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FEDHEALTH FLEXIFED 4 2019

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Type of Medical Aid Plan: 
Threshold
Medical Aid Year: 
2019
Day to day Benefits: 

There is a nominal savings amount. There is access to a Medivault which allows you to top up savings to your Wallet at any time of the year up to a maximum annual amount of 25% of gross contribution. There is also a Threshold benefit. Once your claims have accumulated up to the required amount, Fedhealth will pay claims from the Threshold with a co-payment of 20% for certain day-to-day expenses. No co-payments will apply to Fedhealth Network GP and Specialist consultations. 

In Hospital Benefits
Hospital Rate of Payment: 
100% of Scheme Rate
Hospitals: 

Unlimited at hospital of choice

Upfront Payments to hospitals: 

Arthroscopic procedures- hip, wrist and other; R2 400: Balloon sinuplasty; R4 200; Colonoscopy, upper GI endoscopy; R2 400. 

Casualty / Emergency Visits: 
Whether admitted to hospital or not, emergency treatment, like stitches, is covered. Authorisation must be obtained and a co-payment of R570 per visit for non-PMBs applies
Specialists: 
Network; unlimited cover at cost: Non-network; covered at 100% of Fedhealth rate.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Physio- Subject to referral by a medical practitioner, pre-auth & treatment protocols. Occupational therapy subject to savings. Does not accumulate to threshold.
Radiology and pathology: 
Unlimited at Fedhealth rate.
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Colonoscopy, upper GI endoscopy; R2 400 co-payment.
MRI and CT scans: 
Covered in and out of hospital. Co-payment for non-PMB MRI/CT scans R2 200.
ICU and High Care: 
Unlimited at negotiated tariff.
Dialysis: 
R444 700 at Designated Service Provider. 40% co-payment on use of non-DSP.
Organ Transplants: 
R444 700
Oncology / Cancer: 
R444 700
Neck and Back Operations: 
No benefit unless back and neck rehabilitation program is completed. Co-payment of R4 200.
Joint Replacements: 
No co-payment at contracted providers. Non-use of contracted providers limited to R26 200
Prosthesis: 
Internal: Various sub-limits apply
Aorta Stent Grafts R58 500
Bone lengthening devices: Combined benefit limit for all unlisted internal prosthesis applies: *R25 000
Cardiac pacemakers R27 800
Cardiac stents R27 800
Cardiac valves R27 800
Carotid stents Combined benefit limit for all unlisted internal prosthesis applies: *R25 000
Detachable platinum coils R50 700
Elbow replacement R27 800
Embolic Protection Devices Combined benefit limit for all unlisted internal prosthesis applies: *R25 000
Hip replacement R27 800
Intraocular lenses (per lens) R3 200
Knee replacement R27 800
Other approved spinal implantable devices Combined benefit limit for all unlisted internal prosthesis applies: *R25 000
Peripheral Arterial Stent Grafts Combined benefit limit for all unlisted internal prosthesis applies: *R25 000
Shoulder replacement R27 800
Spinal plates and screws Combined benefit limit for all unlisted internal prosthesis applies: *R25 000
Total ankle replacement Combined benefit limit for all unlisted internal prosthesis applies: *R25 000
External R11 600 at cost
Medical and Surgical Appliances: 
In and out-of-hospital. Subject to Savings/ Wallet or self-funded. Does not accumulate to Threshold. Paid from Threshold up to R11 600 per family per year with a sub-limit of R4 340 for foot orthotics
Maternity Confinements: 
Network GP's and Specialists covered at cost. Non-network GP's and Specialists covered at 100%. Other healthcare professionals covered at 100%.
In Hospital Dentistry: 
For children under 7. Hospital and anaesthetist costs from the in-hospital benefit. Dentist account paid by the member.
Take home Medicine: 
7-days of take home medication after discharge from hospital if dispensed by the hospital and reflects on original hospital account.
Rehabilitation, Hospice and Step-down facilities: 
Unlimited at negotiated tariff up to PMB level of care
Treatment for Mental Health: 
Unlimited GP consultations at a Fedhealth Network GP. Savings does not have to be depleted first. Limited to 2 mental health consultations per beneficiary per year
HIV / AIDS: 
Unlimited
Ambulance Service: 
Europ Assistance
International Travel Benefit: 
No information available
Day-to-day benefits
GP consultations: 

Network GPs - Unlimited cover from risk.
Non-network GPs - Paid from Savings/ Wallet or self-funded. Accumulates to Threshold.

