Fedhealth Maxima Exec medical aid plan: 2020

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Maxima Exec
2020 Costs:
Total Cost pm:

Main member:

R6,766

Adult:

R5,874

Child:

R2,152
Savings: R R R
Extended Fund: R R R
Self Payment Gap:
R R R
Above Threshold:



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IN HOSPITAL PROCEDURES:
Maxima Exec
Scheme Benefits: Notes and Links:
non-Network Specialists: 2020 benefits coming soon
network Specialists: 2020 benefits coming soon
  • The Blue Plan gap cover will increase this to 500% scheme rate
non-Network GPs: 2020 benefits coming soon
  • The Blue Plan gap cover will increase this to 500% scheme rate
network GPs: 2020 benefits coming soon
  • The Blue Plan gap cover will increase this to 500% scheme rate
Hospital Choice:
  • Choose any hospital
Penalty for using other hospital:
  • Choose any hospital
Specialised Radiology:
  • 100% scheme rate
Supplementary Services: (Physio, etc) 2020 benefits coming soon
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • R555,900 per family
  • Corneal graft: R20,700 per person
Co-payments:
  • Arthroscopic procedure, hip: R2,400
  • Arthroscopic procedure, wrist: R2,400
  • Arthroscopic procedures - other: R2,400
  • Spinal surgery:R4,200
  • Balloon sinuplasty: R4,200
  • Colonoscopy, upper GI endoscopy: R2,400
  • Joint replacement: single hip and knee with voluntary use of non-network provider:R26,200
  • Joint replacement: single hip and knee with involuntary use of non-network provider:R4,200
  • Other joint replacements:R4,200
  • Laparoscopic procedures:R4,200
  • Laparoscopic varicocelectomy:no co-payment
  • Rhizotomies and facet pain blocks (one per person per year):R4,200
  • Wisdom Teeth:R4,200
Alternatives to hospitals:
  • Nursing services: Unlimited
  • Sub acute facilities, physical rehab: Unlimited
  • Terminal care: R31,000
Casualty:
  • R570 co-payment for non-PMB
  • Both the Blue Plan and Red Plan gap cover will pay up to R20,000 per person for unpaid casualty costs in event of emergency
Other:
  • Follow up treatment for 30 days post hospitalisation for physio, x-rays, pathology etc
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R157,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R157,000 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):
Maxima Exec
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Extended Fund: R R R
Self Payment Gap:
R R R
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:
  • Contracted GPs: paid from savings, then by scheme.
  • Non-Contracted GPs: paid from day-to-day benefit. Accumulates and refunds from Threshold at scheme rates.
  • See Primary Health Care benefit above
Childcare:
  • 1 test with audiologist, birth to 8 weeks
Specialists consultations:
  • From day-to-day benefit, unless PMB with a 10% co-payment if not refered by GP
  • Contracted Specialists: accummulate to threshold at cost, and paid at cost
  • Non-Contracted Specialists: accummulate to threshold at 100% scheme rate, and paid at 100% scheme rate
  • See Primary Health Care benefit above
Pathology:
  • From day-to-day benefit. Unlimited once threshold is reached.
  • See Primary Health Care benefit above
General radiology:
  • From day-to-day benefit. Unlimited once threshold is reached.
  • See Primary Health Care benefit above
Specialised radiology:
  • Unlimited
  • MRI and CT Scans: R2,200 co-payment, unless PMB
Supplementary Services: (Physio, etc)
  • Audiology, dietetics, genetic counselling, occupational therapy, orthoptics, podiatry, psychologists, speech therapy, social workers, physio, biokinetics and chiropractics: paid from day-to-day benefit, for in-and out of hospital. Does not accumulate to threshold. Paid from threshold up to R17,400 per family
  • Alternative healthcare: paid from day-to-day benefit. Does not accumulate or pay from threshold



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MATERNITY BENEFITS:
Maxima Exec
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:
  • 2 x 2D scans, from day-to-day benefit



