FlexiFED DEFINED BY - Fedhealth
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flexi F E D 2021 DEFINED BY DETAIL
DEFINED BY
flexiFED… Attuned to the finer details of healthcare
Two years ago, Fedhealth launched the revolutionary flexiFED range, together with the MediVault
system. While this still remains a first and only for the South African medical aid market, we have now
refined the details and polished the mechanics. We have stripped away the complications and added
what was needed.
With meticulous attention to detail, we are now proud to announce that in 2021 the Fedhealth product is
not just a first and only of its kind… it’s refined like never before.
Some of flexiFED’s finer details include:
• Select your own level of day-to-day funds (flexible) or fixed
• Choose to reduce your monthly contribution by either 11% or 25%
• Plans are tailored around YOUR life stage
• Don’t pay for certain benefits until you need them with our 30-day upgrade policy
• We pay more from Risk to stretch day-to-day benefits further
When taking a closer look at Fedhealth Medical Scheme, we’re especially proud of our 84 years in
healthcare, our solvency rate of 43.43% (as at 31 December 2019), and our Global Credit Rating of AA-
retained for 14 consecutive years. Proof that we have both the experience and financial savvy to show
up for our members when they need us most.
Run by members for members, we put you first by staying on top of the latest healthcare trends and
constantly evaluating how we can give you more, whilst remaining as affordable as possible.
Choose Fedhealth to protect your precious health in a way that lets you be YOU.
Contents Defined by Detail Trauma treatment at a casualty ward
Female contraception
Choose your hospital cover In-hospital dentistry for children under 7
Medical Savings Account
Customise your hospital cover
MediVault & Wallet
Refine your repayment structure Threshold benefit
Maternity benefit
Choose your level of day-to-day benefits Doula benefit for labour support during
natural childbirth
flexiFED option range Postnatal midwifery benefit
Early childhood benefits
Overview of the flexiFED structure Consultations with a paediatrician
Infant hearing screening benefit
Unlimited private hospital cover for peace of mind Childhood illness specialised drug benefit
Optometry benefits
Day clinic/ doctors’ rooms procedures Dentistry benefits
covered from the in-hospital benefit
Threshold benefit
In-hospital benefit
The MediVault and Wallet
Examining our cancer cover
Oncology Disease Management A proactive stance on health:
Independent Clinical Oncology Network (ICON) screening benefits
Chemotherapy and associated medicine
Radiotherapy Additional benefits
Specialised medication 24-hour Fedhealth Nurse Line
Consultations and visits Paed-IQ
Pathology Fedhealth Baby Programme
Radiology Emergency transport/ response
General radiology MediTaxi
Specialised radiology SOS Call Me
PET scans Upgrades within 30 days of a life-changing event
Surgery and hospitalisation Child rates for financially dependent children
Stoma therapy up to the age of 27
Terminal care and private nursing Only pay for three children
Post-active treatment
Programmes and Wellness initiatives
Taking care of every detail during pregnancy Corporate wellness days
Health Risk Assessments
A closer look at the chronic medicine benefit Sisters-on-Site
Prescribed minimum benefit conditions Back and Neck Rehabilitation Programme
Chronic disease benefit Mental Health Programme
Chronic disease list Weight Management Programme
Medication for additional chronic conditions GoSmokeFree smoking cessation programme
The Medicine Price List Aid for AIDS (HIV management)
Chronic conditions on the Chronic Disease List (CDL) Paed IQ
Additional chronic conditions covered on certain options Diabetes Care
Obtaining chronic medicine
flexiFED contributions
Mental health
flexiFED rate calculations
Network hospital list Contact details
Sanlam Gap Cover @FedhealthMed at your service
Fedhealth website
Cover for day-to-day expenses Fedhealth Family Room
Day-to-day benefits paid by Fedhealth LiveChat and chatbot
Consultations with a network GP Fedhealth Member App
Treatment for 30 days after discharge from hospital Fedhealth WhatsApp Bot
Take-home medicine Network GP, specialist and hospital locator
Specialised radiology
STEP
01
Choose
your
hospital
cover
STEP
AFFORDABILITY
02
FLEXIBILITY Customise
your
CONTROL hospital
cover
STEP
Fedhealth’s flexiFED options allow you to create
your own option to suit your needs and budget
in 4 easy steps.
03
If you are ready to build your one-of-a-kind
medical aid solution... THEN LET’S BEGIN…
Refine
your
repayment
structure
STEP
04
Choose
your
level of
day-to-day
benefits
STEP
01
Choose
your
hospital
cover
STEP
STEP Choose your 02
01 hospital cover Customise
your
hospital
Hospital cover (also called Risk cover) cover
is the foundation of your medical aid bene-
fits.
