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Is your medical scheme hitting you with double digit increases next year?

by | Nov 14, 2017 | Medical Aid | 3 comments

Is your medical scheme hitting you with double digit increases next year?

It’s medial aid review time of year again, and if you aren’t already a Fedhealth member, we want to highlight a few of their changes in 2018.

A bit about the Scheme to begin with:

• The Scheme’s solvency ratio is sitting at 30,8% (the requirement is 25%).
• The Scheme has maintained a Global Credit rating of AA – for 11 consecutive years.
• In the top 3 medical aid brands (Sunday Times Top brands survey).
• Average weighted increase for 2018 is 9,5%.

Now onto individual plan options and a summary of changes for 2018.

BLUE DOOR PLUS

  • The plan has a cool new preventative screening benefit.
  • A newborn hearing test is covered with an audiologist up to the age of 8 weeks.
  • Out of network co-payment has increased from R10,000 to R11,000.
  • Maternity: unlimited at cost at PMB level of care. Elective Caesarean sections subject to R11 000 co-payment.
  • Specialised radiology limit increased to R12 800 per beneficiary up to an overall limit of R25 800 per family per year.
  • Day-to-day benefit for optometry. The frame limit increased to R193.

See 2018 plan rates below.

 Highest household income

Main member

Adult dependant

Child dependant

R1 – R5,564

R844

R714

R401

R5,565 – R9,095

R1,070

R901

R516

R9,096 – R11,235

R1,500

R1,269

R568

R11,236 – R12,840

R1,907

R1,524

R736

+ R12,841

R2,585

R2,284

R973

HOSPITAL PLANS – MAXIMA CORE + MAXIMA CORE GRID

  • Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme).
  • Members can use any pharmacy for chronic medicine without having to pay a 40% co-payment. Out-of-formulary co-payment still applies.
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks.
  • Doula benefit increased to R1 270 per delivery.
  • For non-PMB hip & knee joint replacements, members must use one of the scheme’s DSPs, ICPS or JointCare. Non-use of DSP will result in a co-payment.
  • Out-of-network co-payment increased from R10 000 to R11 000 on Maxima CoreGRID.
  • Specialised radiology: In- and out-of-hospital. Paid from in-hospital benefit if pre-authorised. A R2 100 co-payment for each non-PMB MRI/ CT scan for member’s account.
  • Trauma treatment in a casualty ward: R550 co-payment.
  • Benefit limits increased by 5.8%.

See 2018 plan rates below.

Plan Main member Adult dependant Child dependant
Maxima Core R 2,082 R1,806 R732
Maxima CoreGRID R1,838 R1,596 R646

MAXIMA ENTRY ZONE

  • Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme).
  • Members can use any pharmacy for chronic medicine without having to pay a 40% co-payment. Out-of-formulary co-payment still applies.
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks. • Doula benefit increased to R1 270 per delivery.
  • Out-of-network co-payment increased from R5 600 to R6 100.
  • Specialised radiology: In- and out-of-hospital. Paid from in-hospital benefit if pre-authorised. A R2 800 co-payment for each non-PMB MRI/ CT scan for member’s account.
  • Trauma treatment in a casualty ward: R550 co-payment.
  • Benefit limits increased by 5.8%.

See 2018 plan rates below.

Plan Main member Adult dependant Child dependant
Maxima EntryZone R1,424 R1,088 R482

SAVER OPTIONS

MAXIMA ADVANCED

  • Screening benefit – Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme).
  • Members aged 50 to 75 can now have a colorectal cancer screening every year, not every two years.
  • Members can use any pharmacy for chronic medicine without having to pay a 40% co-payment. Out-of-formulary co-payment still applies.
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks.
  • Doula benefit increased to R1 270 per delivery.
  • FP referral with a network FP required for specialist consultations, if consultation is paid from risk benefits (including PMB conditions). 10% co-payment if FP referral not obtained.
  • For non-PMB hip & knee joint replacements, members must use one of the scheme’s DSPs, ICPS or JointCare. Non-use of DSP will result in a co-payment.
  • Trauma treatment in a casualty ward: R550 co-payment
  • Specialised radiology: In- and out-of-hospital. Paid from in-hospital benefit if pre-authorised. A R2 100 co-payment for each non-PMB MRI/ CT scan for member’s account.
  • Benefit limits increased by 5.8%.

See 2018 plan rates below.

Plan Main member Adult dependant Child dependant
R3,607 R3,138 R1,082

MAXIMA BASIS & MAXIMA BASISGRID

  • Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme).
  • Members can use any pharmacy for chronic medicine without having to pay a 40% co-payment. Out-of-formulary co-payment still applies.
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks.
  • Doula benefit increased to R1 270 per delivery.
  • Mental health consultations with FP (in- and out-of- network) limited to 2 per beneficiary per year.
  • FP referral with a network FP required for specialist consultations, if consultation is paid from risk benefits (including PMB conditions). 40% co-payment if FP referral not obtained.
  • Day-to-day benefit for optometry: frame limit increased to R193.
  • Day-to-day benefit for maternity: the Scheme will pay for 12 ante- or postnatal consultations with a midwife, network gynaecologist or network FP increased from six visits. Antenatal classes up to R1 000 by a midwife increased from R950.
  • For non-PMB hip & knee joint replacements, members must use one of the scheme’s DSPs, ICPS or JointCare. Non-use of DSP will result in a co-payment.
  • Out-of-network co-payment increased from R10 000 to R11 000 on Maxima BasisGRID
  • Trauma treatment in a casualty ward: R550 co-payment.
  • Specialised radiology: In- and out-of-hospital. Paid from in-hospital benefit if pre-authorised. A R2 100 co-payment for each non-PMB MRI/ CT scan for member’s account.
  • Benefit limits increased by 5.8%.

