Fedhealth Maxima Standard medical aid plan: 2017

Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims. Pay for all children.

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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: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • R1,900 co-payment
Supplementary Services: (Physio, etc)
  • Physio and biokinetics: 100% scheme rate
  • Audiology, dietetics, genetic counselling, occupational therapy, orthoptics, podiatry, psychologists, speech therapy, social workers and chiropractics: R10,500 per family, from day-to-day benefit for in and out of hospital
Transplants:
  • R400,000 per family
  • Corneal graft: R18,700 per family
Co-payments:
  • Colonoscopy, upper GI endoscopy, Arthroscopic procedures: R2,100 co-payment
  • Wisdom teeth extraction, balloon sinuplasty, spinal surgery, joint replacements, all laparoscopic procedures, rhizotomies and facet pain block: R3,700 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:
  • Depending on the GP, paid from day-to-day benefit, or paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

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)
  • Audiology, dietetics, genetic counselling, occupational therapy, orthoptics, podiatry, psychologists, speech therapy, social workers, physio, biokinetics and chiropractics: R10,500 per family, from day-to-day benefit for in and out of hospital
  • Alternative healthcare: paid from day-to-day benefit, but not from threshold

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

Compare with these plans:

Consultations:
  • 4 postnatal consultations with midwife
  • Otherwise, from day-to-day benefit
Scans:
  • 2 x 2D scans, from day-to-day benefit

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R400,000 per family
  • Biological medicine: no cover
  • Brachytherapy materials: R39,900

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: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: R6,740 per person and R20,000 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

Compare with these plans:

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

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 14 conditions covered
  • R5,120 per person, and R10,200 per family. Thereafter only PMBs are covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

Compare with these plans:
Acute (presrcibed) medication:
  • R5,120 per person and R10,200 per family, from day-to-day benefit
Over-the-counter:
  • Paid from savings benefit only and does not add up to threshold
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:
  • R3,010 per person and R9,170 per family, from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

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: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

Compare with these plans:


Out-of-hospital:
  • Psychiatrists: R10,500 per family from day-to-day benefit. Benefit shared with supplementary services

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OTHER BENEFITS:
General Appliances:
  • R10,500 per family, from day-to-day benefit, in and out of hospital
  • Does not add up to threshold
  • Foot orthotics: sub-limit of R3,910 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • R400,000
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: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

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: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

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