docHospital plans Choose from:
download 
Report 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
