HMOs in the Philippines and how to compare them

No HMO is the right one for everyone. The plan that fits you is the one whose hospitals are near you, whose limit is high enough for the care you are likely to need, and whose rules on conditions you already have work for you. Compare any two plans on these six points:

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What an HMO is and who regulates it

A health maintenance organization (HMO) is a company that arranges and pays for your health care in return for a fixed fee paid in advance. The law describes it as providing “pre-agreed or designated health care services to its enrolled members for a fixed pre-paid fee for a specified period of time” (Executive Order 192, Sec. 2). You get a card, and the HMO pays the hospitals and doctors in its network directly, up to the plan’s limits.

HMOs were moved from the Department of Health to the Insurance Commission (IC) in 2015 (EO 192, Sec. 1). The IC licenses them and takes complaints about them.

The six points in detail

The network. An HMO pays in full only at its accredited hospitals and clinics, its network hospitals. A plan with a long list of hospitals is no help if none is near where you or your parents live. Ask for the list for your city and check the hospitals you would actually use.

The maximum benefit limit. Every plan has a maximum benefit limit, the most it pays in a year. Some apply it per illness, others to everything in the year together. A long hospital stay can use up a limit quickly, so check what happens to the bill above it.

The room type. Plans say which room they pay for, for example a ward, a semi-private or a private room. If you take a more expensive room, many plans make you pay the difference and some reduce other benefits in proportion. Read how the plan handles this.

Pre-existing conditions. A pre-existing condition is an illness you had, or had signs of, before the cover started. The IC limits how HMOs treat them: an HMO may look back at most two years from the start of the contract, a waiting period for a pre-existing condition may not be longer than one year, and once you renew after a year of continuous cover, an illness already covered cannot be excluded again as pre-existing (IC Circular Letter 2018-66). Ask how the plan defines the term and how long you wait.

Outpatient care and dental. Many plans include doctor’s consultations, laboratory tests and some dental care without a hospital stay. Others cover mainly hospital stays. Check what is included and how often.

The annual physical exam. Many plans include a yearly check-up. Check which tests it covers and where you can have it done.

How to read a plan sheet

Most HMO plan sheets are laid out in the same parts. Read them in this order:

1. Who is covered: the member and any dependants, with age limits for joining and for renewing.
2. Inpatient benefits: the limit, the room type, and what is paid in hospital (room and board, doctors’ fees, medicines, tests).
3. Outpatient benefits: consultations, tests and procedures done without a hospital stay.
4. Emergency care: what is paid at a hospital outside the network in an emergency, and how much is paid back.
5. Preventive care: the annual physical exam and any vaccines.
6. Exclusions and limitations: what is not paid at all, and what is paid only up to a smaller limit.
7. Pre-existing conditions: the definition and the waiting period.
8. Cancellation and the free look period: your right to cancel soon after you join.

When an HMO sells a plan online, the IC requires it to show the exclusions and limitations and your right to cancel, including any free look period, before you buy (IC Circular Letter 2021-10). Read those parts first.

To use the card at a hospital, you usually show it and the hospital asks the HMO for approval, a letter of authorization, before treatment that is not an emergency.

Checking an HMO

Before you pay, check that the HMO holds a certificate of authority from the Insurance Commission. The IC publishes the list on its website: HMOs with certificates of authority (on 26 October 2026, the list shown was dated as of 30 September 2026). Our guide to the Insurance Commission shows how to check a company, agent or broker and how to complain.

Individual, family, senior and company plans

• Individual plans cover one person, bought on their own.
• Family plans add a spouse and children to one plan, with age limits for children.
• Plans for seniors are sold by some HMOs to older members, usually with stricter age limits and waiting periods. See cover for seniors.
• Company plans cover a group of employees under one contract. See HMO for a small business.

If you are deciding between an HMO and an insurance policy, see HMO vs health insurance.

This page explains how HMO plans generally work. It does not describe any company’s plan. Each plan’s own terms decide what it pays.