STEP
It takes care of your significant hospital
expenses, and other costs like oncology,
maternity and chronic medicines. Everybody
has different needs, and it is important to
03
choose a solid foundation that addresses
Refine
your unique circumstances.
your
repayment
Choose from one of the 4 flexiFED options structure
STEP
04
Choose
your
level of
day-to-day
benefits
STEP
01
BACK TO CONTENTS PAGE
flexiFED 1 overview
STEP Choose your
01 hospital cover
flexiFED 2 Overview
flexiFED 3 Overview
flexiFED 4 Overview
Choose
Emergency and planned your
procedure hospital cover
hospital
Day clinic & doctor’s rooms cover
procedures
Oncology Choose from one of the 4 flexiFED options below:
Maternity, infant and STEP
02
children
flexiFED 1 flexiFED 2 flexiFED 3 flexiFED 4
Chronic Young Singles Family Start-ups Young Families Mature Families
Mental Health
Emergency and planned Emergency and planned Emergency and planned Emergency and planned
procedure hospital cover procedure hospital cover procedure hospital cover procedure hospital cover
Full contributions table
Hospital Cover Oncology Oncology Oncology Oncology
Customise
Screening benefits
Maternity, infant and children Maternity, infant and children Maternity, infant and children Maternity, infant and children
your
Unique benefits hospital
Additional benefits Chronic Chronic Chronic Chronic cover
Wellness Initiatives Mental health Mental health Mental health Mental health
Benefit structure
STEP
03
The amounts below indicate the The amounts below indicate the The amounts below indicate the The amounts below indicate the
cost for your Hospital / Risk cover cost for your Hospital / Risk cover cost for your Hospital / Risk cover cost for your Hospital / Risk cover
only. As we build your perfect only. As we build your perfect only. As we build your perfect only. As we build your perfect
Fedhealth option over the next few Fedhealth option over the next few Fedhealth option over the next few Fedhealth option over the next few
steps, these amounts can change steps, these amounts can change steps, these amounts can change steps, these amounts can change
R1 788 R2 500 R2 825 R3 747
R3 189 R4 671 R5 374 R7 146 Refine
your
R3 842 R5 413 R6 389 R8 299 repayment
structure
R4 495 R6 155 R7 404 R9 452
STEP
UNIQUE TO FEDHEALTH
We are the only medical aid scheme that pays for the following unique benefits like unlimited GP benefits, specialised
radiodology and female contraceptives from your Hospital/Risk cover – not from your day-to-day funds. This means you
04
can keep your day-to-day funds (which we’ll get to shortly) for other expenses.
Customised interaction
CLICK HERE TO SEE ALL OUR UNIQUE BENEFITS
Choose
with members
your
Contact details level of
Remember: The great thing about Fedhealth is that you can choose the cover you need right now…
Download brochure not the cover you might need in future. We’re the only medical aid that allows you to upgrade your option at any day-to-day
time of the year if a life-changing event (like pregnancy or diagnosis of serious disease) happens. benefits
STEP
01
Choose
your
hospital
cover
STEP
STEP Customise your 02
02 hospital cover Customise
your
hospital
At Fedhealth we are all about control, flex- cover
ibility and choice. Our flexiFED options are
made one member at a time, and you can
STEP
customise your Hospital / Risk cover to fit
your budget and your needs perfectly.
With Fedhealth, you can choose to
03
get 11% or 25% off your monthly
Refine
contribution! your
repayment
structure
STEP
04
Choose
your
level of
day-to-day
benefits
STEP
STEP Customise your
01
BACK TO CONTENTS PAGE
Network Hospital List
Sanlam Gap Cover
See how much you can save
on GRID and Elect 02 hospital cover
Choose
your
hospital
cover
With Fedhealth, you can choose between two optional variants
to add a substantial discount. STEP
Full cover at
all private
Full cover at
network
SA
V
E
11
%
Full cover at SAV
any private
hospital with a
E
25
%
02
hospitals hospitals co-payment for
elective surgery
Customise
ANY HOSPITAL GRID Elect your
hospital
The standard flexiFED variant
offers no additional discounts.
In exchange, you must use
Fedhealth’s Private Hospital
In exchange, you will be
charged a fixed excess of
cover
flexiFED 1 is a network hospital Network for planned procedures. R12 500 on all hospital admis-
option, while flexiFED 2, 3, and 4 The network includes over 100 of sions, except for emergencies.
covers planned procedures at South Africa’s best private hospi- This excess however only
any private hospital. tals and 90% of our members live applies to the hospital bill; STEP
03
within a 10-kilometre radius of you could still have
these hospitals. You can still use a co-payments on out-of-net-
non-network hospital if you wish, work specialists, a procedure
but you will then have to pay a co-payment or shortfalls
R12 500 co-payment. However, because benefit limits have
the co-payment does not apply in been exceeded.
case of emergencies.
Refine
your
repayment
flexiFED 1 flexiFED 2 flexiFED 3 flexiFED 4 flexiFED 2 flexiFED 3 flexiFED 4 flexiFED 1 flexiFED 2 flexiFED 3 flexiFED 4
structure
! Avoid network restrictions with Sanlam GAP Cover. STEP
Sanlam
04
To avoid the network restrictions on Elect and GRID, take Sanlam Gap Cover
from R200 p/m (individuals) and R352 p/m (families).
Even with Gap Cover, you will still pay less than the ‘any hospital’ flexiFED option
and you won't have to worry about the co-payments mentioned above.
Gap Cover
* Please note these are 2020 rates. 2021 rates unavailable at time of printing.
Customised interaction CLICK HERE TO FIND OUT MORE Choose
with members
your
Contact details level of
Download brochure day-to-day
benefits
STEP
01
BACK TO CONTENTS PAGE
Network Hospital List How much can you save with GRID and Elect?
Sanlam Gap Cover
The amounts below indicate your monthly contribution for your flexiFED Hospital/Risk cover.
It does not include your day-to-day funding, which will be added in the next step.
