Fedhealth Maxima EntrySaver 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 EntrySaver
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R1,759 R1,298 R585
Cost 2017: (R1,640) (R1,181) (R524)
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: R3,396 R2,508 R1,092
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
  • Standard dentistry paid by scheme once savings depleted
  • You need a GP referral for specialists, if paid by scheme or from threshold; otherwise 40% co-payment
  • Specialised radiology and casualty co-payments
  • Cataract co-payment removed
  • No co-payment for tonsillectomy for children under 12
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 EntrySaver
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:
  • Network
  • or R6,100 co-payment
Fusion Gap:
  • R12,800 per person per year for use of a non-network hospital
Specialised Radiology:
  • Co-payment: R2,800, 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:
  • PMBs only
  • Corneal graft: no benefit
Co-payments:
  • Adenoidectomy
  • all open hernia repairs
  • back and neck procedures
  • bunion procedures
  • colonoscopy, upper GI endoscopy
  • diagnostic cystoscopy
  • gastritis, dyspepsia, heartburn
  • hysterectomy (unless for cancer)
  • laparoscopic hernia repairs, laparoscopic procedures
  • spinal surgery
  • nasal procedures
  • skin biopsy/excision
  • tonsil/adenoid procedures (over 12yrs old)
  • varicose vein procedures
  • R5,900 co-payment
  • Arthroscopic procedures: Hip and wrist PMB only, otherwise R7,500 co-payment
  • Elective caesarean: R11,000 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
  • Surgical extraction of wisdom teeth
  • Corneal grafts
  • non-PMB arthroscopic wrist procedures
  • non-PMB joint replacements
  • No benefit for exclusions
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OUT OF HOSPITAL BENEFITS:
Maxima EntrySaver
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. R2,800 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 EntrySaver
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • Specialists from network, covered at full cost. Otherwise, 100% scheme rate
  • Elective caesarean: R11,000 co-payment
  • 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:
  • 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 EntrySaver
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • PMBs only at DSP
  • No benefit
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 EntrySaver
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 and polishing
  • Specialised dentistry: from day-to-day benefit
  • 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 EntrySaver
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 EntrySaver
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • Paid from day-to-day benefit
  • No benefit

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MENTAL HEALTH:
Maxima EntrySaver
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • No benefit, unless PMB

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Out-of-hospital:
  • 2 consults paid from day-to-day benefit
Trauma:
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OTHER BENEFITS:
Maxima EntrySaver
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:
  • PMBs only
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 EntrySaver
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:
  • Lipogram, every 5 years
  • 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:
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Sub-limits:
  • External: PMBs only
  • Internal: PMBs only
  • 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