Fedhealth Maxima Plus 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 Plus
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R7,535 R6,415 R2,303
Cost 2017: (R6,740) (R5,733) (R2,021)
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: R4,980 R4,236 R1,524
Extended Fund: R8,300 R5,990 R1,840
Self Payment: R9,362 R6,795 R2,301
Above Threshold: Unlimited overall, with sublimits for some benefits. Find out more
Children: Pay for maximum 3 children
    In 2018, with this plan:
  • Scheme pays for mammograms from age 45yrs
  • Colorectal exam every year, paid by scheme
  • Scheme pays for newborn hearing test
  • Doula benefit increased to R1270
  • Limit of 2 consults with mental health professional
  • You need a GP referral for specialists, if paid by scheme or from threshold; otherwise 10% co-payment
  • Must use DSP for non-PMB knee or hip replacements
  • No procedure, radiology or 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 Plus
2017 v 2018 benefits Gap benefits Notes
Payout Rate for Specialists: Fusion Gap:
  • Up to 700% 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:
  • Unlimited
  • N/A
Specialised Radiology:
  • Co-payment: none
  • Sublimit: none
  • Rate: 100% scheme rate
Supplementary Services: (Physio, etc)
  • Unlimited
Fusion Gap:
  • Up to 700% scheme rate for specialists and other providers
Transplants:
  • Unlimited
  • Corneal graft: R19,700 per family
Co-payments:
  • N/A
  • N/A
Alternatives to hospitals:
  • Terminal care: R29,500 per family
  • Physical rehabilitation, sub-acute facilities, nursing services, private nurse practitioners, nursing agencies: Unlimited, at negotiated rate
Casualty:
  • Paid by scheme at 100% scheme rate
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  • 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
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OUT OF HOSPITAL BENEFITS:
Maxima Plus
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Network GPs: paid from OHEB or by scheme
  • Non-network GPs: paid from day-to-day benefit at 100% scheme rate.
  • No benefit


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Childcare:
  • Hearing test for newborns up to 8 weeks
  • Immunisations: Covered
  • No benefit
Specialists consultations:
  • Network specialists: from day-to-day benefit. If no referral is obtained from network GP, there is a 10% co-payment
  • Non-network specialists: from day-to-day benefit at 100% scheme rate. If no referral is obtained from network GP, there is a 10% co-payment
  • No benefit
Pathology:
  • Paid from day-to-day benefit
  • No benefit
General radiology:
  • Paid from day-to-day benefit
  • No benefit
Specialised radiology:
  • Unlimited, paid by scheme, if pre-authorised
  • No benefit
Supplementary Services: (Physio, etc)
  • Audiology, dietetics, genetic counselling, occupational therapy, orthoptics, podiatry, psychologists, speech therapy, social workers: paid from R16,600 from day-to-day benefit.
  • Alternative healthcare: paid from day-to-day benefit. Does not accumulate or pay from threshold
  • Physio (biokinetics, chiropractors and physio): from day-to-day benefit
  • No benefit
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MATERNITY BENEFITS:
Maxima Plus
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • Specialists from network, covered at full cost. Otherwise, 200% scheme rate
  • 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, from day-to-day benefit
  • No benefit
Scans:
  • 2 x 2D scans, from day-to-day benefit
  • No benefit
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CANCER (ONCOLOGY):
Maxima Plus
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • Unlimited at DSP (ICON). Subject to Level 3 protocols.
  • Biological medicine: R331,100
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 Plus
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: R7,100 per person and R21,100 per family 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:
  • See Specialised dentistry, above
  • 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 Plus
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • No. of chronic conditions covered: 51 and R14,300 per person and R26,800 per family
  • Co-payment if out of formulary: 40% co-payment
  • No benefit

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Acute (presrcibed) medication:
  • R9,500 per person and R18,800 per family, from day-to-day benefit
  • No benefit
Over-the-counter:
  • Paid from savings only. Does not accumulate or pay from threshold.
  • No benefit
Birth Control:
  • Unlimited
On Discharge:
  • 7 days supply
  • No benefit
Biological:
  • R331,100
  • No benefit
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OPTOMETRY:
Maxima Plus
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • R3,180 per person and R9,700 per family, from day-to-day benefit
  • No benefit

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MENTAL HEALTH:
Maxima Plus
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • R38,400

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Out-of-hospital:
    Network Psychiatrists:
    • From day-to-day benefit
    • Limited to R16,500 per family from threshold, which is shared with supplementary services
    • Accumulates to threshold at cost
    • 10% co-payment if no referral from network GP
    Non-network psychiatrists:
    • As above, but accumulates at 100% scheme tariff (not at cost)
Trauma:
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OTHER BENEFITS:
Maxima Plus
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • In-hospital: Unlimited
    Out -of-hospital:
  • From day-to-day benefit
  • Limited to R14,800 per family from threshold
  • Foot orthotics: sub-limit of R4,130 per person
  • No benefit

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1.1. Hearing Aids:
  • See "General Appliances" limit
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
  • No benefit
Dialysis:
  • Unlimited
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 Plus
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered
  • No benefit

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Pneumonia vaccines:
  • One per lifetime, 65 yrs+
  • 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:
  • 1 densitometry test per lifetime, 65 yrs+
  • 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:
  • Detachable platinum coils: R48,300
  • Cardiac stents: R47,700
  • Cardiac valves: R42,400
  • Cardiac pacemakers: R55,700
  • Aorta stent grafts: R55,700
  • Carotid stents: See combined limit (above)
  • Peripheral arterial stent grafts: See combined limit (above)
  • Embolic protection devices: See combined limit (above)
  • Shoulder replacement: R42,400
  • Elbow replacement: R42,400
  • Hip replacement: R42,400. Double benefit for bilateral replacement
  • Knee replacement: R42,400. Double benefit for bilateral replacement
  • Bone lengthening device: See combined limit (above)
  • Spinal plates and screws: See combined limit (above)
  • Other approved spinal implantable devices: See combined limit (above)
  • Intraocular lenses: R3,100 per lens
  • Ankle replacement: See combined limit (above)

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Sub-limits:
  • External: combined R34,400benefit (see below), or as per sublimit
  • Internal: R20,800
  • 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