Choose
your
hospital
flexiFED 1 R1 788 R3 189 R2 441 R3 842 R4 495
cover
flexiFED 1Elect R1 393 R2 482 R1 900 R2 989 R3 496
Monthly reduction in contributions R395 R707 R541 R853 R999 STEP
02
ANNUAL reduction in contributions R4 740 R8 484 R6 492 R10 236 R11 988
flexiFED 2 R2 500 R4 671 R3 242 R5 413 R6 155
flexiFED 2GRID R2 222 R4 155 R2 882 R4 815 R5 475
Monthly reduction in contributions R278 R516 R360 R598 R680
ANNUAL reduction in contributions R3 336 R6 192 R4 320 R7 176 R8 160
Customise
your
flexiFED 2Elect R1 871 R3 502 R2 429 R4 060 R4 618 hospital
Monthly reduction in contributions R629 R1 169 R813 R1 353 R1 537 cover
ANNUAL reduction in contributions R7 548 R14 028 R9 756 R16 236 R18 444
STEP
03
flexiFED 3 R2 825 R5 374 R3 840 R6 389 R7 404
flexiFED 3GRID R2 511 R4 780 R3 414 R5 683 R6 586
Monthly reduction in contributions R314 R594 R426 R706 R818
ANNUAL reduction in contributions R3 768 R7 128 R5 112 R8 472 R9 816
flexiFED 3Elect R2 117 R4 028 R2 879 R4 790 R5 552
Refine
Monthly reduction in contributions R708 R1 346 R961 R1 599 R1 852
your
ANNUAL reduction in contributions R8 496 R16 152 R11 532 R19 188 R22 224 repayment
structure
flexiFED 4 R3 747 R7 146 R4 900 R8 299 R9 452
flexiFED 4GRID R3 326 R6 351 R4 353 R7 378 R8 405
Monthly reduction in contributions R421 R795 R547 R921 R1 047 STEP
ANNUAL reduction in contributions
flexiFED 4Elect
Monthly reduction in contributions
R5 052
R2 806
R941
R9 540
R5 404
R1 742
R6 564
R3 687
R1 213
R11 052
R6 285
R2 014
R12 564
R7 166
R2 286
04
Customised interaction ANNUAL reduction in contributions R11 292 R20 904 R14 556 R24 168 R27 432 Choose
with members
your
Contact details level of
Download brochure day-to-day
benefits
STEP
01
Choose
your
hospital
cover
STEP
STEP Refine your 02
03 repayment
structure
Customise
your
hospital
cover
Some people are happy to do a little extra admin if STEP
it saves them money. For others, convenience and
simplicity is king. Whichever means more to you,
you can choose how you want to structure
03
your MediVault repayments.
Refine
The choice is yours. your
repayment
structure
STEP
04
Choose
your
level of
day-to-day
benefitsSTEP
STEP Refine your
01
BACK TO CONTENTS PAGE
MediVault amounts
flexiFED contributions
Rate Calculator
03 repayment structure
Choose
your
hospital
cover
The key to affordable medical aid is understanding
what you pay for and what you get. STEP
South African medical aid schemes all work the same way (or until now, at least). The total contribution you pay every
month, is made up of two parts. The first part is your Hospital/Risk cover, which we explained under Step 1, and the
second part is your contribution for day-to-day benefits, or savings as some call it. The savings portion may be up to
25% of your total contribution.
02
This means that from Day 1, you pay for both your Hospital/Risk cover and your day-to-day benefits – long before
you’ve used any of it. Basically, you are forced to take out a compulsory loan JUST to have day-to-day benefits you Customise
might not even plan on using! This is the main difference between Fedhealth’s flexiFED range and other medical your
schemes. We believe that younger, healthier members love the control, flexibility, and affordability we offer, and the
fact that it is now their choice to manage their medical aid spend instead of a forced, compulsory loan that remains the hospital
norm for all other medical aids. cover
How Fedhealth’s day-to-day benefits work
Fedhealth uses the revolutionary MediVault to pay for day-to-day benefits. In the next step we will look at how the STEP
03
MediVault system works in more detail, but for now it’s important to understand that the MediVault system makes a
pre-determined amount of money available to you for your day-to-day benefits, but you only pay for the portion of
your MediVault allowance that you actually use – not all of it.
This is what makes the MediVault a game changer. With other medical aid schemes you pay for your day-to-day
funds in full from the beginning of the year… as if you’ve already transferred your full MediVault from the outset.
Why should you pay for something you haven’t used yet?
Refine
your
repayment
The choice is yours! structure
With Fedhealth, you choose whether you prefer the control and upfront savings of the MediVault system where you choose a
FLEXIBLE repayment structure, or the familiarity and simplicity of the old-school FIXED repayment structure.
