Fedhealth Maxima Advanced medical aid plan: 2017 vs 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

COSTS and OVERVIEW:
Maxima Advanced
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R3,607 R3,138 R1,082
Cost 2017: (R3,251) (R2,756) (R968)
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit: Unlimited overall, with sub-limits
PMBs: Day-to-day expenses for PMBs (eg. cancer) are always paid for by the scheme, according to protocols. Find out more
Savings: R4,332 R3,768 R1,296
Children: Pay for maximum 3 children
    In 2018, with this plan:
  • Scheme pays for mammograms from age 45yrs
  • Colorectal exam every year, paid by scheme
  • Any pharmacy for chronic meds
  • Scheme pays for newborn hearing test
  • Doula benefit increased to R1270
  • You need a GP referral for specialists, if paid by scheme or from threshold; otherwise 10% co-payment
  • Must use DSP for non-PMB knee or hip replacements
  • Specialised radiology and casualty co-payments
See below for other changes
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Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family


IN HOSPITAL PROCEDURES:
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
Payout Rate for Specialists: Fusion Gap:
  • Up to 600% scheme rate for specialists and other providers
  • In case of admission related to accident:
    -R300 per day, for days 1-13
    -R600 per day for days 14-20
    -R1,200 per day for days 21-30
  • R350pm per family. More Info or download application below.

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Hospital Choice:
  • Unlimited
  • N/A
Specialised Radiology:
  • Co-payment: R2,100, unless PMB
  • Sublimit: none
  • Rate: 100% scheme rate
Fusion Gap:
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Supplementary Services: (Physio, etc)
  • Physio: subject to protocols
  • Dietetics, occupational therapy and speech therapy: from day-to-day benefit
  • Otherwise, 100% scheme rate
Fusion Gap:
  • Up to 600% scheme rate for specialists and other providers
Transplants:
  • R423,200 per family
  • Corneal graft: R19,700 per person
Co-payments:
  • Arthroscopic procedures
  • colonoscopy, upper GI endoscopy
  • R2,300 co-payment
  • Baloon sinuplasty
  • laparoscopic hernia repairs, laparoscopic procedures
  • spinal surgery
  • joint replacements (except hip and knee)
  • involuntary use of non-DSP for hip or knee replacement
  • rhizotomies and facet pain blocks
  • surgical removal of wisdom teeth
  • R4,000 co-payment
  • Hip and Knee replacement, voluntary use of non-DSP: R25,000 co-payment
Fusion Gap:
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Alternatives to hospitals:
  • Terminal care: R29,500 per family
  • Physical rehabilitation, sub-acute facilities, nursing services, private nurse practitioners, nursing agencies: Unlimited, at negotiated rate
Casualty:
  • Paid by scheme at 100% scheme rate
  • li>R550 co-payment if not PMB
  • Casualty costs not covered by medical aid, in case of emergency treatment: R12,800 per incident. Cover also applies to costs covered by savings account.
Other:
  • Post hospitalization treatment for up to 30 days after discharge, paid for by scheme. Includes physio, occupational therapy, speech therapy, ultrasounds, standard radiology and pathology
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OUT OF HOSPITAL BENEFITS:
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Paid from day-to-day benefit, unless PMB
  • Out of hospital treatment for conditions that are PMBs is always paid for by the scheme (not out of savings), but according to protocols
  • No benefit


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Childcare:
  • Hearing test for newborns up to 8 weeks
  • Immunisations: Covered
  • No benefit
Specialists consultations:
  • Paid from day-to-day benefit, unless PMB
  • If no referral is obtained from network GP, there is a 40% co-payment
  • No benefit
Pathology:
  • Paid from day-to-day benefit, unless PMB
  • No benefit
General radiology:
  • Paid from day-to-day benefit, unless PMB
  • No benefit
Specialised radiology:
  • Unlimited, paid by scheme. R2,100 co-payment, unless PMB
  • No benefit
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit, unless PMB
  • No benefit
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MATERNITY BENEFITS:
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • Specialists from network, covered at full cost. Otherwise, 100% scheme rate
  • Doula benefit: R1,270 per delivery
  • Premature birth, more than 6 weeks:R12,000 lump payment
  • In case of admission related to premature birth:
    • R300 per day, for days 1-13
    • R600 per day for days 14-20
    • R1,200 per day for days 21-30

