Fedhealth Maxima Exec medical aid plan: 2019

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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.

Maxima Exec
2018 Costs:
Total Cost pm:

Main member:

R4,805

Adult:

R4,103

Child: (Pay only for first 3)

R1,463
Savings Account (yr): R3,972 R3,396 R1,212
Extended Fund: R5,700 R4,440 R740
Self Payment Gap:
R8,348 R6,064 R1,956
Above Threshold:
  • Once your savings are depleted, and you have paid the self payment gap, scheme will cover most out of hospital expenses at scheme rate, with sublimits for some benefits.
2019 Costs:
Total Cost pm:

Main member:

R5,336
(11.05%)

Adult:

R4,625

Child: (Pay only for first 3)

R1,666
Savings: R9,024 R7,824 R2,820
Extended Fund: R R R
Self Payment Gap:
R4,627 R2,658 R691
Above Threshold: No limit
(with 10% co-payment)
No limit No limit
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In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Maxima Exec
Scheme Benefits: Gap Benefits:
Specialists:
  • Contracted GPs and specialists: covered in full
  • Non-Contracted Specialists: 200% scheme rate
  • Non-Contracted GPs: 100% scheme rate
  • Other healthcare professionals: 100% scheme rate
  • 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, unless PMB
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)
  • Audiology, dietetics, genetic counselling, occupational therapy, orthoptics, podiatry, psychologists, speech therapy, social workers, physio, biokinetics and chiropractics: paid from day-to-day benefit, for in-and out of hospital. Does not accumulate to threshold. Paid from threshold up to R17,400 per family
  • Alternative healthcare: paid from day-to-day benefit. Does not accumulate or pay from threshold
  • 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:
  • R555,900 per family
  • Corneal graft: R20,700 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 procedure, hip: R2,400
  • Arthroscopic procedure, wrist: R2,400
  • Arthroscopic procedures - other: R2,400
  • Spinal surgery:R4,200
  • Balloon sinuplasty: R4,200
  • Colonoscopy, upper GI endoscopy: R2,400
  • Joint replacement: single hip and knee with voluntary use of non-network provider:R26,200
  • Joint replacement: single hip and knee with involuntary use of non-network provider:R4,200
  • Other joint replacements:R4,200
  • Laparoscopic procedures:R4,200
  • Laparoscopic varicocelectomy:no co-payment
  • Rhizotomies and facet pain blocks (one per person per year):R4,200
  • Wisdom Teeth:R4,200
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
  • Nursing services: Unlimited
  • Sub acute facilities, physical rehab: Unlimited
  • Terminal care: R31,000
Casualty:
  • R570 co-payment for non-PMB
Other:
  • Follow up treatment for 30 days post hospitalisation for physio, x-rays, pathology etc
  • No benefit, unless PMB
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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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 Exec
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R3,972 R3,396 R1,212
Extended Fund: R5,700 R4,440 R740
Self Payment:
(per year, if you use up all your savings)
R8,348 R6,064 R1,956
Above Threshold: Once your savings are depleted, and you have paid the self payment gap, scheme will cover most out of hospital expenses at scheme rate, with sublimits for some benefits.
General info:
  • Fedhealth Contracted GPs: Unlimited
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • Contracted GPs: paid from savings, then by scheme.
  • Non-Contracted GPs: paid from day-to-day benefit. Accumulates and refunds from Threshold at scheme rates.
Childcare:
  • 1 test with audiologist, birth to 8 weeks
  • No extra benefit available
Specialists consultations:
  • From day-to-day benefit, unless PMB with a 10% co-payment if not refered by GP
  • Contracted Specialists: accummulate to threshold at cost, and paid at cost
  • Non-Contracted Specialists: accummulate to threshold at 100% scheme rate, and paid at 100% scheme rate
Pathology:
  • From day-to-day benefit. Unlimited once threshold is reached.
General radiology:
  • From day-to-day benefit. Unlimited once threshold is reached.
Specialised radiology:
  • Unlimited
  • MRI and CT Scans: R2,200 co-payment, unless PMB
Supplementary Services: (Physio, etc)
  • Audiology, dietetics, genetic counselling, occupational therapy, orthoptics, podiatry, psychologists, speech therapy, social workers, physio, biokinetics and chiropractics: paid from day-to-day benefit, for in-and out of hospital. Does not accumulate to threshold. Paid from threshold up to R17,400 per family
  • Alternative healthcare: paid from day-to-day benefit. Does not accumulate or pay from threshold
