Fedhealth Maxima Basis medical aid plan: 2017

Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB. Pay for all children.

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
  • Covered in full for specialists and GPs in Fedhealth network
  • Otherwise, 100% scheme rate
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • R1,900 co-payment
Supplementary Services: (Physio, etc)
  • Physio and biokinetics: 100% scheme rate
  • Dietetics, occupational therapy, speech therapy: from day-to-day benefit
Transplants:
  • R250,000 per family
  • Corneal graft: No benefit
Co-payments:
  • Colonoscopy, upper GI endoscopy, wisdom teeth extraction, open hernia surgery: R3,700 co-payment
  • Spinal surgery, joint replacements, : R5,300 co-payment
  • Laparoscopic procedures: R5,800 co-payment
  • Arthroscopic procedure: R6,900 co-payment
Alternatives to hospitals:
  • Terminal care: R27,900 per family
  • Physical rehabilitation, sub-acute facilities, nursing services: Unlimited and paid by scheme

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit
  • Once that is depleted, consults with nominated GP: unlimited
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • Paid by scheme, with a R1,900 co-payment
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:

Consultations:
  • Paid from day-to-day benefit
  • If your benefits run out, scheme will still pay for 6 ante- or post-natal consultations and antenatal classes
Scans:
  • Paid from day-to-day benefit
  • If your benefits run out, scheme will still pay for 2 x 2D scans and 1 amniocentesis scan

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R250,000 per family
  • Biological medicine: no cover
  • Brachytherapy materials: no benefit

Note: 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.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: from day-to-day benefit. Once depleted, scheme will pay for two consults including scaling and polishing per person.
  • Specialised dentistry: from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:

Orthodontics:
  • See Specialised dentistry, above
Maxillo Facial Surgery:
  • Unlimited

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
On Discharge:
  • 7 days supply
Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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OPTOMETRY:
Optometry:
  • Paid from day-to-day benefit, with sub-limits for frames and lenses
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R22,600 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:


Out-of-hospital:
  • Paid from day-to-day benefit

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OTHER BENEFITS:
General Appliances:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:

1.1. Hearing Aids:
  • Paid from day-to-day benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit
Dialysis:
  • R250,000
HIV:
  • Covered if on the management program
Emergency Transport: Europ Assistance
International Coverage:
  • R5 million, for under 70yrs
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:

Pneumonia vaccines:
  • Covered
    • , 50yrs+
Back Rehabilitation Programme:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, 21-65yrs, every 3 years
Mammogram:
  • Covered, 50-74yrs, every 3 years
PAS Test:
HIV Test:
  • Covered

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:
Sub-limits:

    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