Fedhealth FlexiFed 1 Main medical aid plan: 2020

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FlexiFed 1 Main
Total Cost pm:

Main member:

R1,721

Adult:

R1,349

Child:

R628
Savings: R R R

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IN HOSPITAL PROCEDURES:
FlexiFed 1 Main
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • 100% scheme rate
network Specialists:
  • Covered in full
non-Network GPs:
  • 100% scheme rate
network GPs:
  • Covered in full
Hospital Choice:
  • Choose from Network Hospitals
Penalty for using other hospital:
  • R6,700 co-payment if you voluntarily choose another hospital
  • The Blue Plan gap cover will pay one "penalty co-payment" up to R10,000 per policy per year
Specialised Radiology:
  • MRI, CT scans: R3,000 co-payment
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • PMBs only
  • Corneal graft: no benefit
Co-payments:
  • Adenoidectomy, back and neck procedures, bunion procedures and conservative admissions, colonoscopy, upper GI endoscopydiagnostic cytoscopy, gastritis, dyspepsia, heartburn, nasal procedures, skin biopsy/excision, all open hernia surgery, laparoscopic hernia repairs, laparoscopic procedures, spinal surgery, laparoscopic varicocelectomy, varicose vein procedures: R6,500
  • Arthroscopic procedures - knee, shoulder, ankle and other: R8,200
  • Hysterectomy (unless for cancer): R3,800
  • Laparoscopic procedures:R6,200
  • Tonsillectomy, 12yrs+:R6,500
Alternatives to hospitals:
  • Nursing services: Unlimited
  • Sub acute facilities, physical rehab: Unlimited, up to PMB level of care
  • Terminal care: R31,000
Casualty: 2020 benefits coming soon
  • Both the Blue Plan and Red Plan gap cover will pay up to R10,000 per person for unpaid casualty costs in event of emergency
Other:
  • In and out of hospital, appliances, external accessories and orthotics: day-to-day benefit
  • Follow up treatment for 30 days post hospitalisation for physio, x-rays, pathology etc
Excluded:
    Note:
    • Gap cover is an add-on to your medical aid, not a stand alone product
    • Gap cover has a maximum benefit payout of R165,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R165,000 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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    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):
    FlexiFed 1 Main
    Scheme Benefits Notes and Links:
    Main Member: Adult: Child:
    General info:
    • Consider getting Primary Health Care (PHC) (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
    • R370/main | R245/adult | R110/child
    • Read more here
    GP consultations:
    • From day-to-day benefit
    • Once your day-to-day claims (paid from savings, wallet or out-of-pocket) have accumulated to the amounts below, Fedhealth will pay for unlimited consults with nominated GP
    • M =R3,600
      M =R6,000
      M =R7,200
      M =R8,700
    • See Primary Health Care benefit above
    Childcare:
    • 1 test with audiologist, birth to 8 weeks
    Specialists consultations:
    • From day-to-day benefit, unless PMB
    • See Primary Health Care benefit above
    Pathology:
    • From day-to-day benefit, unless PMB
    • See Primary Health Care benefit above
    General radiology:
    • From day-to-day benefit, unless PMB
    • See Primary Health Care benefit above
    Specialised radiology:
    • MRI, CT scans: R3,000 co-payment, unless PMB
    Supplementary Services: (Physio, etc)
    • From day-to-day benefit, unless PMB

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    MATERNITY BENEFITS:
    FlexiFed 1 Main
    Scheme Benefits Notes and Links:
    Hospital stay:
    • Covered
    • Doula benefit: R1,300
    • The Blue Plan gap cover will increase this to 500% scheme rate
    Consultations:
      Fedhealth pays for:
    • Postnatal: 4 consults with midwife
    Scans:
    • No benefit

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    CANCER (ONCOLOGY):
    FlexiFed 1 Main
    Scheme Benefits Notes and Links:
    Overall coverage (in and out of hospital):
    • PMBs only, at DSP
    • You have the option of moving to a higher plan within 30 days of cancer diagnosis

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    DENTISTRY:
    FlexiFed 1 Main
    Scheme Benefits Notes and Links:
    Standard Dentistry:
    • Once your day-to-day claims (paid from savings, wallet or out-of-pocket) have accumulated to the amounts below, Fedhealth will pay for 2 consults per person, including x-rays and scaling and polishing
    • M =R3,600
      M =R6,000
      M =R7,200
      M =R8,700
    • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
    • R370/main | R245/adult | R110/child
    • Read more here
    Specialised Dentistry:
    • Specialised dentistry: From day-to-day benefit
    In-Hospital Dentistry:
    • Maxilo-facial surgery: unlimited, subject to approval
    • Dental admissions: No benefit, unless PMB
    Orthodontics:
    • From day-to-day benefits
    Maxillo Facial Surgery:
    • PMBs only

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    MEDICATION:
    FlexiFed 1 Main
    Scheme Benefits: Notes and Links:
    Chronic: 2020 benefits coming soon
    Acute (presrcibed) medication:
    • From day-to-day benefits
    • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
    • R370/main | R245/adult | R110/child
    • Read more here
    Over-the-counter:
    • From day-to-day benefits
    Birth Control:
    • From day-to-day benefits
    On Discharge:
    • 7 days
    Biological: 2020 benefits coming soon

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    OPTOMETRY:
    FlexiFed 1 Main
    Scheme Benefits: Notes and Links:
    Optometry:
    Limit:From day-to-day benefit
    Consult:n/a
    Frames:n/a
    Single lensesn/a
    Bifocals:n/a
    Multifocalsn/a
    Contactsn/a
    Refractive Surgery:n/a
    Notes:n/a

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    MENTAL HEALTH:
    FlexiFed 1 Main
    Scheme Benefits Notes and Links:
    In-hospital:
    • PMBs always paid in full at DSP, and include up to 21 days admission
    Out-of-hospital:
    • Out of hospital PMBs: always paid in full
    • Non-PMBs: sfrom day-to-day benefit
    Trauma: 2020 benefits coming soon

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    OTHER BENEFITS:
    FlexiFed 1 Main
    Scheme Benefits Notes and Links:
    General Appliances:
      In and out of hospital:
    • Appliances, external accessories and orthotics: day-to-day benefit
    1.1. Hearing Aids:
    • From day-to-day benefits
    1.2. Wheelchairs:
    • From day-to-day benefits
    Dialysis:
    • PMBs only
    International Insurance: 2020 benefits coming soon
    Other: 2020 benefits coming soon

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    WELLNESS/PREVENTATIVE BENEFITS:
    FlexiFed 1 Main
    Scheme Benefits: Notes and Links:
    Flu vaccination:
    • Covered
    Pneumonia vaccines:
    • Covered
    Biometric Screening:
    • Covered
    Child Immunisation:
    • Covered
    Pap Smear:
    • Covered, every 3 years
    Mammogram:
    • No cover
    PAS Test:
    • Covered
    HIV Test:
    • Covered
    Other:
    • Lipogram: every 5 yrs
    • Faecal occult blood test:

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    PROSTHETICS:
    FlexiFed 1 Main
    Scheme Benefits: Notes and Links:
    Overal Limit:
    • PMBs only
    Sub-limits:

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      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