Hospital plans Choose from: Maxima Core Maxima EntryZone Value-for-money protection in-hospital, plus chronic medication cover Life s unexpected events take us by surprise when illness, accidents or other serious incidents strike. Hospital plans offer the peace of mind that the member s protected should this type of event happen. Our hospital plans are the ideal solution for anyone who s just starting out, from the student to the young, single professional. Maxima Range Unlimited hospitalisation is available at all private hospitals through Maxima Core, and members on Maxima EntryZone will enjoy unlimited hospitalisation at all Network Hospitals. As an added bonus, both options care for members with chronic conditions with a Chronic Disease Benefit that covers 25 chronic conditions at 100% of the Medicine Price List. Hospital Plans
RISK BENEFITS Major Medical Benefit Chronic Disease Benefit RISK BENEFITS Major Medical Benefit Hospitalisation Network GPs and Specialists Non-network GPs and Specialists Other healthcare professionals From R1 529pm No overall annual limit Up to 200% of Fedhealth Rate Up to 100% of Fedhealth Rate From R1 073pm No overall annual limit Network hospitals only Unlimited cover at cost with Fedhealth Network GPs and Specialists Up to 100% of Fedhealth Rate How the scheme works Major Medical Benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised - Network Hospitals apply to Maxima EntryZone. Chronic Disease Benefit Medication for approved chronic diseases is covered from this benefit. Day-to-Day Benefit PMB level of care applies at the Designated Pharmacy Provider, GP Network and Specialist Network only. Chronic Disease Benefit Day-to-Day Benefit PMB chronic conditions only from Medi-Rite pharmacies and subject to a restrictive formulary. Covers up to 100% of the Medicine Price List No Day-to-Day Benefit. PMB level of care applies at the Designated Pharmacy provider, GP Network and Specialist Network only. Unlimited specialised radiology paid from the Major Medical Benefit if pre-authorised
[ 1 BENEFIT major medical benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised - Network Hospitals apply to Maxima EntryZone ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Overall annual limit (OAL) Unlimited Unlimited at network hospitals only Healthcare Professional Tariff (HPT) - Fedhealth Network GPs and Specialists - Non-Fedhealth Network GPs and Specialists Covered at cost Covered at 100% of FR Covered at cost Covered at 100% of FR - Other Healthcare Professionals Covered at 200% of FR Covered at 100% of FR Prescribed Minimum Benefits (PMBs) Unlimited in state hospitals Hospitalisation costs Unlimited at negotiated tariff Unlimited at negotiated tariff at network hospitals only. R5 000 co-payment on voluntary use of a non-network hospital Co-payments See details on page 2 Alternatives to hospitalisation - Sub-acute facilities and physical rehabilitation facilities - Nursing services, private nurse practitioners & nursing agencies Ambulance services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Maxillo-facial surgery PMB level of care only Unlimited at negotiated tariff Unlimited with Europ Assistance Unlimited at cost Unlimited (See HPT above) Unlimited, subject to approval (See HPT above) Unlimited, subject to approval (See HPT above) - Surgical extraction of impacted wisdom teeth Emergency treatment in a casualty ward Female health benefit: contraceptives Immune deficiency related to HIV infection Oncology - Specialised medication Co-payment applies to surgical extraction of impacted wisdom teeth R213 000 at ICON. Subject to Standard Protocols (See HPT above) for surgical extraction of impacted wisdom teeth Unlimited at FR Unlimited (See HPT above) at ICON FR - Fedhealth Rate ICON - Independent Clinical Oncology Network HPT - Healthcare Professional Tariff
[ 2 BENEFIT Organ transplant including immunosuppression medication major medical benefit (continued) ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED R213 000 (See HPT on page 1) in state facilities - Corneal graft Pathology, radiology (general) Post-hospitalisation benefit Post-natal midwifery benefit Prostheses - Internal Various sub-limits apply (see page 4) Unlimited at FR Up to 30 days after discharge at FR 4 consultations per pregnancy at FR - External R9 970 at cost Psychiatric services R21 500 (See HPT on page 1) Renal Dialysis (chronic) - Haemodialysis and peritoneal dialysis R213 000 at FR in state facilities Specialised medication benefit (eg. biologicals) - oncology & non-oncology Specialised radiology Unlimited at FR Take-out medicines 7 days medication per hospital event at