Hospital plans Choose from:

Transcription

Hospital plans Choose from:
Maxima Range
Hospital plans
Hospital Plans
Value-for-money protection in-hospital, plus chronic medication
cover
Choose from:
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.
Maxima Core
Maxima EntryZone
Our hospital plans are the ideal solution for anyone who’s just starting out, from
the student to the young, single professional.
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.
BENEFIT
S
Chronic Disease
Benefit
K BENEFITS
K
RIS
RIS
Major Medical Benefit
maxima core
From
Hospitalisation
Major
Medical
Benefit
No overall annual limit
From
R1 073pm
No overall annual limit
Network hospitals only
Network GPs and Specialists
Unlimited cover at cost with Fedhealth Network GPs and Specialists
Non-network GPs and Specialists
Up to 100% of Fedhealth Rate
Other healthcare professionals
How the scheme works
R1 529pm
maxima entryzone
Chronic Disease Benefit
Up to 200% of Fedhealth Rate
Up to 100% of Fedhealth Rate
PMB chronic conditions only from Medi-Rite pharmacies
and subject to a restrictive formulary. Covers up to 100% of the
Medicine Price List
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.
No Day-to-Day Benefit.
Day-to-Day Benefit
PMB level of care applies at the Designated Pharmacy provider,
GP Network and Specialist Network only.
PMB level of care applies at the Designated Pharmacy Provider, GP Network and
Specialist Network only.
Day-to-Day Benefit
Unlimited specialised radiology paid from the
Major Medical Benefit if pre-authorised
hospital plans Maxima Core & Maxima EntryZone
[ 1
major medical benefit
All costs for hospitalisation are covered from this benefit and must be pre-authorised - Network Hospitals apply to Maxima EntryZone
maxima core
BENEFIT
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
Covered at cost
Covered at cost
- Non-Fedhealth Network GPs and Specialists
Covered at 100% of FR
Covered at 100% of FR
- Other Healthcare Professionals
Covered at 200% of FR
Covered at 100% of FR
Prescribed Minimum Benefits (PMBs)
Hospitalisation costs
Unlimited in state hospitals
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
PMB level of care only
- Nursing services, private nurse practitioners & nursing agencies
Unlimited at negotiated tariff
Ambulance services
Unlimited with Europ Assistance
Appliances, external accessories, orthotics, blood, blood equivalents and blood products
Unlimited at cost
Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy
and biokinetics)
Unlimited (See HPT above)
Maxillo-facial surgery
Unlimited, subject to approval (See HPT above)
- Surgical extraction of impacted wisdom teeth
Unlimited, subject to approval (See HPT above)
Co-payment applies to surgical extraction of
impacted wisdom teeth
Emergency treatment in a casualty ward
No benefit for surgical extraction of impacted
wisdom teeth
Unlimited at FR
Female health benefit: contraceptives
No benefit
Immune deficiency related to HIV infection
Unlimited (See HPT above)
Oncology
R213 000 at ICON.
Subject to Standard Protocols (See HPT above)
PMBs only at ICON
- Specialised medication
No benefit
No benefit
FR - Fedhealth Rate
ICON - Independent Clinical Oncology Network
HPT - Healthcare Professional Tariff
hospital plans Maxima Core & Maxima EntryZone
[ 2
major medical benefit
(continued)
maxima core
BENEFIT
maxima entryzone
ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED
Organ transplant including immunosuppression medication
R213 000 (See HPT on page 1)
PMBs only in state facilities
- Corneal graft
No benefit
No benefit
Pathology, radiology (general)
Unlimited at FR
Post-hospitalisation benefit
Up to 30 days after discharge at FR
Post-natal midwifery benefit
4 consultations per pregnancy at FR
Prostheses
- Internal
Various sub-limits apply (see page 4)
PMBs only
- External
R9 970 at cost
PMBs only
Psychiatric services
R21 500 (See HPT on page 1)
PMBs only
R213 000 at FR
PMBs only in state facilities
Renal Dialysis (chronic)
- Haemodialysis and peritoneal dialysis
Specialised medication benefit (eg. biologicals) - oncology & non-oncology
No benefit
Specialised radiology
Unlimited at FR
Take-out medicines
7 days medication per hospital event at MPL
Terminal care benefit
HPT - Healthcare Professional Tariff
R26 500 at FR
FR - Fedhealth Rate
MPL - Medicine Price List
co-payments
maxima core
PROCEDURE
maxima entryzone
CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY
Colonoscopy, Upper GI endoscopy
R2 500
Open hiatus hernia surgery, Hysterectomy (unless for cancer), Inguinal hernia surgery, Varicose vein procedures
R 3 360
Spinal surgery, Joint replacements
R6 720
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,
Hysterectomy (unless for cancer), Nasal procedures, Scopes (upper GI endoscopy, colonoscopy, cystoscopy), Skin biopsy/ excision, Tonsil/ adenoid procedures, Varicose vein procedures