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MATERNITY BENEFITS:
Maxima Exec
Scheme Benefits Gap benefits
Hospital stay:
  • Covered
  • Doula benefit: R1,300
Consultations:
    Fedhealth pays for:
  • Postnatal: 4 consults with midwife
Scans:
  • 2 x 2D scans, from day-to-day benefit
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CANCER (ONCOLOGY):
Maxima Exec
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R555,900 per family, at DSP. (Level 2 treatment protocols)
  • Specialised medicine: R173,400
  • You have the option of moving to a higher plan within 30 days of cancer diagnosis
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DENTISTRY:
Maxima Exec
Scheme Benefits Gap benefits
Standard Dentistry:
  • Standard dentistry: from day-to-day benefit. Unlimited once Threshold is reached.
Specialised Dentistry:
  • Specialised dentistry: R7,400 per person and R22,100 per family from day-to-day benefit.
  • Includes inlays, crowns, bridges, mounted study models, metal base partial dentures, implants, orthognathic surgery, oral surgery, orthodontic treatment, periodontists, prosthdontists and dental technicians.
In-Hospital Dentistry:
  • Maxilo-facial surgery: unlimited, subject to approval
  • In-hospital, children under 7: hospital and anaesthetist paid by scheme. Dentist account paid out-of-pocket
  • Surgical extraction of wisdom teeth: R4,200 co-payment
  • Dental admissions:no co-payment
Orthodontics:
  • See Specialised dentistry, above
Maxillo Facial Surgery:
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MEDICATION:
Maxima Exec
Scheme Benefits Gap benefits
Chronic:
  • Conditions covered: CDL conditions
  • Co-payment for use of non-formulary:
Acute (presrcibed) medication:
  • R7,100 per person and R13,100 per family, from day-to-day benefit
Over-the-counter:
  • From savings only. Does not accumulate or pay from threshold.
Birth Control:
  • Oral, patches, rings, certain injectables,as wella s IUDs (incl Mirena): paid by scheme
On Discharge:
  • 7 days
Biological:
  • R173,400
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OPTOMETRY:
Maxima Exec
Scheme Benefits Gap benefits
Optometry:
Limit:R3,340 per person and R10,190 per family. Paid from day-to-day benefit.
Consult:from above limit
Frames:from above limit
Single lensesfrom above limit
Bifocals:from above limit
Multifocalsfrom above limit
Contactsfrom above limit
Refractive Surgery:from above limit
Notes:
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MENTAL HEALTH:
Maxima Exec
Scheme Benefits Gap benefits
In-hospital:
  • In-hospital: R32,000 per family. PMBs always paid in full at DSP, and include up to 21 days admission
Out-of-hospital:
    Psychiatrists:
  • From day-to-day benefit, unless PMB, sublimit of Additional Medical Services of R17,400
  • Do not accumulate to threshold
  • Network psychiatrists cost, with 10% co-payment if GP referral not obtained
  • Non-network psychiatrists 100% scheme rate, with 10% co-payment if GP referral not obtained
Trauma:
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OTHER BENEFITS:
Maxima Exec
Scheme Benefits Gap benefits
General Appliances:
  • From day-to-day benefit, unless PMB, in and out of hospital
  • Does not accumulate to threshold
  • Limited to R15,500 per family from threshold
  • Foot orthotics: sub-limit of R4,340 per person
  • No benefit
1.1. Hearing Aids:
  • See "General Appliances" limit
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
  • No benefit
Dialysis:
  • R555,900 per family
HIV:
  • No benefit
Emergency Transport:
  • No benefit
International Insurance:
  • No benefit
Other:
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WELLNESS/PREVENTATIVE BENEFITS:
Maxima Exec
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • Covered, 65yrs+
  • No benefit
Back Rehabilitation Programme:
  • Covered
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered, every 3 years
  • No benefit
Mammogram:
  • Covered
  • No benefit
PAS Test:
  • Covered
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • Lipogram: every 5 yrs
  • Bone densitometry: women,65yrs+ and men 70yrs+
  • Faecal occult blood test: covered, 50-75yrs
  • No benefit
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PROSTHETICS:
Maxima Exec
Scheme Benefits Gap benefits
Overal Limit:
  • Internal:R29,200 unless listed below
  • External:R17,300
Sub-limits:
  • Detachable platinum coils: R50,700
  • Cardiac stents: R50,100
  • Cardiac valves: R44,500
  • Cardiac pacemakers: R48,700
  • Aorta stent grafts: R58,500
  • Shoulder replacement: R34,800
  • Elbow replacement: R33,200
  • Hip replacement: R33,200
  • Knee replacement: R33,200
  • Intraocular lenses: R3,200 per lens
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    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