STEP
P
AY
MEN
P
AY
M EN
04
T
T
RE
RE
E
FLEXIBL FLEXIBLE MONTHLY PAYMENTS FIXED FIXED MONTHLY PAYMENTS
E
E
S S
R
R
T U T U
R U C T R U C T
Customised interaction Some people are happy to do a little extra admin if it saves them money. For others, convenience and simplicity Choose
with members
is key. Whichever means more to you, you can choose how you want to structure your MediVault repayments. your
Contact details
CLICK HERE TO SEE HOW THEY COMPARE level of
Download brochure day-to-day
benefitsSTEP
01
BACK TO CONTENTS PAGE
See how they compare:
MediVault amounts AY
M E
N AY
M E
N
P P
T
T
E
RE
E
FLEXIBL FIXED
flexiFED contributions
R
Rate Calculator
E
E
S S
R
R
T U T U
Choose
R U C T R U C T
What makes our MediVault system so unique, is that you can
choose to start paying for your day-to-day benefits when you
This is medical aid as you know it currently. This option offers
you simplicity and security by letting us take care of all the
your
need to use them – not from day one. admin. The Scheme will transfer a pre-determined amount to
your Wallet on 1 January every year – this amount will be
hospital
If you select the FLEXIBLE option, you simply transfer funds from pro-rated should you join after 1 January. cover
your MediVault to your Wallet when you need to pay for
day-to-day medical expenses. The funds you transfer to your This is similar to how all other medical schemes in South
Africa work. You will know upfront how much day-to-day
Wallet are then repaid over 12 months, interest free.
funds you have available for the year and you’ll start to repay
that amount every month from the beginning of the year. Both
STEP
02
the available funds and repayments will be pro-rated if you
join Fedhealth later than January...
What’s GREAT about this option? What’s GREAT about this option?
You don’t pay for day-to-day benefits until you use Simplicity – you choose once and your monthly
them. This could save you thousands every month. repayment will never vary.
You pay less without compromising on the quality of
your Risk benefits.
One debit order every month. Customise
You are in full control over how much you pay for your No admin, we’ll manage your day-to-day funds
your
medical aid. automatically. hospital
You will have one debit order each month – made up cover
of your Risk/Hospital cover contribution and your
MediVault repayments.
Any unused funds in your Wallet will transfer to the
next year, so you won’t lose it. STEP
!
Why it’s not for everybody �
Your repayments might change over time, depending
on how much of your MediVault you use !
Why it’s not for everybody�
Your initial monthly reduction in contributions will be
less, because you start repaying your day-to-day
benefit immediately.
03
! There is less flexibility. You have to repay the entire
amount allocated to you, whether you use it or not. Refine
However, any unused funds will transfer to the next
year, so you won’t lose it. your
SUMMARY: The MediVault FLEXIBLE repayment structure offers SUMMARY: The FIXED repayment structure offers you simplicity
repayment
you full control over your repayments and could save you and repayment security. It’s perfect for anyone who prefers structure
thousands. This feature is perfect for someone who wants more minimal admin and effort. You won’t enjoy the same flexibility and
control over their medical aid expenses, and doesn’t mind a little upfront reduction in contribution, but your day-to-day benefits
extra admin to enjoy the perks. will simply be there, ready to use whenever you need them. Your
monthly repayment will be a set amount, with no surprises.
STEP
MECHANICS: One monthly debit order
On the FLEXIBLE structure, your Hospital cover and
MECHANICS: One monthly debit order
On the FIXED structure, your Hospital cover and
04
MediVault repayment will be combined into one MediVault repayment will be combined into one
Customised interaction
monthly debit order which could vary depending on monthly debit order that will always be the same
Choose
with members
your MediVault usage. amount for the whole year. your
Contact details level of
Download brochure day-to-day
benefitsSTEP
01
Choose
your
hospital
cover
STEP Choose your STEP
04 level of
day-to-day
02
benefits Customise
your
hospital
cover
Now that your hospital cover and repayment
structure are selected, it’s time to take control
and select your day-to-day benefits. Day-to-day
expenses include all the frequent, everyday STEP
medical expenses you have that are not covered
under the hospital or risk cover. Think of things like
paying for medication at the pharmacy,
specialised frames for your glasses and other
03
similar expenses.
Refine
With Fedhealth, affordability is in your hands.
your
We have unlocked ample access to
repayment
day-to-day benefits for you, and you decide
structure
how much… or how little of it you want to use.
STEP
04
Choose
your
level of
day-to-day
benefitsSTEP
STEP Choose your level of
01
BACK TO CONTENTS PAGE
Day-to-day benefits
Threshold benefits
The MediVault and Wallet
FIXED Repayment Structure
04 day-to-day benefits
Choose
your
hospital
cover
FLEXIBLE repayment structure
If you select the FLEXIBLE repayment structure you choose how much
of your MediVault allowance you want to use throughout the year. STEP
M
How much is in the
MediVault
M+1
M+2
flexiFED 1
R9 300
R12 900
R14 100
flexiFED 2
R9 900
R15 300
R21 000
flexiFED 3
R11 100
R16 800
R22 200
flexiFED 4
R14 700
R26 700
R30 300
02
M + 2+ R15 300 R24 600 R26 100 R33 900
Customise
your
hospital
Let’s use flexiFED 2 as an example cover
Total Hospital/ Risk contribution R2 500 R4 671 R3 242 R5 413 R6 155 STEP
Total amount available for
day-to-day benefits
(MSA + MediVault)
R10 224 R15 900 R15 708 R21 684 R25 368
Note - You don’t have to use any... or all... of the funds in your MediVault if you don’t want to and you will
only repay the amount you have used. To calculate how much you have to pay to the Scheme every month,
simply divide the amount you intend to use by 12 and add that to your Hospital Cover contribution.