hospital plans Maxima Core & Maxima EntryZone
[ 3
co-payments
(continued)
maxima core
PROCEDURE
maxima entryzone
CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY
Surgical extraction of impacted wisdom teeth
R3 360
No benefit
R2 500
R5 000
R2 500
R5 000
Arthroscopic procedures
Ankle, Knee, Shoulder
Laparoscopic procedures
Diagnostic, Nissen/ Toupey
All arthroscopic and laparoscopic procedures not listed above
Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered
maxima entryzone network hospitals
HOSPITAL
PROVINCE
SUBURB
HOSPITAL
PROVINCE
SUBURB
HOSPITAL
PROVINCE
SUBURB
Life Beacon Bay Hospital
Eastern Cape
East London
Life Fourways Hospital
Gauteng
Fourways Gardens
Mediclinic Kimberley
Northern Cape
Kimberley
Life Mercantile Hospital
Eastern Cape
Korsten
Life The Glynnwood
Gauteng
Benoni
Life Bay View Private Hospital
Western Cape
Mossel Bay
Life St George’s Hospital
Eastern Cape
Centrahill
Louis Pasteur Hospital
Gauteng
Pretoria Central
Netcare Blaauwberg Hospital
Western Cape
Bloubergrant
Life St James Hospital
Eastern Cape
Southernwood
Midvaal Private Hospital
Gauteng
Three Rivers
Mediclinic Cape Gate
Western Cape
Cape Gate
Life St Mary's Private Hospital
Eastern Cape
Umtata
Life Robinson Private Hospital
Gauteng
Randfontein
Mediclinic Cape Town
Western Cape
Mill Street
Horizon Eye Care Centre
Free State
Bloemfontein
Life Roseacres Clinic
Gauteng
Primrose
Ceres Private Hospital
Western Cape
Ceres
Mediclinic Hoogland
Free State
Bethlehem
Life Chatsmed Garden Hospital
Kwa-Zulu Natal
Chatsworth
Life Claremont Hospital
Western Cape
Claremont
Life Pasteur Hospital
Free State
Bloemfontein
Durdoc Clinic
Kwa-Zulu Natal
Durban Central
Life Kingsbury Hospital
Western Cape
Claremont
Life Rosepark Hospital
Free State
Bloemfontein
Life Entabeni Hospital
Kwa-Zulu Natal
Durban
Mediclinic Geneva
Western Cape
George
Netcare Bougainville Hospital
Gauteng
Hercules
Maxwell Clinic
Kwa-Zulu Natal
Qualbert
Mediclinic George
Western Cape
George
Life Brenthurst Clinic
Gauteng
Johannesburg
Life Mount Edgecombe Hospital
Kwa-Zulu Natal
Mount Edgecombe
Western Cape
Cape Town
Life Carstenhof Clinic
Gauteng
Midrand
Life Westville Hospital
Kwa-Zulu Natal
Westville
Melomed Mitchells Plain Medical
Centre
Cormed Clinic
Gauteng
Vanderbijlpark
Zoutpansberg Private Hospital
Limpopo
Polokwane
Life West Coast Private Hospital
Western Cape
Vredenburg
Life Dalview Clinic
Gauteng
Brakpan
Life Cosmos Hospital
Mpumalanga
Witbank
Life Flora Clinic
Gauteng
Roodepoort
Life Peglerae Hospital
North West
Rustenburg
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
hospital plans Maxima Core & Maxima EntryZone
[ 4
internal prosthesis benefit table
This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth
maxima core
BENEFIT
Detachable platinum coils
LIMIT PER FAMILY PER YEAR
R43 289
Cardiac stents
PMBs only
Cardiac valves
PMBs only
Cardiac pacemakers
PMBs only
Aorta stent grafts
Intraocular lenses (per lens)
maxima entryzone
R49 906
R2 804
Carotid stents
Peripheral arterial stent grafts
PMBs only
Embolic protection devices
Shoulder replacement
Elbow replacement
See combined benefit limit for all unlisted internal prosthesis*
Hip replacement
Knee replacement
Bone lengthening devices
Spinal plates and screws
Other approved spinal implantable devices
Combined benefit limit for all unlisted internal prosthesis
*R21 308
hospital plans Maxima Core & Maxima EntryZone
[ 5
screening benefit
This benefit provides access to a number of screening and preventative programmes aimed at improving members’ health
maxima core
BENEFIT
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
Children’s Health
Immunisation Programme
Cardiac Health
Cholesterol screening (full lipogram)
maxima entryzone
CRITERIA
ALL LIMITS ARE PER BENEFICIARY
Women; ages 50 to 74
Women; ages 21 to 65
1 every 3 years
1 every 3 years
As per State EPI
As per State EPI
All lives; aged 20 and older
1 every 5 years
All lives
All lives
1 every year
1 every year
General
General practitioner consultation (in network only)
Flu vaccination
EPI - Expanded Programme on Immunisation
chronic disease benefit
Medication for approved chronic diseases is covered from this benefit
maxima core
maxima entryzone
Limit
Unlimited
Conditions covered
25 Chronic Conditions below
Formulary
Restrictive formulary
Designated Service Provider (DSP)
Medi-Rite pharmacy
HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS
Limit
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.
25 CHRONIC CONDITIONS
Addison’s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure,
Cardiomyopathy, COPD/ Emphysema/ Chronic Bronchitis, Chronic Renal Disease,
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 30day 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
maxima core
Member
1 529
Adult Dependant
1 295
Child Dependant
534
maxima entryzone
Member
1 073
Adult Dependant
802
Child Dependant
361