See 2018 plan rates below.

Plan Main member Adult dependant Child dependant
Maxima Basis R2,722 R2,374 R826
Maxima BasisGRID R2,407 R2,106 R732

MAXIMA SAVER & MAXIMA SAVER GRID

  • Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme).
  • Members can use any pharmacy for chronic medicine without having to pay a 40% co-payment. Out-of-formulary co-payment still applies.
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks.
  • Doula benefit increased to R1 270 per delivery
  • Mental health consultations with FP (in- and out-of-network) limited to 2 per beneficiary per year.
  • FP referral with a network FP required for specialist consultations, if consultation is paid from risk benefits (including PMB conditions). 40% co-payment if FP referral not obtained.
  • Out-of-network co-payment increased from R10 000 to R11 000 on Maxima SaverGRID.
  • Trauma treatment in a casualty ward: R550 co-payment.
  • Specialised radiology: In- and out-of-hospital. Paid from in-hospital benefit if pre-authorised. A R2 100 co-payment for each non-PMB MRI/ CT scan for member’s account.
  • Benefit limits increased by 5.8%.
  • Co-payment for cataract surgery removed.
  • No co-payment for tonsillectomies for children under the age of 12.

See 2018 plan rates below.

Plan Main member Adult dependant Child dependant
Maxima Saver R2,259 R1,887 R657
Maxima SaverGRID R2,003 R1,678 R584

MAXIMA ENTRYSAVER

  • Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme)
  • Members can use any pharmacy for chronic medicine without having to pay a 40% co-payment. Out-of-formulary co-payment still applies.
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks.
  • Doula benefit increased to R1 270 per delivery.
  • NEW! Day-to-day benefit for basic preventative dentistry paid from Risk once Savings is depleted. Two consultations with scale and polish p.b.p.a. (includes infection control and sterilised instruments); topical application of fluoride (two per beneficiary per year for children between ages three and 12), and fissure sealant for children younger than 14.
  • Mental health consultations with FP (in- and out-of- network) limited to 2 per beneficiary per year.
  • FP referral with a network FP required for specialist consultations, if consultation is paid from risk benefits (including PMB conditions). 40% co-payment if FP referral not obtained.
  • Trauma treatment in a casualty ward: R550 co-payment.
  • Specialised radiology: In- and out-of-hospital. Paid from in-hospital benefit if pre-authorised. A R2 800 co-payment for each non-PMB MRI/ CT scan for member’s account.
  • Benefit limits increased by 5.8%
  • Co-payment for cataract surgery removed.
  • No co-payment for tonsillectomies for children under the age of 12.
  • Out-of-network co-payment increased from R5 600 to R6 100.

See 2018 plan rates below.

Plan Main member Adult dependant Child dependant
Maxima EntrySaver R1,759 R1,299 R565

MAXIMA DYNAMIC SAVER

  • Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme).
  • Members can use any pharmacy for chronic medicine without having to pay a 40% co-payment. Out-of-formulary co-payment still applies.
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks.
  • Doula benefit increased to R1 270 per delivery.
  • FP referral with a network FP required for specialist consultations, if consultation is paid from Risk benefits (including PMB conditions). 40% co-payment if FP referral not obtained.
  • Trauma treatment in a casualty ward: R550 co-payment.
  • Specialised radiology: In- and out-of-hospital. Paid from in-hospital benefit if pre-authorised. A R2 800 co-payment for each non-PMB MRI/ CT scan for member’s account.
  • Benefit limits increased by 5.8%.
  • Out-of-network co-payment increased from R10 000 to R11 000.

*Rates based on Highest household income per month. See 2018 plan rates below.

Income Main member Adult dependant Child dependant
Risk Savings Total Risk Savings Total Risk Savings Total
R1 – R8,560 R958 R175 R1133 R880 R161 R1041 R322 R59 R381
R8,561 – R10,700 R1203 R220 R1423 R1106 R203 R1309 R405 R74 R479
R10,701 – R16,050 R1326 R243 R1569 R1218 R223 R1441 R446 R82 R528
R16,051 > R1449 R265 R1714 R1331 R244 R1575 R487 R89 R576

