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Comprehensive options
Comprehensive options Maxima Range Choose from: Maxima Plus Maxima Exec Maxima Standard Maxima StandardNet Maxima Basis Extensive medical cover, in and out of hospital There’s a reason comprehensive medical aid options are so appealing: they offer extensive cover for almost all medical expenses you could face. With Fedhealth’s comprehensive options, members enjoy the perfect cover for every phase of their lives, tailored around their changing medical needs. From the young couple dreaming about a baby, to the single, career-driven CEO, or a grown-up family with student dependants – we keep them all in good health. Each comprehensive option offers unlimited hospitalisation and provides different levels of cover for day-to-day claims, such as medical consultations and prescribed medication. This is funded from a Savings Account, as well as the Out-of-Hospital Expenses Benefit. The only exception is Maxima Basis, which funds this only from the Out-of-Hospital Expenses Benefit. All comprehensive options have a Threshold Benefit. Unlimited private hospitalisation at any hospital is available on all comprehensive options, except for Maxima StandardNet, which offers unlimited hospitalisation at Network Hospitals only. Maxima Basis members starting a family will be pleasantly surprised by the Maternity Benefit which this option offers: • 2 x 2D antenatal scans per year • Antenatal classes to the value of R950 presented by a midwife • 4 x antenatal and four postnatal consultations with a midwife • 1 x amniocentesis (if required). All of this is covered from the Out-of-Hospital Expenses Benefit and Risk. Should a member suffer from a chronic condition, they could also benefit from extensive chronic cover provided by our comprehensive options. The range of conditions covered varies according to the option. Comprehensive Options Savings ITS BE Chronic Disease Benefit OHEB How the scheme works maxima exec maxima plus From R5 452pm From R3 178pm maxima standard & standardnet From maxima basis R2 238pm From No overall annual limit No overall annual limit Hospitalisation Major Medical Benefit Major Medical Benefit O - D AY B E N E F Threshold Benefit Y-T RISK S DA N IT EF No overall annual limit Network hospitals only for StandardNet Network GPs and Specialists Unlimited cover at cost with Fedhealth Network GPs and Specialists Non-network GPs Up to 100% of Fedhealth Rate Non-network Specialists Other healthcare professionals Up to 200% of Fedhealth Rate Up to 300% of Fedhealth Rate Oncology R1 978pm Up to 100% of Fedhealth Rate Up to 200% of Fedhealth Rate Unlimited R272 000 R474 000 Specialised medication R297 000 R148 000 Organ transplant Unlimited R373 000 R349 000 R272 000 Renal dialysis Unlimited R373 000 R349 000 R272 000 No benefit 51 Conditions 51 Conditions 39 Conditions 25 Conditions R12 900 per beneficiary R24 100 per family R6 100 per beneficiary R11 300 per family R4 860 per beneficiary R9 670 per family Medi-Rite pharmacies and subject to a restrictive formulary Chronic Disease Benefit R11 700 Threshold Level R9 520 Threshold Level R9 520 Threshold Level R9 520 Threshold Level Medication for approved chronic diseases is covered from this benefit. Self-Payment Gap Major Medical Benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised - Network Hospitals apply to Maxima StandardNet Chronic Disease Benefit R638 Threshold Benefit The Threshold Benefit pays for certain day-to-day expenses once Savings* and OHEB have been depleted and claims have been accumulated to the required level. Day-to-Day Benefit Day-to-day expenses are covered from Savings* and the Out-of-Hospital Expenses Benefit (OHEB). * Not applicable to Maxima Basis Day-to-Day Benefit R11 062 per member p.a. Adult = R8 440 Child = R2 718 Self-Payment Gap R1 638 R7 882 per member p.a. Adult = R6 354 Child = R1 492 Self-Payment Gap R3 216 R6 304 per member p.a. Adult = R4 854 Child = R1 099 Unlimited GP visits at Fedhealth Network GPs Self-Payment Gap R6 610 R2 910 per member p.a. Adult = R2 180 Child = R296 comprehensive options Maxima Plus, Exec, Standard & Standard [ 1 , Basis Net major medical benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised - Network Hospitals apply to Maxima StandardNet maxima plus maxima exec BENEFIT maxima standard maxima standardnet maxima basis ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Overall annual limit (OAL) Unlimited Unlimited at network hospitals only Unlimited Healthcare Professional Tariff (HPT) - Fedhealth Network GPs and Specialists Covered at cost Covered at cost - Non-Fedhealth Network GPs Covered at 100% of FR Covered at 100% of FR Covered at 100% of FR - Non-Fedhealth Network Specialists Covered at 200% of FR Covered at 200% of FR Covered at 100% of FR - Other Healthcare Professionals Covered at 300% of FR Covered at 200% of FR Covered at 200% of FR Covered at cost Prescribed Minimum Benefits (PMBs) Unlimited in state hospitals Hospitalisation costs Unlimited at negotiated tariff Co-payments Unlimited at negotiated tariff at network hospitals only. R5 000 co-payment on voluntary use of non-network hospitals Unlimited at negotiated tariff See details on page 2 Alternatives to hospitalisation - Sub-acute facilities and physical rehabilitation facilities PMB level of care only Unlimited at negotiated tariff - 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 Incl 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 Unlimited at FR Female health benefit: contraceptives FR - Fedhealth Rate Unlimited at MPL ICON - Independent Clinical Oncology Network HPT - Healthcare Professional Tariff DSP - Designated Service Provider MPL - Medicine Price List comprehensive options Maxima Plus, Exec, Standard & Standard [ 2 , Basis Net major medical benefit maxima plus (continued) maxima exec BENEFIT maxima standard maxima standardnet maxima basis ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Organ transplant including immunosuppression medication Unlimited (See HPT on page 1) R373 000 (See HPT on page 1) - Corneal graft R17 800 per beneficiary R17 800 per beneficiary R349 000 (See HPT on page 1) R272 000 (See HPT on page 1) R17 800 per beneficiary Pathology, radiology (general) No benefit 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) Various sub-limits apply (See page 4) - External R18 700 R14 800 Psychiatric services R34 500 (See HPT on page 1) R27 400 (See HPT on page 1) Unlimited at FR R373 000 at FR Various sub-limits apply (See page 4) R9 970 R21 500 (See HPT on page 1) Renal Dialysis (chronic) - Haemodialysis and peritoneal dialysis Specialised medication benefit (eg. biologicals) - oncology & non-oncology R297 000 R349 000 at FR R148 000 R272 000 at FR No benefit 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 maxima plus maxima exec PROCEDURE Colonoscopy, Upper GI endoscopy maxima standard maxima basis CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY R2 010 R2 500 Surgical extraction of impacted wisdom teeth Open hiatus hernia surgery maxima standardnet R3 360 No co-payment R3 360 Rhizotomies and facet pain block (limited to 1 of either procedures per beneficiary per year) R3 600 No benefit Balloon sinuplasty R5 930 No benefit comprehensive options Maxima Plus, Exec, Standard & Standard [ 3 , Basis Net co-payments maxima plus (continued) maxima exec PROCEDURE maxima standardnet maxima standard maxima basis CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY Joint replacements No co-payment R6 720 Arthroscopic procedures Ankle, Knee, Shoulder No co-payment R2 010 R2 500 Hip, Wrist No co-payment R2 010 Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered Laparoscopic procedures Appendectomy, Hernia repairs (other than inguinal hernia repair) No co-payment R2 010 Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered Diagnostic, Nissen/ Toupey No co-payment R2 010 R2 500 Nephrectomy Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered No co-payment All arthroscopic and laparoscopic procedures not listed above Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered screening benefit This benefit provides access to a number of screening and preventative programmes aimed at improving members’ health maxima plus 