) Plan
(PHP)

TOTAL PREMIUMS

_________________________
Signature over Printed Name

NOTE:

1. The coverage plan of the dependents should be the same as the employee’s plan (principal).
2. If the membership of dependents is terminated or cancelled due to employee’s separation; the pro-rated premium rates shall be
computed – only if no availment has been made prior to the termination or cancellation.
3. There shall be no computation of pro-rated premium rates in the event that – the dependent’s remaining coverage is six (6) months
or less and has availed of any benefits during the coverage.
4. Deduction schedule will start on March 2018 after the scheduled deductions of the previous coverage.

Deadline of Submission: November 15, 2017 (Wednesday)