COMPREHENSIVE OPTIONS

MAXIMA PLUS

  • Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme).
  • Members aged 50 to 75 can now have a colorectal cancer screening every year, not every two years
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks
  • Doula benefit increased to R1 270 per delivery.
  • Mental health consultations with FP (in- and out-of- network) limited to 2 per beneficiary per year
  • FP referral with a network FP required for specialist consultations, if consultation is paid from threshold benefit (Risk benefit), and for PMB benefits. 10% co-payment if FP referral not obtained.
  • OHEB and threshold levels have increased.
  • Accumulation limits on additional medical services, appliances, external accessories and orthotics, advanced dentistry, optometry and prescribed medication increased. These limits also apply to refunds for these expenses from OHEB and the threshold benefit.
  • For non-PMB hip & knee joint replacements, members must use one of the scheme’s DSPs, ICPS or JointCare. Non-use of DSP will result in a co-payment.
  • No change to re-imbursement rates in-hospital.
  • Still no-procedure co-payments
  • No co-payment on specialised radiology.
  • No co-payment on trauma treatment in a casualty ward
  • Benefit limits increased by 5.8%.

See 2018 plan rates below.

Plan Main member Adult dependant Child dependant
Maxima Plus R7,535 R6,415 R2,303

MAXIMA EXEC

  • Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme).
  • Members aged 50 to 75 can now have a colorectal cancer screening every year, not every two years.
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks.
  • Doula benefit increased to R1 270 per delivery.
  • Members can use any pharmacy for chronic medicine without having to pay a 40% co-payment. Out-of-formulary co-payment still applies
  • Mental health consultations with FP (in- and out-of- network) limited to 2 per beneficiary per year
  • FP referral with a network FP required for specialist consultations, if consultation is paid from threshold benefit (risk benefit) and for PMB benefits. 10% co-payment if FP referral not obtained
  • Non-network FPs: Paid from Savings, then OHEB and threshold. From 2018, these consultations will not accumulate to threshold.
  • Network FP consultations: From 2018, these will be paid from Savings first, then OHEB. Thereafter, unlimited from Risk.
  • OHEB and threshold levels have increased.
  • Accumulation limits on additional medical services, appliances, external accessories and orthotics, advanced dentistry, optometry and prescribed medication increased. These limits also apply to refunds for these expenses from OHEB and the threshold benefit.
  • For non-PMB hip & knee joint replacements, members must use one of the scheme’s DSPs, ICPS or JointCare. Non-use of DSP will result in a co-payment
  • Trauma treatment in a casualty ward: R550 co-payment.
  • Specialised radiology: In- and out-of-hospital. Paid from in-hospital benefit if pre-authorised. A R2 100 co-payment for each non-PMB MRI/ CT scan for member’s account.
  • No change to reimbursement rates in-hospital.
  • Benefit limits increased by 5.8%

See 2018 plan rates below.

Plan Main member Adult dependant Child dependant
Maxima Exec R4,805 R4,103 R1,463

MAXIMA STANDARD & MAXIMA STANDARD ELECT

  • Female members can now have a mammogram every three years from 45, no longer 50 (covered by the Scheme).
  • We now cover a newborn hearing test with an audiologist up to the age of eight weeks
  • Doula benefit increased to R1 270 per delivery.
  • Members can use any pharmacy for chronic medicine without having to pay a 40% co-payment. Out-of-formulary co-payment still applies
  • Mental health consultations with FP (in- and out-of- network) limited to 2 per beneficiary per year.
  • FP referral with a network FP required for specialist consultations, if consultation is paid from the threshold benefit (risk benefit) and for PMB benefits. 20% co-payment if FP referral not obtained
  • Network FP visits are still paid unlimited from Risk, and never from your Savings!
  • Threshold levels have increased.
  • Accumulation limits on additional medical services, appliances, external accessories and orthotics, advanced dentistry, optometry and prescribed medication increased. These limits also apply to refunds for these expenses from the threshold benefit
  • For non-PMB hip & knee joint replacements, members must use one of the scheme’s DSPs, ICPS or JointCare. Non-use of DSP will result in a co-payment.
  • Out-of-network co-payment increased from R10 000 to R11 000 on Maxima StandardElect
  • Trauma treatment in a casualty ward: R550 co-payment.
  • Specialised radiology: In- and out-of-hospital. Paid from in-hospital benefit if pre-authorised. A R2 100 co-payment for each non-PMB MRI/ CT scan for member’s account
  • No change to reimbursement rates in-hospital.
  • Benefit limits increased by 5.8%.

See 2018 plan rates below.

Plan Main member Adult dependant Child dependant
Maxima Standard R3310 R2890 R998
Maxima StandardElect R2527 R2210 R763

EXICTING NEW PROGRAMMES FOR 2018

  • WEIGHT MANAGEMENT PROGRAMME Qualifying members benefit from a 12-week biokineticist led programme with access to a dietician and behavioural psychologist to help them lose the weight for good.
  • SMOKING CESSATION PROGRAMME All smokers can have their GoSmokeFree programme consultation paid from Risk (once per beneficiary per year). Nicotine replacement therapy will be paid from Savings on options with a Savings benefit
  • FEDHEALTH FAMILY ROOM A personalised online member platform will give members access to communities based on their interests, life stages with useful advice and even retail discounts.

Until next time.

The InsuranceFundi team