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) Geriatric Health Pneumococcal vaccination Bone densitometry Colorectal cancer screening (faecal occult blood test) General Flu vaccination maxima exec maxima standard 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 years and older 1 every 5 years All lives; older than 65 Women; older than 65 All lives; ages 50 to 75 All lives 1 per lifetime 1 per lifetime 1 every 2 years maxima standardnet maxima basis No benefit 1 every year EPI - Expanded Programme on Immunisation comprehensive options Maxima Plus, Exec, Standard & Standard [ 4 , Basis Net maxima standardnet network hospitals HOSPITAL PROVINCE SUBURB HOSPITAL PROVINCE SUBURB HOSPITAL PROVINCE SUBURB Life Beacon Bay Hospital Eastern Cape East London Life Flora Clinic Gauteng Roodepoort Life Mount Edgecombe Hospital Kwa-Zulu Natal Mount Edgecombe Life Mercantile Hospital Eastern Cape Korsten Life Fourways Hospital Gauteng Fourways Gardens Life Westville Hospital Kwa-Zulu Natal Westville Life St George’s Hospital Eastern Cape Centrahill Life The Glynnwood Gauteng Benoni Netcare Blaauwberg Hospital Western Cape Bloubergrant Life St James Hospital Eastern Cape Southernwood Louis Pasteur Hospital Gauteng Pretoria Central Mediclinic Cape Gate Western Cape Cape Gate Horizon Eye Care Centre Free State Bloemfontein Midvaal Private Hospital Gauteng Three Rivers Mediclinic Cape Town Western Cape Mill Street Life Pasteur Hospital Free State Bloemfontein Life Robinson Private Hospital Gauteng Randfontein Ceres Private Hospital Western Cape Ceres Life Rosepark Hospital Free State Bloemfontein Life Roseacres Clinic Gauteng Primrose Life Claremont Hospital Western Cape Claremont Netcare Bougainville Hospital Gauteng Hercules Life Chatsmed Garden Hospital Kwa-Zulu Natal Chatsworth Life Kingsbury Hospital Western Cape Claremont Life Brenthurst Clinic Gauteng Johannesburg Durdoc Clinic Kwa-Zulu Natal Durban Central Life West Coast Private Hospital Western Cape Vredenburg Cormed Clinic Gauteng Vanderbijlpark Life Entabeni Hospital Kwa-Zulu Natal Durban Life Dalview Clinic Gauteng Brakpan Maxwell Clinic Kwa-Zulu Natal Qualbert 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 StandardNet Network Hospital list internal prosthesis benefit table This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement. Prostheses paid at cost subject to limits maxima plus maxima exec BENEFIT maxima standard maxima standardnet maxima basis ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Detachable platinum coils R43 289 Cardiac stents R42 728 R23 775 PMBs only Cardiac valves R38 018 R23 775 PMBs only R23 775 PMBs only R23 775 See combined benefit limit for all unlisted internal prosthesis* R23 775 See combined benefit limit for all unlisted internal prosthesis* R23 775 See combined benefit limit for all unlisted internal prosthesis* Cardiac pacemakers R49 906 R41 607 Aorta stent grafts R49 906 Intraocular lenses (per lens) Shoulder replacement Elbow replacement Hip replacement R2 804 R38 018 R38 018 R38 018 R29 719 R29 719 R29 719 comprehensive options Maxima Plus, Exec, Standard & Standard [ 5 , Basis Net internal prosthesis benefit table maxima plus maxima exec BENEFIT (continued) maxima standard maxima standardnet maxima basis ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Total ankle replacement See combined benefit limit for all unlisted internal prosthesis* No benefit Bone lengthening devices Spinal plates and screws Carotid stents See combined benefit limit for all unlisted internal prosthesis* Peripheral arterial stent grafts Embolic protection devices Other approved spinal implantable devices Combined benefit for all unlisted internal prosthesis *R30 841 *R24 897 *R21 308 chronic disease benefit Medication for approved chronic diseases is covered from this benefit maxima plus Limit maxima exec maxima standard R12 900 per beneficiary, subject to an R6 100 per beneficiary, subject to an overall limit of R24 100 per family per overall limit of R11 300 per family per year year maxima standardnet R4 860 per beneficiary, subject to an overall limit of R9 670 per family per year IN-BENEFIT (Lists 1, 2 and 3 below) Conditions