Fedhealth Maxima Basis 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 Basis
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R2,722 R2,374 R826
Cost 2017: (R2,501) (R2,129) (R754)
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: R4,896 R4,272 R1,488
Children: Pay for maximum 3 children
    In 2018, with this plan:
  • Scheme pays for mammograms from age 45yrs
  • Any pharmacy for chronic meds
  • Scheme pays for newborn hearing test
  • Doula benefit increased to R1270
  • Limit of 2 consults with mental health professional
  • You need a GP referral for specialists, if paid by scheme or from threshold; otherwise 40% co-payment
  • Maternity consults increased from 6 to 12
  • 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 Basis
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
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:
  • R264,000 per family
  • Corneal graft: no benefit
Co-payments:
  • All open hernia repairs
  • colonoscopy, upper GI endoscopy
  • surgical removal of wisdom teeth
  • R4,000 co-payment
  • Laparoscopic hernia repairs, laparoscopic procedures
  • spinal surgery
  • Joint replacements (except hip and knee)
  • Involuntary use of non-DSP for hip or knee replacement
  • R5,900 co-payment
  • Arthroscopic procedures: R7,500 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: PMBs only
  • 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
    Excluded procedures:
  • Balloon sinuplasty
  • Rhizotomies and facet pain blocks
  • Corneal grafts
  • non-PMB joint replacements
  • No benefit for exclusions
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OUT OF HOSPITAL BENEFITS:
Maxima Basis
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Nominated Network GPs: Unlimited, from day-to-day benefit or paid by scheme if benefit is depleted.
  • Non-nominated Network GPs: 2 consults per person. Paid from day-to-day benefit or paid by scheme if benefit is depleted.
  • Non-network GPs: paid from day-to-day benefit
  • 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 Basis
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:
  • Paid from day-to-day benefit
  • If your benefits run out, scheme will still pay for 12 ante- or post-natal consultations and antenatal classes
  • No benefit
Scans:
  • Paid from day-to-day benefit
  • If your benefits run out, scheme will still pay for 2 x 2D scans and 1 amniocentesis scan
  • No benefit
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CANCER (ONCOLOGY):
Maxima Basis
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • R264,500 per family at DSP (ICON). Subject to Level 1 protocols.
  • Biological medicine: no cover
  • 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 Basis
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • From day-to-day benefit
  • Once benefit is depleted, scheme will pay for: 2 consults per person including scaling, polishing and fillings. Subject to network dentists.
  • Dentures: One plastic set per person every 2 years
  • 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 Basis
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • No. of chronic conditions covered: 27
  • 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:
  • No benefit
  • No benefit
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OPTOMETRY:
Maxima Basis
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • One test
  • One pair single or bifocal lenses per person
  • Frame: R193 per person
  • No benefit

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MENTAL HEALTH:
Maxima Basis
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • R23,900

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Out-of-hospital:
  • 2 consults paid from day-to-day benefit
Trauma:
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OTHER BENEFITS:
Maxima Basis
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:
  • R264,500 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 Basis
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered
  • No benefit

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Pneumonia vaccines:
  • No benefit
  • 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:
  • 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: R48,300
  • Cardiac stents: PMB only
  • Cardiac valves: PMB only
  • Cardiac pacemakers: PMB only
  • Aorta stent grafts: R55,700
  • Carotid stents: See combined limit (above)
  • Peripheral arterial stent grafts: See combined limit (above)
  • Embolic protection devices: See combined limit (above)
  • Shoulder replacement: See combined limit (above)
  • Elbow replacement: See combined limit (above)
  • Hip replacement: See combined limit (above). Double benefit for bilateral replacement
  • Knee replacement: See combined limit (above). Double benefit for bilateral replacement
  • Bone lengthening device: See combined limit (above)
  • Spinal plates and screws: See combined limit (above)
  • Other approved spinal implantable devices: See combined limit (above)
  • Intraocular lenses: R3,100 per lens
  • Ankle replacement: no benefit

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Sub-limits:
  • External: combined R23,800 benefit (see below), or as per sublimit
  • Internal: R11,100
  • 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