Fedhealth Maxima EntrySaver medical aid plan: 2017

Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, 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: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • R2,500 co-payment
Supplementary Services: (Physio, etc)
  • Physio and biokinetics: 100% scheme rate
  • Dietetics, occupational therapy, speech therapy: from day-to-day benefit
Transplants:
  • PMBs only, in state facilities
Co-payments:
  • Colonoscopy, upper GI endoscopy, open hiatus hernia surgery, spinal surgery, back and neck procedures, bunion procedures, cataract surgery, gastritis, dyspepsia, heartburn, hysterectomy, nasal procedures, skin biopsy/excision, tonsil/adenoid procedures, varicose vein procedures, cystoscopy: R5,300 co-payment
  • Arthroscopic procedures: R6,900 co-payment
  • Laparoscopic procedures: R5,800 co-payment
  • Elective caesarean: R10,000 co-payment
Alternatives to hospitals:
  • Terminal care: R27,900 per family
  • Physical rehabilitation, sub-acute facilities, nursing services: PMBs only

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Network GPs: Unlimited, from day-to-day or by scheme
  • Non-network GPs: paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

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 R2,500 co-payment
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
  • 100% scheme rate
  • Elective caesarean: R10,000 co-payment
  • Home delivery: R1,200
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

Compare with these plans:

Consultations:
  • Paid from day-to-day benefit
Scans:
  • Paid from day-to-day benefit

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
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: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

Compare with these plans:

Orthodontics:
  • Paid from day-to-day benefit
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: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

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
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

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: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

Compare with these plans:

1.1. Hearing Aids:
  • Paid from day-to-day benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit
Dialysis:
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: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

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: R1,640 R1,181 R524
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, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

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