Fedhealth Maxima Advanced medical aid plan: 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
Quick Overview
Main: Adult: Child:
Total Cost pm: R3,607 R3,138 R1,082

(Pay only for first 3)

Savings: R4,332 R3,768 R1,296
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Maxima Advanced
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • Network specialists covered in full
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose any hospital
  • No benefit
Specialised Radiology:
  • You or your gap pay R2,100 co-payment
  • Gap cover pays co-payments for procedures approved by medical aid
Supplementary Services: (Physio, etc)
  • Physio: subject to protocols
  • Dietetics, occupational therapy and speech therapy: from day-to-day benefit
  • Otherwise, 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment
  • No benefit for exclusions or benefits paid from day-to-day benefit
Transplants:
  • R423,200 per family
  • Corneal graft: R19,700 per person
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Sublimits increased as necessary
Co-payments:
  • Arthroscopic procedures
  • colonoscopy, upper GI endoscopy
  • R2,300 co-payment paid by you or by your gap cover
  • 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 paid by you or by your gap cover
  • Hip and Knee replacement, voluntary use of non-DSP: R25,000 co-payment
  • Gap cover pays co-payments for procedures approved by medical aid
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
  • No benefit
Casualty:
  • Paid by scheme at 100% scheme rate
  • li>R550 co-payment if not PMB
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
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
  • No benefit
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

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Our quote will include the right gap cover for this plan

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Maxima Advanced
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R4,332 R3,768 R1,296
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
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
Childcare:
  • Hearing test for newborns up to 8 weeks
  • Immunisations: Covered
  • No extra benefit available
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
  • Co-payment paid for authorised out of hospital MRI and CT Scans
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit, unless PMB
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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MATERNITY BENEFITS:
Maxima Advanced
Scheme Benefits Gap benefits
Hospital stay:
  • Specialists from network, covered at full cost. Otherwise, 100% scheme rate
  • Doula benefit: R1,270 per delivery
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
Consultations:
    >
  • 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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Our quote will include the right gap cover for this plan

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CANCER (ONCOLOGY):
Maxima Advanced
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R423,200 per family at DSP (ICON). Subject to Level 2 protocols.
  • Biological medicine: R165,000
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, your sublimits increase as necessary. More info

No phone calls!
Our quote will include the right gap cover for this plan

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DENTISTRY:
Maxima Advanced
Scheme Benefits Gap benefits
Dentistry:
  • From day-to-day benefit
  • Specialised dentistry: from day-to-day benefit
  • In-hospital dentistry: only for children up to age 7
  • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
Orthodontics:
  • Paid from day-to-day benefit
  • No extra benefit available
Maxillo Facial Surgery:
  • Unlimited, subject to approval
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

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Our quote will include the right gap cover for this plan

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MEDICATION:
Maxima Advanced
Scheme Benefits Gap benefits
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
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
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, your sublimits increase as necessary. More info

No phone calls!
Our quote will include the right gap cover for this plan

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OPTOMETRY:
Maxima Advanced
Scheme Benefits Gap benefits
Optometry:
  • Paid from day-to-day benefit
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

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Our quote will include the right gap cover for this plan

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MENTAL HEALTH:
Maxima Advanced
Scheme Benefits Gap benefits
In-hospital:
  • R27,900
  • No benefit
Out-of-hospital:
  • 2 consults paid from day-to-day benefit
  • No benefit
Trauma:
  • No benefit

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Our quote will include the right gap cover for this plan

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OTHER BENEFITS:
Maxima Advanced
Scheme Benefits Gap benefits
General Appliances:
  • Paid from day-to-day benefit, both in and out of hospital
  • No benefit
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: Europ Assistance
  • No benefit
International Insurance: 2018 benefits are coming soon!
  • No benefit
Other: 2018 benefits are coming soon!
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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WELLNESS/PREVENTATIVE BENEFITS:
Maxima Advanced
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
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

No phone calls!
Our quote will include the right gap cover for this plan

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PROSTHETICS:
Maxima Advanced
Scheme Benefits Gap benefits
Overal Limit:
  • External: combined R34,900 benefit (see below), OR as per sublimit
  • Internal: R16,500
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits:
  • 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)
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid

No phone calls!
Our quote will include the right gap cover for this plan


    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