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CANCER (ONCOLOGY):
Maxima Exec
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R555,900 per family, at DSP. (Level 2 treatment protocols)
  • Specialised medicine: R173,400
  • You have the option of moving to a higher plan within 30 days of cancer diagnosis



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DENTISTRY:
Maxima Exec
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard dentistry: from day-to-day benefit. Unlimited once Threshold is reached.
  • 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: R7,400 per person and R22,100 per family from day-to-day benefit.
  • Includes inlays, crowns, bridges, mounted study models, metal base partial dentures, implants, orthognathic surgery, oral surgery, orthodontic treatment, periodontists, prosthdontists and dental technicians.
In-Hospital Dentistry:
  • Maxilo-facial surgery: unlimited, subject to approval
  • In-hospital, children under 7: hospital and anaesthetist paid by scheme. Dentist account paid out-of-pocket
  • Surgical extraction of wisdom teeth: R4,200 co-payment
  • Dental admissions:no co-payment
Orthodontics:
  • See Specialised dentistry, above
Maxillo Facial Surgery:



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MEDICATION:
Maxima Exec
Scheme Benefits: Notes and Links:
Chronic: 2020 benefits coming soon
Acute (presrcibed) medication:
  • R7,100 per person and R13,100 per family, from day-to-day benefit
  • 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 savings only. Does not accumulate or pay from threshold.
Birth Control:
  • Oral, patches, rings, certain injectables,as wella s IUDs (incl Mirena): paid by scheme
On Discharge:
  • 7 days
Biological: 2020 benefits coming soon



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OPTOMETRY:
Maxima Exec
Scheme Benefits: Notes and Links:
Optometry:
Limit:R3,340 per person and R10,190 per family. Paid from day-to-day benefit.
Consult:from above limit
Frames:from above limit
Single lensesfrom above limit
Bifocals:from above limit
Multifocalsfrom above limit
Contactsfrom above limit
Refractive Surgery:from above limit
Notes:



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MENTAL HEALTH:
Maxima Exec
Scheme Benefits Notes and Links:
In-hospital:
  • In-hospital: R32,000 per family. PMBs always paid in full at DSP, and include up to 21 days admission
Out-of-hospital:
    Psychiatrists:
  • From day-to-day benefit, unless PMB, sublimit of Additional Medical Services of R17,400
  • Do not accumulate to threshold
  • Network psychiatrists cost, with 10% co-payment if GP referral not obtained
  • Non-network psychiatrists 100% scheme rate, with 10% co-payment if GP referral not obtained
Trauma: 2020 benefits coming soon



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OTHER BENEFITS:
Maxima Exec
Scheme Benefits Notes and Links:
General Appliances:
  • From day-to-day benefit, unless PMB, in and out of hospital
  • Does not accumulate to threshold
  • Limited to R15,500 per family from threshold
  • Foot orthotics: sub-limit of R4,340 per person
1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • R555,900 per family
International Insurance: 2020 benefits coming soon
Other: 2020 benefits coming soon



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WELLNESS/PREVENTATIVE BENEFITS:
Maxima Exec
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • Covered, 65yrs+
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
  • Bone densitometry: women,65yrs+ and men 70yrs+
  • Faecal occult blood test: covered, 50-75yrs



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PROSTHETICS:
Maxima Exec
Scheme Benefits: Notes and Links:
Overal Limit:
  • Internal:R29,200 unless listed below
  • External:R17,300
Sub-limits:
  • Detachable platinum coils: R50,700
  • Cardiac stents: R50,100
  • Cardiac valves: R44,500
  • Cardiac pacemakers: R48,700
  • Aorta stent grafts: R58,500
  • Shoulder replacement: R34,800
  • Elbow replacement: R33,200
  • Hip replacement: R33,200
  • Knee replacement: R33,200
  • Intraocular lenses: R3,200 per lens



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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