03
Refine
( Transferred MediVault amount ÷ 12 )
+ Hospital/Risk Cover contribution
= TOTAL MONTHLY CONTRIBUTION
your
repayment
structure
Example 1
If you use your flexiFED option as a hospital plan with no funds for day-to-day benefits
TOTAL MONTHLY REPAYMENT TO THE SCHEME R2 500 R4 671 R3 242 R5 413 R6 155 STEP
Example 2
If you use half your available MediVault funds
AMOUNT USED
TOTAL MONTHLY REPAYMENT TO THE SCHEME
R4 950
R2 913
R7 650
R5 309
R7 650
R3 880
R10 500
R6 288
R12 300
R7 180
04
Customised interaction Choose
with members Example 3
your
Contact details If you use ALL your available MediVault funds
level of
AMOUNT USED R9 900 R15 300 R15 300 R21 000 R24 600
Download brochure TOTAL MONTHLY REPAYMENT TO THE SCHEME R3 325 R5 946 R4 517 R7 163 R8 205 SEE FIXED REPAYMENT STRUCTURE
day-to-day
benefitsSTEP
Choose your level of
01
BACK TO CONTENTS PAGE
STEP
04
Day-to-day benefits
Threshold benefits
day-to-day benefits
The MediVault and Wallet
FLEXIBLE Repayment Choose
Structure your
Contributions hospital
FIXED repayment structure cover
If you select the FIXED repayment structure a pre-determined amount
is transferred to your Wallet, and that is your day-to-day benefit for the year.
STEP
How much is in the
MediVault
M
M+1
flexiFED 1
R3 600
R5 400
flexiFED 2
R4 800
R7 200
flexiFED 3
R7 200
R9 600
flexiFED 4
R12 000
R21 000
02
M+2 R6 600 R11 400 R12 600 R24 000
M + 2+ R8 400 R15 000 R15 000 R27 600
Customise
your
hospital
Let’s use flexiFED 2 as an example
cover
STEP
03
RISK contribution - flexiFED 2 R2 500 R4 671 R3 242 R5 413 R6 155
RISK contribution - flexiFED 2GRID R2 222 R4 155 R2 882 R4 815 R5 475
RISK contribution - flexiFED 2Elect R1 871 R3 502 R2 429 R4 060 R4 618
Fixed amount for day-to-day benefits
on ALL flexiFED 2 permutations R4 800 R7 200 R7 200 R11 400 R15 000
Refine
your
Total FIXED monthly contribution repayment
to the Scheme for flexiFED 2 R2 900 R5 271 R3 842 R6 363 R7 405
structure
Total FIXED monthly contribution
to the Scheme for flexiFED 2GRID R2 622 R4 755 R3 482 R5 765 R6 725
STEP
Total FIXED monthly contribution
to the Scheme for flexiFED 2Elect R2 271 R4 102 R3 029 R5 010 R5 868
04
Notes
Customised interaction Choose
with members • You will have one deduction every month for your total repayment.
• The amount will be fixed for the entire year.
your
Contact details • You do not have to transfer funds from your MediVault to your Wallet. level of
This will be done on your behalf at the beginning of every year.
Download brochure SEE FLEXIBLE REPAYMENT STRUCTURE day-to-day
benefitsflexiFED option range
With our flexiFED option range, members can stop paying for cover they don’t use. Instead, they can select cover that fits their current needs… but with the option to change when the unexpected happens. It’s cover
that grows with the member.
flexiFED 2
flexiFED 1 Family start-ups
Young singles
For young families who are just starting out.
For young people who are single, in a relationship or married.
Access to a MediVault Access to a MediVault
for day-to-day benefits for day-to-day benefits
Most people at this life stage prefer Many people at this life stage still prefer
hospital plans, but hospital plans have no Unlimited nominated network hospital plans, but hospital plans have no
day-to-day benefits. flexiFED 1 can be GP consults from Risk day-to-day benefits. flexiFED 2 can be
like a hospital plan: if you don’t use the like a hospital plan; if you don't use the
after day-to-day claims have reached the
MediVault you don’t pay for it, but should MediVault you don't pay for it, but should
Threshold level.
you need it you don’t have to rely on you need it, you don’t have to rely on
family or your bank for a loan. You just
Customised childhood benefits:
family or your bank for a loan. You just
access your MediVault and pay it back. access your MediVault and pay it back. ALL PAID FROM RISK
Paed-IQ (telephonic parenting advice line)
Female contraception
paid from Risk. Paediatric consultations without referral up to 12
Unlimited accident and Rich maternity benefits: months old
emergency treatment 2x 2D antenatal scans and 8 ante- or
Infant hearing screening benefit
postnatal consults with midwife, network
at any private hospital.
GP and gynae
Specialised radiology Childhood immunisations
for that fall from your MTB. Fedhealth Baby programme
Circumcisions
Basic maternity benefit Amniocentesis
Trauma treatment in a casualty ward for those falls
from the swing
Antenatal classes to the value of R1 120
Basic dental benefit Doula benefit
Unlimited nominated network GP consults after
day-to-day claims have reached the Threshold level
Customised mental Postnatal midwifery benefit
Childhood illness specialised drug benefit up to 18
health benefit Rental of a water bath
years old
for support with substance abuse and
eating disorders, etc. Unlimited private hospital cover Paediatrician for the delivery room
Only pay for up to three children, the rest are covered
for planned procedures for free
at network hospitals (or the smaller network We cover natural deliveries, epidurals
Unlimited cover (PMB level) for neonatal complica-
depending on your choice). and C-sections
tions, infant cancers, infant injuries and fractures
Unlimited 30-day post
hospital benefit
(e.g. physio/ dietician/ OT/ speech).
