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.

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 Core^GRID.
• 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.

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.

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.

MAXIMA BASIS & MAXIMA BASIS^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.
• 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 Basis^GRID
• 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.

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 Saver^GRID.
• 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.

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.

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.

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.

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.

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 Standard^Elect
• 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.

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