Fedhealth Maxima Entryzone 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 EntryZone
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R1,424 R1,080 R482
Cost 2017: (R1,326) (R991) (R446)
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: No savings option on this plan
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
  • Specialised in and out of hospital 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 EntryZone
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: PMBs only
  • 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: 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
  • Arthroscopic hip procedures
  • non-PMB arthroscopic wrist procedures
  • non-PMB joint replacements
  • No benefit for exclusions
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OUT OF HOSPITAL BENEFITS:
Maxima EntryZone
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Network GP: 1 consult per person
  • Otherwise, no 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:
  • No benefit, unless PMB
  • No benefit
Pathology:
  • No benefit, unless PMB
  • No benefit
General radiology:
  • No benefit, unless PMB
  • No benefit
Specialised radiology:
  • Unlimited, paid by scheme. R2,800 co-payment, unless PMB
  • No benefit
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB
  • No benefit
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MATERNITY BENEFITS:
Maxima EntryZone
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
  • No benefit
Scans:
  • No benefit
  • No benefit
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CANCER (ONCOLOGY):
Maxima EntryZone
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 EntryZone
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • Standard dentistry: No benefit, unless PMB
  • In-hospital wisdom teeth extraction: no 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:
  • No 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 EntryZone
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:
  • No benefit
  • No benefit
Over-the-counter:
  • No benefit
  • No benefit
Birth Control:
  • Oral and injectible contraceptives only, subject to formulary
On Discharge:
  • 7 days supply
  • No benefit
Biological:
  • No benefit
  • No benefit
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OPTOMETRY:
Maxima EntryZone
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • No benefit
  • No benefit

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

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Out-of-hospital:
  • No benefit, unless PMB
Trauma:
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OTHER BENEFITS:
Maxima EntryZone
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • No benefit, unless PMB
  • No benefit

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1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • No 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 EntryZone
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:
  • No benefit
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • Lipogram, every 5 years
  • 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:
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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