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Consultations:
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  • 4 postnatal consultations with midwife
  • Otherwise, paid from day-to-day benefit
  • No benefit
Scans:
  • Paid from day-to-day benefit
  • No benefit
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CANCER (ONCOLOGY):
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • R423,200 per family at DSP (ICON). Subject to Level 2 protocols.
  • Biological medicine: R165,000
  • Oncology Booster: Once the oncology limit is reached, gap pays for full cover thereafter
All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
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DENTISTRY:
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • From day-to-day benefit
  • Specialised dentistry: from day-to-day benefit
  • In-hospital dentistry: only for children up to age 7
  • Dental reconstruction due to due to trauma or oncology treatment: R40,000 per event
  • Full cover for in-hospital co-payments

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Orthodontics:
  • Paid from day-to-day benefit
  • No benefit
Maxillo Facial Surgery:
  • Unlimited, subject to approval
  • Dental reconstruction as result of trauma or oncology: R40,000 per event

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

MEDICATION:
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • No. of chronic conditions covered: 51 and R4,480 per person and R8,060 per family
  • Co-payment if out of formulary: 40% co-payment
  • No benefit

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Acute (presrcibed) medication:
  • Paid from day-to-day benefit
  • No benefit
Over-the-counter:
  • Paid from day-to-day benefit
  • No benefit
Birth Control:
  • Unlimited
On Discharge:
  • 7 days supply
  • No benefit
Biological:
  • R165,000
  • No benefit
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OPTOMETRY:
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • Paid from day-to-day benefit
  • No benefit

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MENTAL HEALTH:
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • R27,900

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Out-of-hospital:
  • 2 consults paid from day-to-day benefit
Trauma:
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OTHER BENEFITS:
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • Paid from day-to-day benefit, both in and out of hospital
  • No benefit

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1.1. Hearing Aids:
  • Paid from day-to-day benefit
  • No benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit
  • No benefit
Dialysis:
  • R423,200 per family
HIV:
  • Treatment includes rape- and post-exposure prophylaxis
  • No benefit
Emergency Transport:
  • No benefit
International Insurance: 2018 benefits are coming soon!
  • No benefit
Other: 2018 benefits are coming soon!
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WELLNESS/PREVENTATIVE BENEFITS:
Maxima Advanced
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered
  • No benefit

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Pneumonia vaccines:
  • One per lifetime, 65yrs+
  • No benefit
Back Rehabilitation Programme:
  • Covered
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered, 21-65yrs, every 3 years
  • No benefit
Mammogram:
  • Covered, 45-74yrs, every 3 years
  • No benefit
PAS Test: 2018 benefits are coming soon!
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • 1 densitometry test per lifetime, 65yrs+
  • 1 colorectal cancer screening test, every 2 years for 50-75yrs
  • No benefit

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

2017 v 2018 benefits Gap benefits Notes
Overal Limit:
  • Detachable platinum coils: R50,600
  • Cardiac stents: R47,700
  • Cardiac valves: R42,400
  • Cardiac pacemakers: R56,200
  • Aorta stent grafts: R56,200
  • Carotid stents: R20,400
  • Peripheral arterial stent grafts: R38,200
  • Embolic protection devices: R50,600
  • Replacement of shoulder, elbow, hip, knee; Bone lengthening device, Spinal plates and screws, Other approved spinal implantable devices : R45,100 combined, Double benefit for bilateral hip and knee replacement
  • Ankle replacement: see combined benefit (above)

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Sub-limits:
  • External: combined R34,900 benefit (see below), OR as per sublimit
  • Internal: R16,500
  • An additional R40,000 per sublimit, per event

    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised