Fedhealth Maxima Exec medical aid plan: 2019

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Maxima Exec
2019 Costs:
Total Cost pm:

Main member:

R5,336

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 HOSPITAL PROCEDURES:
Maxima Exec
Scheme Benefits: Notes and Links:
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 Cover
  • Gap cover is available for this plan. Budget about R350 for a fully comprehensive gap cover that will increase the scheme rate to 500% and pay most co-payments and increase sublimits.
Hospital Choice:
  • Choose any hospital
Specialised Radiology:
  • You or your gap pay R2,100 co-payment
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
Transplants:
  • R555,900 per family
  • Corneal graft: R20,700 per person
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
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
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)
What next?
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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 Notes and Links:
Main Member: Adult: Child:
Savings /yr: R9,024 R7,824 R2,820
Extended Fund: R R R
Self Payment Gap:
R4,627 R2,658 R691
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
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
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
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

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MATERNITY BENEFITS:
Maxima Exec
Scheme Benefits Notes and Links:
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
What next?
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Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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CANCER (ONCOLOGY):
Maxima Exec
Scheme Benefits Notes and Links:
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
What next?
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DENTISTRY:
Maxima Exec
Scheme Benefits Notes and Links:
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:
What next?
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MEDICATION:
Maxima Exec
Scheme Benefits: Notes and Links:
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
What next?
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OPTOMETRY:
Maxima Exec
Scheme Benefits: Notes and Links:
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:
What next?
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MENTAL HEALTH:
Maxima Exec
Scheme Benefits Notes and Links:
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
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Trauma:
What next?
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OTHER BENEFITS:
Maxima Exec
Scheme Benefits Notes and Links:
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
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • R555,900 per family
HIV:
Emergency Transport:
International Insurance:
Other:
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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WELLNESS/PREVENTATIVE BENEFITS:
Maxima Exec
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • Covered, 65yrs+
Back Rehabilitation Programme:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, every 3 years
Mammogram:
  • Covered
PAS Test:
  • Covered
HIV Test:
  • Covered
Other:
  • Lipogram: every 5 yrs
  • Bone densitometry: women,65yrs+ and men 70yrs+
  • Faecal occult blood test: covered, 50-75yrs
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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PROSTHETICS:
Maxima Exec
Scheme Benefits: Notes and Links:
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
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.


    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