MPL Terminal care benefit R26 500 at FR HPT - Healthcare Professional Tariff FR - Fedhealth Rate MPL - Medicine Price List co-payments PROCEDURE CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY Colonoscopy, Upper GI endoscopy R2 500 R5 000 co-payment on the following procedures/ admissions All hernia procedures, Back & neck pain, Spinal surgery, Bunion procedures, Cataract surgery, Elective caesarean sections, Gastritis/ dyspepsia/ heartburn, Open hiatus hernia surgery, Hysterectomy (unless for cancer), Inguinal hernia surgery, Varicose vein procedures R 3 360 Hysterectomy (unless for cancer), Nasal procedures, Scopes (upper GI endoscopy, colonoscopy, cystoscopy), Skin biopsy/ excision, Tonsil/ adenoid procedures, Spinal surgery, Joint replacements R6 720 Varicose vein procedures
[ 3 co-payments (continued) PROCEDURE CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY Surgical extraction of impacted wisdom teeth R3 360 Arthroscopic procedures Ankle, Knee, Shoulder R2 500 R5 000 Laparoscopic procedures Diagnostic, Nissen/ Toupey R2 500 R5 000 All arthroscopic and laparoscopic procedures not listed above Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered network hospitals HOSPITAL PROVINCE SUBURB Life Beacon Bay Hospital Eastern Cape East London Life Mercantile Hospital Eastern Cape Korsten Life St George s Hospital Eastern Cape Centrahill Life St James Hospital Eastern Cape Southernwood Life St Mary's Private Hospital Eastern Cape Umtata Horizon Eye Care Centre Free State Bloemfontein Mediclinic Hoogland Free State Bethlehem Life Pasteur Hospital Free State Bloemfontein Life Rosepark Hospital Free State Bloemfontein Netcare Bougainville Hospital Gauteng Hercules Life Brenthurst Clinic Gauteng Johannesburg Life Carstenhof Clinic Gauteng Midrand Cormed Clinic Gauteng Vanderbijlpark Life Dalview Clinic Gauteng Brakpan Life Flora Clinic Gauteng Roodepoort HOSPITAL PROVINCE SUBURB Life Fourways Hospital Gauteng Fourways Gardens Life The Glynnwood Gauteng Benoni Louis Pasteur Hospital Gauteng Pretoria Central Midvaal Private Hospital Gauteng Three Rivers Life Robinson Private Hospital Gauteng Randfontein Life Roseacres Clinic Gauteng Primrose Life Chatsmed Garden Hospital Kwa-Zulu Natal Chatsworth Durdoc Clinic Kwa-Zulu Natal Durban Central Life Entabeni Hospital Kwa-Zulu Natal Durban Maxwell Clinic Kwa-Zulu Natal Qualbert Life Mount Edgecombe Hospital Kwa-Zulu Natal Mount Edgecombe Life Westville Hospital Kwa-Zulu Natal Westville Zoutpansberg Private Hospital Limpopo Polokwane Life Cosmos Hospital Mpumalanga Witbank Life Peglerae Hospital North West Rustenburg HOSPITAL PROVINCE SUBURB Mediclinic Kimberley Northern Cape Kimberley Life Bay View Private Hospital Western Cape Mossel Bay Netcare Blaauwberg Hospital Western Cape Bloubergrant Mediclinic Cape Gate Western Cape Cape Gate Mediclinic Cape Town Western Cape Mill Street Ceres Private Hospital Western Cape Ceres Life Claremont Hospital Western Cape Claremont Life Kingsbury Hospital Western Cape Claremont Mediclinic Geneva Western Cape George Mediclinic George Western Cape George Melomed Mitchells Plain Medical Western Cape Cape Town Centre Life West Coast Private Hospital Western Cape Vredenburg Please note that this list may change/ expand during the year. Please contact the Fedhealth Customer Contact Centre on 0860 002 153 or refer to the website for the latest Maxima EntryZone Network Hospital list
[ 4 BENEFIT internal prosthesis benefit table This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth LIMIT PER FAMILY PER YEAR Detachable platinum coils R43 289 Cardiac stents Cardiac valves Cardiac pacemakers Aorta stent grafts R49 906 Intraocular lenses (per lens) R2 804 Carotid stents Peripheral arterial stent grafts Embolic protection devices Shoulder replacement Elbow replacement Hip replacement See combined benefit limit for all unlisted internal prosthesis* Knee replacement Bone lengthening devices Spinal plates and screws Other approved spinal implantable devices Combined benefit limit for all unlisted internal prosthesis *R21 308
