Fedhealth Maxima Plus:
in-and-out of hospital benefits (2025)

This page has overview information on: Costs, In-hospital, Out of Hospital and Medicine benefits for Fedhealth Maxima Plus. Please consult and verify with the scheme or your broker for full benefits, and an explanation of all the "fine print".

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Terminology:

• PMBs: Prescribed Minimum Benefits. You can read more about PMBs, see a list of all PMB conditions or read more what "PMB only" benefit means.
• DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
• Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
• All schemes have extensive exclusions. We've tried to list the non-common ones here, but please consult your scheme or broker to get the full list.

In-hospital Procedures (2024):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Fedhealth: Maxima Plus
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
GPs and Specialists:	Doctors in network: paid in full Doctors not in network: 200% scheme rate	Gap Cover: Can push payout up to 700% scheme rate (Plans coming soon)
Hospital Choice:	Choose any hospital except: Zuid-Afrikaans Hospital (City of Tshwane), Arwyp Medical Centre (Ekurhuleni), Busamed Modderfontein Private Hospital (City of Johannesburg), Hibiscus Hospital (Ugu), Mooimed Private Hospital (Dr Kenneth Kaunda), Capital Hospital (Durban). Elective procedures at these 7 hospitals: R8,840 co-payment
Penalty for using other hospital:	Elective procedures at the 7 excluded hospitals: R8,840 penalty	Gap Cover: Can cover the penalty in full (Plans coming soon)
Co-payments:	MRIs, CT scans etc: R2,960 co-payment Note: A co-payment is a fee your medical aid can insist you pay, regardless of how much the doctor/charges. It's not the same as an "excess" payment (which is when a doctor charges more than the medical aid rate). If you use a DSP (designated service provider), you never have to pay a co-payment for protocol treatment of a PMB (Prescribed Minimum Benefit). More info here There might be other co-payments if you don't use a DSP, especially if you are being treated for a PMB or when buying medicine.	Gap Cover: Can cover most co-payments (Plans coming soon)
Specialised Radiology:	MRI and CT Scan: R2,960 co-payment, in and out-of hospital	Gap Cover: Can cover most co-payments and increase sublimits (Plans coming soon)
Scopes:		Gap Cover: Can cover most co-payments and increase sublimits (Plans coming soon)
Supplementary Services: (Physio, etc)	100% scheme rate Dietetics, occupational therapy and speech therapy: from day-to-day benefit , R19,400 per family if paid from Threshold. Does not accumulate to Threshold, but does pay from it.
Transplants:	Unlimited Corneal graft: R36,300 per person
Dialysis:	Unlimited
Exclusions:	NB: See scheme's rules for all exclusions. All schemes have plenty!	Gap Cover: Coming soon
Alternatives to hospitals:	Nursing services: Unlimited Sub acute facilities, physical rehab: Unlimited Terminal care: R34,500 per person
Casualty/ER:	Emergency treatment, like stitches: R850 co-payment, unless PMB	Gap Cover: Can cover ER claims (Plans coming soon)
Other:	Appliances, external accessories and orthotics, in and out of hospital: From day-to-day benefit Physio, x-rays, pathology etc: Follow up treatment for 30 days post hospitalisation
PMBs= Prescribed Minimum Benefits (more info) | DSP= Designated Service Provider

Out-of-hospital Procedures (2024):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Fedhealth: Maxima Plus
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
Main Member: Adult: Child: Savings: R7,500 R6,468 R2,316 Extended Fund: Extra funds from the scheme for (mostly) out of hospital claims, over and above any savings account R10,310 R7,440 R2,290 Self Payment Gap: (What you need to pay out of pocket before you can access the "Above Threshold" benefit) R3,878 R2,989 R1,233 "Above Threshold" benefit (ATB): Additional cover the scheme makes available to you, once you've paid the self payment gap. Unlimited Unlimited Unlimited Other Day-to-Day Funds:
PMBs out of hospital:	All schemes must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here. This can include consults with specialists, blood or other tests, radiology and medicine PMB benefits must never be paid from your savings account Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here. See our Guide to PMBs for more information.
GP consultations:	Network GP: From day-to-day benefit , then paid by scheme Non-Network GP: From day-to-day benefit , then from Threshold
Childcare:	Paediatrician: 1 consult, 0-1yr Immunisations: Covered, 0-12yrs Childhood illness specialised drugs: Covered, 0-18yrs	Gap Cover: Can pay for child ER visits (Plans coming soon)
Specialists consultations:	Fedhealth Network: from day-to-day benefit , unlimited at cost once Threshold is reached Non-Network: as above, but at scheme rate and does not accumulate to Threshold
Pathology:	From day-to-day benefit Unlimited, once Threshold is reached
General radiology:	From day-to-day benefit Unlimited, once Threshold is reached
Specialised radiology:	MRI, CT scans: R2,810 co-payment. In and out-of hospital	Gap Cover: Can pay co-payments and increase sublimits (Plans coming soon)
Scopes:		Gap Cover: Can pay co-payments and increase sublimits (Plans coming soon)
Supplementary Services: (Physio, etc)	Supplementary medical services: From day-to-day benefit . Paid from Threshold up to R12,900 per family Alternative medical services (acupuncture, homeopathy, naturopathy, osteopathy and phytotherapy): From day-to-day benefit . Does not accumulate to or pay from Threshold.
General Appliances:	In hospital: Unlimited at cost Out of hospital: From day-to-day or from Threshold up to R17,300 per family per year Foot orthotics: R4,860 sub-limit per person
1.1. Hearing Aids:	See above
1.2. Wheelchairs:	See above
PMBs= Prescribed Minimum Benefits (more info) | DSP= Designated Service Provider

Medication Benefit (2024):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Fedhealth: Maxima Plus
Assume scheme pays all these costs, unless otherwise stated
Main Member: Adult: Child: Savings: R7,500 R6,468 R2,316 Extended Fund: Extra funds from the scheme for (mostly) out of hospital claims, over and above any savings account R10,310 R7,440 R2,290 Self Payment Gap: (What you need to pay out of pocket before you can access the "Above Threshold" benefit) R3,878 R2,989 R1,233 "Above Threshold" benefit (ATB): Additional cover the scheme makes available to you, once you've paid the self payment gap. Unlimited Unlimited Unlimited Other Day-to-Day Funds:
Chronic:	27 PMB conditions: Covered. You can see the full PMB list here. Additional 56 conditions Overall benefit: R16,700 per person and R31,300 per family. Thereafter, the 27 PMB conditions only
Acute (prescribed) medication:	From day-to-day benefit R11,060 per person and R22,010 per family, before and after Threshold
Over-the-counter:	From day-to-day benefit Does not accumulate or pay from extra fund or Threshold
Birth Control:	Oral, patches, contraceptive rings, certain injectables, and IUDs (including Mirena): Paid by scheme, if prescribed
On Discharge:	7 days
Biological:	R390,400 per family
View other benefits for this plan: In-hospital | Out-of-hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics You can also: Compare any two plans, side by side | View all the Fedhealth plans, with costs and brief summary. Find all other open medical aid plans here.
PMBs= Prescribed Minimum Benefits (more info) | DSP= Designated Service Provider