PLUS
Lifestyle benefits:
Female contraception and vasectomies
Trauma treatment in a HIV screening + flu vaccine PLUS
casualty ward paid from Risk Unlimited nominated network GP
Weight management programme consults from Risk after day-to-day
for sports or hazardous pursuit injuries Fedhealth Family Room for valuable pregnancy/
claims have reached the Threshold level
(co-pay applies). Smoking cessation programme baby advice
Upgrades within 30 days of a
Fedhealth Nurse Line for medical advice life-changing event, such as pregnancy Fedhealth Nurse Line for medical advice
or the diagnosis of a dread
Upgrades within 30 days of a MediTaxi post-hospitalisation transport disease MediTaxi post-hospitalisation transport
life-changing event,
Fedhealth Family Room rewards
such as pregnancy or the diagnosis of a
dread disease.
GO BACKflexiFED option range
flexiFED 3 flexiFED 4
Young families Mature families
For young, still growing families. For mature families looking for cover that leaves nothing to chance.
Access to a MediVault
Customised childhood benefits: for day-to-day benefits
Access to a MediVault
for day-to-day benefits
Many people prefer hospital plans because Rich maternity benefits
ALL PAID FROM RISK they are simple and affordable, but
Many people prefer hospital plans hospital plans have no day-to-day benefits.
because they are simple and affordable, flexiFED 4 can be like a hospital plan; if you
Paed-IQ (telephonic parenting advice line) up to 14
but hospital plans have no day-to-day don’t use the MediVault you don’t pay for
benefits. flexiFED 3 can be like a hospital it, but should you need it, you don’t have Child rates up to the age of 27
Fedhealth Nurse Line for advice
plan; if you don’t use the MediVault you to rely on your bank for a loan. You just
don’t pay for it, but should you need it, Paediatric consultations without referral up to 24 access your MediVault and pay it back.
you don’t have to rely on your bank for a months old
loan. You just access your MediVault and
Infant hearing screening benefit
Screening benefit for breast
pay it back. Unlimited network GP cancer
Infant/ childhood immunisations (DoH recommended) consults from R1 (> age 45), cervical cancer (ages 21-65),
Trauma treatment in a casualty ward (co-pay applies) cholesterol, colorectal, HIV, PSA (ages 45 – 69)
Rich maternity benefits:
for accidental injuries like fractures, burns, near Cover for mental health
2x 2D antenatal scans and 12 ante- and drowning. disorders:
postnatal consults with midwife, network Unlimited nominated network GP consults after
GP and gynae anxiety and panic disorders, ADHD,
day-to-day claims have reached the Threshold level. eating disorders, OCD Health risk assessments
Fedhealth Baby programme Tonsillectomy under age 12
Doula benefit In-hospital dentistry up to age 7 Advanced and basic dental
Postnatal midwifery benefit Nasal procedures
benefits Optical benefits
Private ward cover e.g. extraction of impacted wisdom teeth
Childhood illness specialised drug benefit up to 18
Amniocentesis years old.
Antenatal classes to the value of R1 120 Specialised medicine like Synagis, Botox and growth Non-PMB chronic benefits
hormones for children up to age 10
Unlimited accident and
Support for post-partum depression emergency treatment at
Additional chronic benefit for children up to the age of
18 with asthma, eczema and acne up to the age of 21.
any private hospital
(co-pays apply) Terminal care benefit
Cover for the following conditions:
Lifestyle benefits: - Childhood diabetes
- Childhood epilepsy Varicose vein procedures
Female contraception and vasectomies - Haemophilia
- Heart rhythm disorders in children Bunion procedures
Mammograms - Juvenile rheumatoid arthritis
Screening benefit covering cholesterol Diabetes managed care
Unlimited cover for childhood cancers, leukaemia and
Health Risk Assessments tumors programme
Customised mental health
Conservative Back and Neck Rehabilita- Only pay for up to three children, the rest are covered support programmes
tion Programme for free Conservative Back and
Customised mental health support Neck Rehabilitation
programmes
Acne benefit up to age 21
Unlimited nominated network GP PLUS Oncology benefits
consults from Risk after day-to-day
claims have reached the Threshold level. Flu vaccine PLUS
Child rates up to 27 for financially Unlimited specialised
Fedhealth Family Room Flu vaccine
dependent children. radiology (co-pays apply)
Upgrades within 30 days of a Weight management programme Fedhealth Family Room
life-changing event, such as pregnancy
or the diagnosis of a dread disease. Fedhealth Nurse Line for medical advice
Upgrades within 30 days of Weight management programme
a life-changing event, Smoking cessation programme
Optometry benefit MediTaxi post-hospitalisation transport such as pregnancy or the diagnosis
Basic dentistry benefit Fedhealth Nurse Line for medical advice
of a dread disease.
Predictive modelling of claims to identify and MediTaxi post-hospitalisation transport
Terminal care benefit
intervene early to manage emerging health risks
Oncology benefits Predictive modelling of claims to identify and
Post-hospitalisation benefit intervene early to manage emerging health risks
Threshold benefit
GO BACKOverview of the BENEFIT STRUCTURE
flexiFED structure
Our flexiFED 1, 2, 3 and 4 options free members from one-size-fits-all
plans by giving them more control over how they structure their own
cover, and how much they pay.
Members start by choosing one of four options, flexiFED 1, 2, 3 or 4,
to provide them with in-hospital benefits, chronic benefits, screening
benefits, day-to-day benefits and additional benefits.
