Fedhealth Maxima Advanced medical aid plan: 2017

Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB. Pay for all children.

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
  • Covered in full for specialists and GPs in Fedhealth network
  • Otherwise, 100% scheme rate
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:
Hospital Choice:
  • Network
Specialised Radiology:
  • R1,900 co-payment
Supplementary Services: (Physio, etc)
  • Physio and biokinetics: 100% scheme rate
  • Audiology, dietetics, genetic counselling, occupational therapy, orthoptics, podiatry, psychologists, speech therapy, social workers and chiropractics: from day-to-day benefit for in and out of hospital
Transplants:
  • R400,000 per family
  • Corneal graft: R18,700 per family
Co-payments:
  • Colonoscopy, upper GI endoscopy, Arthroscopic procedures: R2,100 co-payment
  • Wisdom teeth extraction, balloon sinuplasty, spinal surgery, joint replacements, all laparoscopic procedures, rhizotomies and facet pain block: R3,700 co-payment
Alternatives to hospitals:
  • Terminal care: R27,900 per family
  • Physical rehabilitation, sub-acute facilities, nursing services: Unlimited and paid by scheme

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • Paid by scheme, with a R1,900 co-payment
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:

Consultations:
  • 4 postnatal consultations with midwife
  • Otherwise, from day-to-day benefit
Scans:
  • Paid from day-to-day benefit

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R400,000 per family
  • Biological medicine: R156,000
  • Brachytherapy materials: R50,000

Note: 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.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:

Orthodontics:
  • Paid from day-to-day benefit
Maxillo Facial Surgery:
  • Unlimited

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 25 conditions covered
  • R4,240 per person, and R7,620 per family. Thereafter only PMBs are covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
On Discharge:
  • Paid from day-to-day benefit
Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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OPTOMETRY:
Optometry:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R26,400 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:


Out-of-hospital:
  • Paid from day-to-day benefit

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OTHER BENEFITS:
General Appliances:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:

1.1. Hearing Aids:
  • Paid from day-to-day benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit
Dialysis:
  • R400,000
HIV:
  • Covered if on the management program
Emergency Transport: Europ Assistance
International Coverage:
  • R5 million, for under 70yrs
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:

Pneumonia vaccines:
  • Covered
    • , 50yrs+
Back Rehabilitation Programme:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, 21-65yrs, every 3 years
Mammogram:
  • Covered, 50-74yrs, every 3 years
PAS Test:
HIV Test:
  • Covered

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

Compare with these plans:
Sub-limits:

    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