[ 5 screening benefit This benefit provides access to a number of screening and preventative programmes aimed at improving members health BENEFIT CRITERIA ALL LIMITS ARE PER BENEFICIARY Women s Health Breast cancer screening with mammography Cervical cancer screening (PAP smear - test only) Liquid based Cytology will be reimbursed up to the rate for a standard PAP smear Women; ages 50 to 74 Women; ages 21 to 65 1 every 3 years 1 every 3 years Children s Health Immunisation Programme As per State EPI As per State EPI Cardiac Health Cholesterol screening (full lipogram) All lives; aged 20 and older 1 every 5 years General General practitioner consultation (in network only) Flu vaccination All lives All lives chronic disease benefit Medication for approved chronic diseases is covered from this benefit 1 every year 1 every year EPI - Expanded Programme on Immunisation Limit Conditions covered Formulary Designated Service Provider (DSP) Limit Unlimited 25 Chronic Conditions below Restrictive formulary Medi-Rite pharmacy HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Unlimited Non-compliance with DSP and/ or formulary requirements will attract a co-payment of 40%. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price list, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply. Addison s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, COPD/ Emphysema/ Chronic Bronchitis, Chronic Renal Disease, 25 CHRONIC CONDITIONS Coronary Artery Disease, Crohn s Disease, Diabetes Insipidus, Diabetes Mellitus type 1 & 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia, Hyperlipidaemia, Hypertension, day-to-day benefit PMB level of care at Specialist Network, GP Network and Designated Pharmacy provider only Hypothyroidism, Multiple Sclerosis, Parkinson s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus, Ulcerative Colitis
[ 6 Benefits that set us apart What sets us apart is that together with our first-rate medical aid options, we offer unique value-added benefits. With some of these tangible benefits we pay more from Risk than other schemes. Benefits unique to Fedhealth: Child rates for financially dependent children up to 27 years of age so student dependants pay rates applicable to children, provided they re unmarried and not earning more than the maximum social pension Upgrades to higher options any time of the year within 30 days of diagnosis of a dread disease, or in the case of a life changing event which means the member s never locked into an option, and can upgrade should something dramatic happen that changes their circumstances during the year. *New contributions will apply Where we pay more from Risk than other schemes: Post-hospitalisation treatment for up to 30 days after discharge from hospital (physiotherapy, pathology, occupational therapy, speech therapy and general radiology) that means most follow-up treatment for a full 30- day period paid directly from Risk 7 days of take-home medication - after discharge from hospital paid for provided the medication is dispensed by the hospital and reflects on the original hospital account Specialised radiology like MRI and CT scans - paid from Risk - no matter what option the member s on, whether performed in or out-of-hospital Trauma treatment at a casualty ward - whether admitted to hospital or not, emergency treatment, like stitches, is always paid from Risk The Screening Benefit - health screenings for women and children, cardiac screenings as well as an annual flu vaccine funded from Risk. How we add value: The Fedhealth Baby Programme 24-Hour Fedhealth Nurseline FREE trauma counselling for practical and emotional support Emergency transport/ response through Europ Assistance Comprehensive managed care programmes: Aid for AIDS (AfA) for those living with HIV/AIDS, AsthmaCare ensures that asthma patients still lead a normal life, DiabeticCare assists diabetics in managing their blood sugar, CardioCare to prevent heart attacks in Coronary Heart Disease sufferers, and Oncology Disease Management that supports cancer sufferers with comprehensive care including cover for chemotherapy, radiotherapy, approved medication, related consultations, pathology and general radiology. And then members still get: Professional and extreme sports cover - injuries sustained during sporting activities are covered within the benefits and rules of the Scheme, provided the treatment is received within the borders of South Africa In-hospital dentistry for children under 8 - we cover the hospital and anaesthetist costs from the Major Medical Benefit. The dentist s account will need to be paid by the member. *The Authorisation Centre must be contacted at least 48 hours before the procedure. Authorisation will be granted provided no dental authorisation was granted for the same child within at least six months of the required admission date. This benefit does not apply to Maxima EntryZone Easy membership for child dependants - who are at an age and status to afford their own medical aid, meaning no underwriting required for child dependants moving from their parent s medical aid onto their own at Fedhealth.
[ 7 contributions Member 1 529 Adult Dependant 1 295 Child Dependant 534 Member 1 073 Adult Dependant 802 Child Dependant 361