The next step is having the option to pay lower
contributions by choosing between two discounts.
Next, the member also enjoys the advantage of the MediVault - an
amount available for their day-to-day medical expenses. They can
either choose a FLEXIBLE or FIXED repayment structure for the
MediVault - depending on whether they prefer flexibility and afforda- On flexiFED, members enjoy the following benefits:
bility of only paying for what they use, OR the predictability of a set
amount allocated at the beginning of the year. • In-hospital benefit –Members have no overall annual limit for hospitalisation.
Last but not least, after the member’s day-to-day claims have • Chronic disease benefit – This benefit covers chronic conditions on the CDL. It’s covered in full up to the Medicine Price
List if members use medicine on the formulary and obtain it from either one of our Preferred Providers or designated ser-
accumulated to the Threshold level, members on flexiFED 1, 2 and 3 vice providers depending on the option. Additional conditions are covered on flexiFED 3 and flexiFED 4.
still have certain benefits covered from the Threshold benefit, like
unlimited network GP visits and dentistry benefits. Members on • Day-to-day benefits – Day-to-day expenses on the flexiFED option range are first funded from any available Savings the
flexiFED 4 have a comprehensive Threshold benefit. Please see the member might have. Once their Savings is depleted, day-to-day expenses can be paid from the Wallet once the member
has activated their MediVault and transferred funds to their Wallet, on a FLEXIBLE repayment structure, or from the funds
following pages for more details on the flexiFED Risk benefits and allocated to them on 1 January (FIXED repayment structure).
what they offer members.
Each of the flexiFED options has a Nominal Savings contribution. This allows members to transfer/retain any accumulated
Savings from a previous option/ scheme when joining a flexiFED option. Any member on a flexiFED option can also top
up this Savings Account at any time up to a maximum annual amount of 25% of their gross contribution. Any claim sub-
mitted which is not payable from Risk will be funded from the member’s Savings Account first.
•Threshold benefit
On flexiFED 1, 2 and 3, the Threshold benefit pays for limited day-to-day expenses once claims have accumulated to the
Control, customisation Threshold level.
On flexiFED 4 the Threshold benefit pays for comprehensive day-to-day expenses once claims have accumulated to the
and choice like Threshold level.
never before! • Day-to-day benefits paid by the Scheme – We pride ourselves on paying more from Risk so the members’ day-to-day
benefit lasts longer.
• Screening benefit – Preventative screenings and assessments like lifestyle screenings, wellness screenings (includes finger
prick glucose and total cholesterol, blood pressure, waist circumference and body mass index (BMI) and physical screenings
are covered from this benefit.
• Savings – The funds in the member’s Medical Savings Account (MSA) will be used first when he or she has day-to-day
medical expenses.
GO BACKUnlimited private
hospital cover
for peace of mind
We pay for unlimited
private hospitalisation!
All Fedhealth options have an unlimited in-hospital benefit. Mem- By law, all medical schemes are required to cover the treatment of If referral is not obtained, there will be a co-payment on specialist
bers must obtain pre-authorisation for all planned hospital admis- 270 hospital-based conditions and 27 chronic conditions, i.e. the claims paid from the Risk benefit. The co-payment depends on
sions and in the case of an emergency admission, they must obtain Chronic your option.
authorisation within two working days after going to hospital. Disease List (CDL), in full without co-payment or deductibles, as
well as any emergency treatment and certain out-of-hospital treat- Please note: Qualification for reimbursement as a PMB is not
On certain options, members must use a hospital on the Fedhealth ment. based solely on the diagnosis (condition), but also on the treat-
Hospital Network. If they use any other hospital, they will have to ment provided (level of care). This means that although a mem-
pay a co-payment on the hospital account. This means that all schemes must provide PMB level of care at cost ber’s condition may be a PMB condition, the Scheme would only
for these conditions. The Medical Schemes Act 131 of 1998 allows be obliged to fund it in full if the treatment provided was deemed
The in-hospital benefit covers hospital costs as well as the accounts schemes to require members to make use of Designated Service to be PMB level of care.
from doctors, specialists e.g. the anaesthetist and other healthcare Providers (DSPs) in order for a member to be entitled to funding in
providers like the x-ray department. full. Schemes may also apply formularies – a list of medicines which Co-payments on certain procedures
should be used to treat PMBs, and managed care protocols – based For some treatments and procedures, members must pay an
This benefit also covers selected procedures performed in day on evidence-based medicine and cost-effectiveness principles to amount out of their own pocket. This is called a co-payment.
wards, day clinics and doctor’s rooms. On certain options, members manage this Co-payments apply to the hospital account and/or certain proce-
must use day clinics on the Fedhealth Day Clinic Network. benefit. dures, depending on the option.