covered Formulary 39 conditions See lists 1 & 2 on page 6 Comprehensive formulary Designated Service Provider (DSP) Unlimited PMBs only IN-BENEFIT (List 1) 51 conditions See lists 1, 2 & 3 on page 6 No formulary restrictions maxima basis See list 1 page 6 Restrictive formulary Service provider of choice Medi-Rite pharmacy OUT-OF-BENEFIT (List 1 below only) Formulary Comprehensive formulary Restrictive formulary Designated Service Provider (DSP) Service provider of choice Medi-Rite pharmacy HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Limit In-benefit means that you have not exhausted your Chronic Disease Benefit limit. Out-of-benefit means that you have exhausted your Chronic Disease Benefit limit. Non-compliance with DSP and/ or formulary requirements, as per the specific option will attract a co-payment of 40%. If this is in respect of a PMB condition, then the co-payment is not refundable from Savings. 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. Unlimited Out-of-benefit does not apply comprehensive options Maxima Plus, Exec, Standard & Standard [ 6 , Basis Net chronic disease benefit (continued) CHRONIC CONDITIONS LISTS LIST 1. PMB Conditions (all options): 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, Hypothyroidism, Multiple Sclerosis, Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus, Ulcerative Colitis LIST 2. (Maxima Plus, Exec, Standard and StandardNet): Ankylosing Spondylitis, Anorexia Nervosa, Attention Deficit Disorder (in children only), Bulimia Nervosa, Depression, Dermatomyositis, Generalised Anxiety Disorder, Narcolepsy, Obsessive Compulsive Disorder, Panic Disorder, Paraplegia/Quadriplegia (associated medicine), Post-Traumatic Stress Syndrome, Scleroderma, Tourette’s Syndrome LIST 3. (Maxima Plus and Exec): Angina, Barrett’s Oesophagus, Conn’s Syndrome, Cushing’s Syndrome, Deep Vein Thrombosis, Gastro-Oesophageal Reflux Disease, Polyarteritis Nodosa, Pulmonary Interstitial Fibrosis, Thromboangitis Obliterans, Thrombocytopaenic Purpura, Valvular Heart Disease, Zollinger-Ellison Syndrome day-to-day benefit Day-to-day expenses are covered from available funds in the Savings Account, Out-of-Hospital Expenses Benefit (OHEB) and carry over Savings. Limits may apply when calculating certain claims for accumulation to Threshold. These limits will also apply for refunds from OHEB and Threshold maxima plus maxima exec BENEFIT Co-payments in Threshold maxima standard maxima standardnet maxima basis LIMIT PER FAMILY PER YEAR No co-payment 10% co-payment 20% co-payment Appliances, external accessories and orthotics R13 300 per family per year before and after Threshold. (R3 710 sub-limit for foot orthotics). Subject to Savings, OHEB and Threshold R10 000 per family per year before and after Threshold. (R3 710 sub-limit for foot orthotics). Subject to Savings, OHEB and Threshold R10 000 per family per year before and after Threshold. (R3 710 sub-limit for foot orthotics). Subject to OHEB and Threshold Alternative healthcare Accupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including prescribed medication) Subject to Savings and OHEB. Does not accumulate to or pay from Threshold Subject to OHEB. Does not accumulate to or pay from Threshold Additional medical services Audiology, dietetics, occupational therapy, orthoptics, podiatry, psychologists, social workers and speech therapy R14 900 per family per year before and after Threshold. Subject to Savings, OHEB and Threshold R10 000 per family per year before and after Threshold. Subject to Savings, OHEB and Threshold Dentistry (Advanced) Including oral surgery, osseo-integrated implants, orthognathic surgery and orthodontic treatment FR - Fedhealth Rate R6 390 per beneficiary per year, R19 000 per family per year before and after Threshold. Subject to Savings, OHEB and Threshold R10 000 per family per year before and after Threshold. Subject to OHEB and Threshold R6 390 per beneficiary per year, R19 000 per family per year before and after Threshold. Subject to OHEB and Threshold. No benefit for osseo-integrated implants OHEB - Out-of-Hospital Expenses Benefit comprehensive options Maxima