Specialist consultations: 

Network Specialists and all other healthcare professionals Paid from Savings/ Wallet or self-funded. Unlimited at cost once Threshold is reached. 20% co-payment iwithout GP referral.

Non-network Specialists: Paid from Savings/ Wallet or self-funded. Accumulates toward Threshold at Fedhealth rate only. 20% co-payment iwithout GP referral.

Acute medicine: 

R5 680 per beneficiary per year, R11 400 per family per year, before and after Threshold. Paid from Savings/ Wallet or self-funded. Does not accumulate to Threshold.

Over-the-counter (OTC) Medicine: 

Paid from Savings/ Wallet or self-funded. Does not accumulate to or pay from Threshold

Optometry benefits: 
Limit of R3 340 per person per year, up to an overall limit of R10 190 per family per year
Basic dentistry: 
Paid from Savings/ Wallet or self-funded and Threshold. Unlimited once Threshold is reached.
Specialised Dentistry: 
Limit of R7 400 per person per year, up to an overall limit of R22 100 per family per year before & after Threshold. Paid from Savings/ Wallet or self-funded and Threshold
Orthodontics: 

Limit of R7 400 per person per year, up to an overall limit of R22 100 per family per year before & after Threshold. Paid from Savings/ Wallet or self-funded and Threshold

MRI and CT Scans (Out of Hospital): 
MRI/ CT scans are paid whether they are performed in- or out-of-hospital. A co-payment applies for non-PMB MRI/ CT scans
Radiology and Pathology: 
Unlimited once Threshold is reached.
Pregnancy benefits: 
2x2D scans; antenatal classes up to R1 050; 12 antenatal &/or postnatal consults with a midwife, Network GP or Network Gynaecologist, amniocentesis.k
Physiotherapy and Occupational Therapy day to day: 
Does not accumulate to Threshold. Paid from Threshold up to the Additional Medical Services limit of R11 600 per family, per year.
Chronic Conditions
Provider: 
MediRite, Dis-chem, Clicks & Pharmacy Direct
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,
HIV, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis,
Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus
Erythematosus, Ulcerative Colitis
 
Additional conditions covered on flexiFED 4
(CDL as above + the following 16)
Acne, Ankylosing Spondylitis, Anorexia Nervosa, Attention Defi cit Disorder
(in children only), Bulimia Nervosa, Depression, Dermatomyositis, Eczema,
Generalised Anxiety Disorder, Narcolepsy, Obsessive Compulsive Disorder,
Panic Disorder, Paraplegia/Quadriplegia (associated medicine),
Post-traumatic Stress Syndrome, Scleroderma, Tourette’s Syndrome
Additional Chronic Conditions: 
Acne, Ankylosing Spondylitis, Anorexia Nervosa, Attention Deficit Disorder(in children only), Bulimia Nervosa, Depression, Dermatomyositis, Eczema, Generalised Anxiety Disorder, Narcolepsy, Obsessive Compulsive Disorder,Panic Disorder, Paraplegia/Quadripl
Preventative Care Benefits
Preventative Benefits: 
Women’s health: Cervical cancer screening (Pap smear) Women; ages 21 to 65. 1 every three years
Children’s health Immunisation Programme (as per state EPI) Birth to 12 years
Cardiac health Cholesterol screening (full lipogram) All lives; aged 20 and older. 1 every five years
General Flu vaccination: All lives: 1 every year
HIV finger prick test: All lives; 1 every year
Breast cancer screening with mammography: All lives aged 45 and older: 1 every three years
Pneumococcal vaccination: All lives aged 65 and older. 1 per lifetime
Colorectal cancer screening (faecal occult blood test): All lives aged 50 to 75. 1 every year
Men’s health Prostate Specific Antigen (PSA): Men ages 45 to 69. 1 every year
Health risk assessments
Wellness screening (BMI, blood pressure, finger prick cholesterol & glucose tests)
All lives, 1 every year
Preventative screening by contracted wellness network provider (waist-to-hip ratio, body
fat %, flexibility, posture & fitness)
All lives; 1 every year
Total Contributions
Total Contribution Main Member: 
3031.00
Total Contribution Adult: 
2684.00
Total Contribution Child*: 
927.00
flexiFED 4
Monthly Medical Savings
Savings Child*: 
8.00
Savings Adult: 
22.00
Savings Main Member: 
25.00
Annual Threshold Amounts
Annual Threshold Main Member: 
13650.00
Risk Contributions
Risk Contribution Main Member: 
3006.00
Risk Contribution Adult: 
2662.00
Risk Contribution Child: 
919.00
Medical Aid Plan Name Term: 
Any