Fedhealth Maxima Plus 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 Plus
Quick Overview
Main: Adult: Child:
Total Cost pm: R7,535 R6,415 R2,303

(Pay only for first 3)

Savings: R4,980 R4,236 R1,524
Extended Fund: R8,300 R5,990 R1,840
Self Payment:
(per year, if you use up all your savings)
R9,362 R6,795 R2,301
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 Plus
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:
  • N/A
  • N/A
Supplementary Services: (Physio, etc)
  • Unlimited
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment
Transplants:
  • Unlimited
  • Corneal graft: R19,700 per family
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Sublimits increased as necessary
Co-payments:
  • N/A
  • N/A
Alternatives to hospitals:
  • Terminal care: R29,500 per family
  • Physical rehabilitation, sub-acute facilities, nursing services, private nurse practitioners, nursing agencies: Unlimited, at negotiated rate
  • No benefit
Casualty:
  • Paid by scheme at 100% scheme rate
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  • 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)

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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.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Maxima Plus
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R4,980 R4,236 R1,524
Extended Fund: R8,300 R5,990 R1,840
Self Payment:
(per year, if you use up all your savings)
R9,362 R6,795 R2,301
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: paid from OHEB or 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 10% 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 10% 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, if pre-authorised
  • No benefit
Supplementary Services: (Physio, etc)
  • Audiology, dietetics, genetic counselling, occupational therapy, orthoptics, podiatry, psychologists, speech therapy, social workers: paid from R16,600 from day-to-day benefit.
  • Alternative healthcare: paid from day-to-day benefit. Does not accumulate or pay from threshold
  • Physio (biokinetics, chiropractors and physio): from day-to-day benefit
  • No benefit

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

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MATERNITY BENEFITS:
Maxima Plus
Scheme Benefits Gap benefits
Hospital stay:
  • Specialists from network, covered at full cost. Otherwise, 200% 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

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CANCER (ONCOLOGY):
Maxima Plus
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Unlimited at DSP (ICON). Subject to Level 3 protocols.
  • Biological medicine: R331,100
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, your sublimits increase as necessary. More info

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Our quote will include the right gap cover for this plan

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DENTISTRY:
Maxima Plus
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

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MEDICATION:
Maxima Plus
Scheme Benefits Gap benefits
Chronic:
  • No. of chronic conditions covered: 51 and R14,300 per person and R26,800 per family
  • Co-payment if out of formulary: 40% co-payment
  • No benefit
Acute (presrcibed) medication:
  • R9,500 per person and R18,800 per family, from day-to-day benefit
  • No benefit
Over-the-counter:
  • Paid from savings only. Does not accumulate or pay from threshold.
  • No benefit
Birth Control:
  • Unlimited
On Discharge:
  • 7 days supply
  • No benefit
Biological:
  • R331,100
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, your sublimits increase as necessary. More info

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

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OPTOMETRY:
Maxima Plus
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

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MENTAL HEALTH:
Maxima Plus
Scheme Benefits Gap benefits
In-hospital:
  • R38,400
  • No benefit
Out-of-hospital:
    Network Psychiatrists:
    • From day-to-day benefit
    • Limited to R16,500 per family from threshold, which is shared with supplementary services
    • Accumulates to threshold at cost
    • 10% co-payment if no referral from network GP
    Non-network psychiatrists:
    • As above, but accumulates 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

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OTHER BENEFITS:
Maxima Plus
Scheme Benefits Gap benefits
General Appliances:
  • In-hospital: Unlimited
    Out -of-hospital:
  • From day-to-day benefit
  • Limited to R14,800 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:
  • Unlimited
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

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WELLNESS/PREVENTATIVE BENEFITS:
Maxima Plus
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • One per lifetime, 65 yrs+
  • 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:
  • 1 densitometry test per lifetime, 65 yrs+
  • 1 colorectal cancer screening test, every 2 years for 50-75yrs
  • No benefit

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

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PROSTHETICS:
Maxima Plus
Scheme Benefits Gap benefits
Overal Limit:
  • External: combined R34,400benefit (see below), or as per sublimit
  • Internal: R20,800
  • 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: R47,700
  • Cardiac valves: R42,400
  • Cardiac pacemakers: R55,700
  • 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: R42,400
  • Elbow replacement: R42,400
  • Hip replacement: R42,400. Double benefit for bilateral replacement
  • Knee replacement: R42,400. 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