Plus, Exec, Standard & Standard [ 7 , Basis Net day-to-day benefit maxima plus BENEFIT maxima exec (continued) maxima standard maxima standardnet maxima basis LIMIT PER FAMILY PER YEAR General Practitioners - Fedhealth Network GPs - Non-Fedhealth Network GPs Maternity Subject to OHEB then unlimited from Risk Subject to Savings, OHEB and Threshold. Unlimited accumulation to and refund from Threshold at FR 2 x 2D antenatal scans per year before and after Threshold. Subject to Savings, OHEB and Threshold Optometry Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, readers and optometric examinations Over-the-counter medication Prescribed medication Radiology (Specialised) Specialists excluding psychiatrists - Fedhealth Network Specialists - Non-Fedhealth Network Specialists Subject to OHEB then unlimited from Risk Subject to OHEB and Threshold. Unlimited accumulation to and refund from Threshold at FR 2 x 2D antenatal scans per year Antenatal classes up to R950 by a midwife 4 antenatal consultations and 4 postnatal consultations with midwife 1 amniocentesis Subject to OHEB then Risk R2 860 per beneficiary per year, R8 700 per family per year before and after Threshold. Subject to Savings, OHEB and Threshold R2 860 per beneficiary per year, R8 700 per family per year before and after Threshold Subject to OHEB and Threshold Subject to Savings only. Does not accumulate to or pay from Threshold R455 per beneficiary per year, R913 per family per year. Sub-limit of Prescribed Medication limits. Subject to OHEB and refunded from Threshold. Does not accumulate to Threshold R8 520 per beneficiary per year, R16 900 per family per year before and after Threshold. Subject to Savings, OHEB and Threshold R8 520 per beneficiary per year, R16 900 per family per year before and after Threshold. Subject to OHEB and Threshold Paid from the Major Medical Benefit if pre-authorised Subject to Savings, OHEB and accumulation at cost to Threshold. Unlimited at cost once Threshold is reached Subject to Savings, OHEB and Threshold. Unlimited accumulation to and refund from Threshold at FR Subject to OHEB and accumulation at cost to Threshold. Unlimited at cost once Threshold is reached Subject OHEB and Threshold. Unlimited accumulation to and refund from Threshold at FR OHEB - Out-of-Hospital Expenses Benefit comprehensive options Maxima Plus, Exec, Standard & Standard [ 8 , Basis Net day-to-day benefit maxima plus (continued) maxima exec BENEFIT maxima standard maxima standardnet maxima basis LIMIT PER FAMILY PER YEAR Specialists: Psychiatrists - Fedhealth Network Psychiatrists - Non-Fedhealth Network Psychiatrists Subject to Additional Medical Services limit of R14 900 per family per year before and after Threshold. Subject to Savings, OHEB and accumulation at cost to Threshold Subject to Additional Medical Services limit of R10 000 per family per year before and after Threshold. Subject to Savings, OHEB and accumulation at cost to Threshold Subject to Additional Medical Services limit of R10 000 per family per year before and after Threshold. Subject to OHEB and accumulation at cost to Threshold Subject to Additional Medical Services limit of R14 900 per family per year before and after Threshold. Subject to Savings, OHEB and Threshold. Accumulation to and refund from Threshold at FR only Subject to Additional Medical Services limit of R10 000 per family per year before and after Threshold. Subject to Savings, OHEB and Threshold. Accumulation to and refund from Threshold at FR only Subject to Additional Medical Services limit of R10 000 per family per year before and after Threshold. Subject to OHEB and Threshold. Accumulation to and refund from Threshold at FR only THRESHOLD BENEFIT The Threshold Benefit pays for certain day-to-day expenses once Savings and OHEB have been depleted and claims have accumulated up to the required level. The Threshold Level is reached through the accumulation of claims paid from Savings, FR - Fedhealth Rate OHEB and the member’s own pocket through the year at the Fedhealth Rate, unless otherwise specified. