Fedhealth Maxima Core medical aid plan: 2017

Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid 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: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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: PMBs only
Transplants:
  • R250,000 per family
  • Corneal graft: No benefit
Co-payments:
  • Colonoscopy, upper GI endoscopy, hysterectomy, open hiatus hernia surgery, varicose vein procedures, wisdom teeth extraction: R3,700 co-payment
  • Spinal surgery, joint replacements: R5,300 co-payment
  • Arthroscopic procedures: R6,900 co-payment
  • Laparoscopic procedures: R5,800 co-payment
Alternatives to hospitals:
  • Terminal care: R27,900 per family
  • Physical rehabilitation, sub-acute facilities, nursing services: PMBs only

.
.

OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Network GP: 1 consult per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • Paid by scheme, with a R1,900 co-payment
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

.
.

MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Consultations:
  • 4 postnatal consultations with midwife
Scans:
  • No benefit

.
.

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: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

.
.

DENTISTRY:
Dentistry:
  • No benefit, unless PMB
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • Unlimited

.
.

MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No 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

.
.

OPTOMETRY:
Optometry:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

.
.

MENTAL HEALTH:
In-hospital:
  • R22,600 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:
  • No benefit

.
.

OTHER BENEFITS:
General Appliances:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
HIV:
  • Covered if on the management program
Emergency Transport: Europ Assistance
International Coverage:
  • R5 million, for under 70yrs
Other:

.
.

WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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

.
.

PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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