Fedhealth Maxima Standard medical aid plan: 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 Standard
Quick Overview
Main: Adult: Child:
Total Cost pm: R3,310 R2,890 R998

(Pay only for first 3)

Savings: R7,152 R6,240 R2,160
Self Payment:
(per year, if you use up all your savings)
R5,168 R3,220 R1,008
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.
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Maxima Standard
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • Network specialists covered in full
  • 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
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)
  • Physio: subject to protocols
  • 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 R11,000 per family
  • Otherwise, 100% scheme rate
  • 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:
  • R423,200 per family
  • Corneal graft: R19,700 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 procedures
  • colonoscopy, upper GI endoscopy
  • R2,300 co-payment paid by you or by your gap cover
  • Balloon sinuplasty
  • laparoscopic hernia repairs, laparoscopic procedures
  • spinal surgery
  • joint replacements (except hip and knee)
  • involuntary use of non-DSP for hip or knee replacement
  • rhizotomies and facet pain blocks
  • surgical removal of wisdom teeth
  • R4,000 co-payment paid by you or by your gap cover
  • Hip and Knee replacement, voluntary use of non-DSP: R25,000 co-payment
  • Gap cover pays co-payments for procedures approved by medical aid
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
  • No benefit
Casualty:
  • Paid by scheme at 100% scheme rate
  • li>R550 co-payment if not PMB
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
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
  • No benefit
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)

No phone calls!
Our quote will include the right gap cover for this plan

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.

.
.
.
.
OUT OF HOSPITAL BENEFITS (non-PMB):
Maxima Standard
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R7,152 R6,240 R2,160
Self Payment:
(per year, if you use up all your savings)
R5,168 R3,220 R1,008
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:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • Network GPs: Unlimited, and paid by scheme
  • Non-network GPs: paid from day-to-day benefit at 100% scheme rate
  • No benefit
Childcare:
  • Hearing test for newborns up to 8 weeks
  • Immunisations: Covered
  • No extra benefit available
Specialists consultations:
  • Network specialists: from day-to-day benefit. If no referral is obtained from network GP, there is a 20% 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 20% 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. R2,100 co-payment, unless PMB
  • Co-payment paid for authorised out of hospital MRI and CT Scans
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 R11,000 per family
  • Alternative healthcare: paid from day-to-day benefit. Does not accumulate or pay from threshold
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MATERNITY BENEFITS:
Maxima Standard
Scheme Benefits Gap benefits
Hospital stay:
  • Specialists from network, covered at full cost. Otherwise, 100% scheme rate
  • Doula benefit: R1,270 per delivery
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
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

No phone calls!
Our quote will include the right gap cover for this plan

.
.
CANCER (ONCOLOGY):
Maxima Standard
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R423,200 per family at DSP (ICON). Subject to Level 1 protocols. 40% co-payment if you don't use ICON.
  • Biological medicine: No benefit
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, your sublimits increase as necessary.
  • No benefit for non-DSP penalty
  • More info

No phone calls!
Our quote will include the right gap cover for this plan

.
.
DENTISTRY:
Maxima Standard
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: R7,100 per person and R21,100 per family from day-to-day benefit
  • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
Orthodontics:
  • See Specialised dentistry, above
  • No extra benefit available
Maxillo Facial Surgery:
  • Unlimited, subject to approval
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MEDICATION:
Maxima Standard
Scheme Benefits Gap benefits
Chronic:
  • No. of chronic conditions covered: 39 and R5,410 per person and R10,800 per family
  • Co-payment if out of formulary: 40% co-payment
  • No benefit
Acute (presrcibed) medication:
  • R5,410 per person and R10,800 per family, from day-to-day benefit
  • No benefit
Over-the-counter:
  • Paid from day-to-day benefit. Does not accumulate or pay from threshold.
  • No benefit
Birth Control:
  • Unlimited
On Discharge:
  • 7 days supply
  • No benefit
Biological:
  • No benefit
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
OPTOMETRY:
Maxima Standard
Scheme Benefits Gap benefits
Optometry:
  • R3,180 per person and R9,700 per family, from day-to-day benefit
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MENTAL HEALTH:
Maxima Standard
Scheme Benefits Gap benefits
In-hospital:
  • R23,900
  • No benefit
Out-of-hospital:
    Network Psychiatrists:
    • From day-to-day benefit
    • Does not accumulate to threshold
    • Limited to R11,000 per family from threshold, which is shared with supplementary services
    • 20% co-payment if no referral from network GP
    Non-network psychiatrists:
    • As above, but at 100% scheme tariff (not at cost)
  • No benefit
Trauma:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
OTHER BENEFITS:
Maxima Standard
Scheme Benefits Gap benefits
General Appliances:
  • From day-to-day benefit, in and out of hospital
  • Does not accumulate to threshold
  • Limited to R11,000 per family from threshold
  • Foot orthotics: sub-limit of R4,130 per person
  • No benefit
1.1. Hearing Aids:
  • See "General Appliances" limit
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
  • No benefit
Dialysis:
  • R423,200 per family
HIV:
  • Treatment includes rape- and post-exposure prophylaxis
  • No benefit
Emergency Transport: Europ Assistance
  • No benefit
International Insurance: 2018 benefits are coming soon!
  • No benefit
Other: 2018 benefits are coming soon!
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
WELLNESS/PREVENTATIVE BENEFITS:
Maxima Standard
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
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: 2018 benefits are coming soon!
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
PROSTHETICS:
Maxima Standard
Scheme Benefits Gap benefits
Overal Limit:
  • External: combined R23,800 benefit (see below), or as per sublimit
  • Internal: R11,100
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits:
  • Detachable platinum coils: R48,300
  • Cardiac stents: R26,500
  • Cardiac valves: R26,500
  • Cardiac pacemakers: R26,500
  • 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: R26,500
  • Elbow replacement: R26,500
  • Hip replacement: R26,500. Double benefit for bilateral replacement
  • Knee replacement: R26,500. 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)
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid

No phone calls!
Our quote will include the right gap cover for this plan


    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