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Threshold. A 20% co-payment will apply to all claims paid from the Threshold Benefit on Maxima Standard, StandardNet and Basis and a 10% co-payment will apply to all claims paid from the Threshold Benefit on Maxima Exec. No co-payment will apply to GP or specialist consultations in-network. OHEB - Out-of-Hospital Expenses Benefit [ 9 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 to ensure that members’ day-to-day medical spending not only goes further, but also works harder when they really need it. Benefits unique to Fedhealth: • Unlimited GP visits to Network GPs paid from Risk and never from Savings on all comprehensive options • 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 not to deplete the member’s day-to-day benefit • 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 and never from Savings – 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 and never from the member’s day-to-day benefit • Cover for female contraception - including oral, patches, certain injectables as well as IUDs that include Mirena®, contraceptive rings and implants on all comprehensive options. *Must be prescribed by a GP or gynaecologist and not applicable to pills prescribed for acne • The Screening Benefit - health screenings for women and children, cardiac screenings as well as an annual flu vaccine funded from Risk and not from the member’s day-to-day benefit. And on top comprehensive options, this benefit even includes screening and preventative programmes for older members as well. 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 while the dentist’s account comes from day-to-day benefits (Savings and OHEB). *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 • 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. contributions [ 10 contributions healthcare spending Rand amounts paid monthly to the Scheme for cover received as well as annual benefit values Examples of healthcare spend available for various family structures, as well as annual threshold levels and self-payment gaps maxima plus (including Savings and OHEB) Member Adult Dependant Child Dependant Risk Savings TOTAL Annual Threshold* Annual OHEB 5 151 4 383 1 546 301 255 89 5 452 4 638 1 635 11 700 8 970 3 110 7 450 5 380 1 650 M M + AD M + AD + CD Annual Savings Annual OHEB Annual Day-to-Day Annual Threshold Level Annual Self- Payment Gap 3 612 6 672 7 740 7 450 12 830 14 480 11 062 19 502 22 220 11 700 20 670 23 780 638 1 168 1 560 Annual Savings Annual OHEB Annual Day-to-Day Annual Threshold Level Annual Self- Payment Gap 2 772 5 136 5 964 5 110 9 100 9 764 7 882 14 236 15 728 9 520 16 800 19 250 1 638 2 564 3 522 Annual Savings Annual OHEB Annual Day-to-Day Annual Threshold Level Annual Self- Payment Gap 2 364 4 368 5 076 3 940 6 790 7 181 6 304 11 158 12 257 9 520 16 800 19 250 3 216 5 642 6 993 Annual Savings Annual OHEB Annual Day-to-Day Annual Threshold Level Annual Self- Payment Gap 2 364 4 368 5 076 3 940 6 790 7 181 6 304 11 158 12 257 9 520 16 800 19 250 3 216 5 642 6 993 Annual Savings Annual OHEB Annual Day-to-Day Annual Threshold Level Annual Self- Payment Gap 0 0 0 2 910 5 090 5 386 2 910 5 090 5 386 9 520 16 800 19 250 6 610 11 710 13 864 maxima exec (including Savings and OHEB) Member Adult Dependant Child Dependant Risk Savings TOTAL Annual Threshold* Annual OHEB 2 947 2 511 879 231 197 69 3 178 2 708 948 9 520 7 280 2 450 5 110 3 990 664 M M + AD M + AD + CD maxima standard (including Savings and OHEB) Member Adult Dependant Child Dependant Risk Savings TOTAL Annual Threshold* Annual OHEB 2 253 1 920 675 197 167 59 2 450 2 087 734 9 520 7 280 2 450 3 940 2 850 391 M M + AD M + AD + CD maxima standardnet (including Savings and OHEB) Member Adult Dependant Child Dependant Risk Savings TOTAL Annual Threshold* Annual OHEB 2 041 1 740 612 197 167 59 2 238 1 907 671 9 520 7 280 2 450 3 940 2 850 391 M M + AD M + AD + CD maxima basis (including OHEB) Member Adult Dependant Child Dependant Risk Savings TOTAL Annual Threshold* Annual OHEB 1 978 1 684 596 0 0 0 1 978 1 684 596 9 520 7 280 2 450 2 910 2 180 296 * Up to a maximum of three children M M + AD M + AD + CD M - member AD - adult dependant CD - child dependant
