Fedhealth Maxima Plus 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 Plus
2018 Costs:
Total Cost pm:

Main member:

R7,535

Adult:

R6,415

Child: (Pay only for first 3)

R2,303
Savings Account (yr): R4,980 R4,236 R1,524
Extended Fund: R8,300 R5,990 R1,840
Self Payment Gap:
R9,362 R6,795 R2,301
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:

R8,354
(10.87%)

Adult:

R7,204

Child: (Pay only for first 3)

R2,610
Savings: R5,520 R4,752 R1,728
Extended Fund: R8,723 R6,295 R1,934
Self Payment Gap:
R10,298 R7,414 R2,491
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In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Maxima Plus
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: 300% scheme rate
  • You or gap cover pay the balance, if any
Hospital Choice:
  • Choose any hospital
Specialised Radiology:
  • N/A
  • N/A
Supplementary Services: (Physio, etc)
  • 100% scheme rate
Transplants:
  • Unlimited
  • Corneal graft: R20,700 per person
Co-payments:
  • None
Alternatives to hospitals:
  • Nursing services: Unlimited
  • Sub acute facilities, physical rehab: Unlimited
  • Terminal care: R31,000
Casualty:
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)
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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 Plus
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R4,980 R4,236 R1,524
Extended Fund: R8,300 R5,990 R1,840
Self Payment:
(per year, if you use up all your savings)
R9,362 R6,795 R2,301
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:
GP consultations:
  • Contracted GPs: paid 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
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. 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 Plus
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 Plus
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Unlimited , at DSP. (Level 3 treatment protocols)
  • Specialised medicine: R347,900
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DENTISTRY:
Maxima Plus
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: no co-payment
  • Dental admissions:no co-payment
Orthodontics:
  • See Specialised dentistry, above
Maxillo Facial Surgery:
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MEDICATION:
Maxima Plus
Scheme Benefits Gap benefits
Chronic:
  • Conditions covered: CDL conditions
  • Co-payment for use of non-formulary:
Acute (presrcibed) medication:
  • R9,000 per person and R19,700 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:
  • R347,900
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OPTOMETRY:
Maxima Plus
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 Plus
Scheme Benefits Gap benefits
In-hospital:
  • In-hospital: R40,300 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 Plus
Scheme Benefits Gap benefits
General Appliances:
  • From day-to-day benefit, unless PMB
  • 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:
  • Unlimited
HIV:
  • No benefit
Emergency Transport:
  • No benefit
International Insurance:
  • No benefit
Other:
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WELLNESS/PREVENTATIVE BENEFITS:
Maxima Plus
Scheme Benefits Gap benefits
Flu vaccination:
  • No benefit
Pneumonia vaccines:
  • No benefit
Back Rehabilitation Programme:
  • No benefit
Biometric Screening:
  • No benefit
Child Immunisation:
  • No benefit
Pap Smear:
  • No benefit
Mammogram:
  • No benefit
PAS Test:
  • No benefit
HIV Test:
  • No benefit
Other:
  • No benefit
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PROSTHETICS:
Maxima Plus
Scheme Benefits Gap benefits
Overal Limit:
  • Internal:R36,100 unless listed below
  • External:R21,800
Sub-limits:
  • Detachable platinum coils: R50,700
  • Cardiac stents: R50,100
  • Cardiac valves: R44,500
  • Cardiac pacemakers: R58,500
  • Aorta stent grafts: R58,500
  • Shoulder replacement: R44,500
  • Elbow replacement: R44,500
  • Hip replacement: R44,500
  • Knee replacement: R44,500
  • 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