Cover for hospital admissions Fedhealth has appointed network specialists, network GPs, net- Treatment for emergencies
We cover the hospital account from the work hospitals and DSP pharmacies, Clicks, Dis-Chem and MediRite To qualify as an emergency, the condition must be unexpected
in-hospital benefit. Specialists and GPs who are on the Fedhealth as well as Pharmacy Direct, Clicks Direct Medicines and Dis-Chem and require immediate treatment. This means that if there is no
network are covered in full. Specialists and GPs who are not on the Direct, courier pharmacies, for the provision of PMBs. If a DSP is immediate treatment, the condition might result in lasting dam-
Fedhealth network, are covered up to the Fedhealth Rate. required on your option, a 40% co-payment will apply if you don’t age to organs, limbs or other body parts, or even in death. If the
use a DSP. Members must use a Fedhealth Network Specialist and a member is on a network hospital option, treatment of an emer-
Referral by a medical practitioner and nominated network GP in order for the cost to be refunded in full. gency medical condition may take place at any hospital, but once
pre-authorisation is required for physical therapy (physiotherapists), their condition has stabilised and they can be safely transferred
which is covered up to the Fedhealth Rate. Should you not use these DSPs for the treatment of a PMB condi- to a network hospital, the co-payment will apply if they opt not to
tion, the Scheme will reimburse treatment at the non-network rate. be transferred.
How Prescribed Minimum Benefits are covered Co-payments are applicable to the voluntary use of non-DSPs. Re-
Prescribed Minimum Benefits or PMBs refer to a basic level of cover ferral must be obtained from a Fedhealth Network GP for
for a defined set of conditions. consultations with Fedhealth Network Specialists.
GO BACKWe cover certain
Day clinic/ doctor’s room procedures unlimited
from the hospital benefit
procedures covered from if done in a day ward,
day clinic or
the in-hospital benefit doctor’s rooms!
The following procedures will be paid from the Gynaecology hydrocoele repair Ophthalmology be paid from the in-hospital benefit
in-hospital benefit if done in a day clinic, day ward or Bartholin cyst - drainage/excision/mar- Meatotomy for meatal ste- Gastroscopy/oesophagogas- Cataract surgery if performed in a doctor’s room or
supialisation nosis troduodenoscopy Foreign body removal suitably equipped procedure room,
an outpatient section of a hospital. Some may incur a Cauterization of warts Orchidopexy for undescend- Haemorrhoidectomy Intra ocular injection e.g. Avas- at up to 100% of the Fedhealth Rate.
procedure co-payment. Overnight admissions will not Cervical cerclage ed testis Inguinal hernia repair tin, including Glaucoma Pre-authorisation must be obtained and
be covered except for Prescribed Minimum Benefits. Colposcopy Urethrocystoscopy for uri- Lymph node/muscle/skin/bone Laser Surgery should no pre-authorisation take place,
Fine needle aspiration - cytology nary incontinence and breast biopsy Posterior and Anterior Vitrec- reimbursement will be restricted to the
LETZ of cervix Proctoscopy and removal of tomy member’s available day-to-day benefit
These procedures must be pre-authorised. If the Dilatation and Curettage Orthopaedics polyps Probing & repair of tear ducts or self-funded by the member. This will
procedure is performed without pre-authorisation, Endometrial ablation Arthrocentesis Resection/debridement of mul- Pterygium (conjunctiva) not accumulate to the Threshold Level:
Hysteroscopy Arthrodesis of hand/elbow/ tiple nails (6 plus) Removal of pterygium
the full amount will be paid from day-to-day Insertion of IUD (Intra-uterine Device) foot Sigmoidoscopy Strabismus repair Gastroscopy (no general
benefits or self-funded by the member and will not Labiaplasty Arthroscopy Umbilical hernia repair anaesthetic will be paid for)
accumulate towards the Threshold level. Arthrotomy of finger/hand/ Wound debridement (skin/sub- Oral and Maxillofacial Sur- Colonoscopy (no general
Urology elbow/knee/hip/toe cutaneous tissue) gery anaesthetic will be paid for)
Adults Aspiration/intra-articular Apisectomy Flexible sigmoidoscopy
If authorisation is requested after the procedure has Bilateral total orchidectomy for prostate injection of joints ENT Surgery Frenectomies Indirect laryngoscopy
taken place, a R1 000 penalty will apply which will be cancer Bunionectomy Adenoidectomy Gingival Graft Removal of impacted wisdom
Bladder biopsy (cancer and other Carpal Tunnel release Antrostomy Implantology teeth
paid from day-to-day benefits or self-funded by the conditions) Cast/application removal Diathermy to nose and pharynx Orthodontic Attachment Intravenous administration of
member, without accumulating to the Threshold level. Bouginage for urethral stricture Ganglionectomy (under LA) Pulpotomy and fillings bolus injections for medicines
Circumcision Injection of tendon/ligament/ DPP (Diagnostic Proof Punc- Wisdom or Impacted Teeth that include antimicrobials and
Cystoscopy & ureteral dilation trigger points/ganglion cyst ture) removal Immunoglobulins (payment of
Members on the following options flexiFED 1, DJ stent removal post pyeloplasty Injection therapeutic carpal ENT Endoscopy Extractions immunoglobulins is subject to the
flexiFED2GRID, flexiFED 3GRID and flexiFED 4GRID will Hydrocelectomy for vaginal hydrocoele tunnel Middle ear procedures (mas- Specialised Medication Benefit)
incur a R2 000 co-payment on the voluntary use of Inguinal hernia repair Insertion or removal of K toidectomy, tympanoplasty/ Plastic and Reconstructive Fine needle aspiration biopsy
Open cystolithotomy for bladder stone wires or other internal fixa- stapedectomy) Surgery Excision of nailbed
non-network day clinics. Prostate biopsy (cancer and other con- tives Myringotomy (including as- Repair wound with layers Drainage of abscess or cyst
ditions) Radical nail bed removal piration and incision) and/or (scalp/axillae/trunk/limbs Injection of varicose veins
Renal calculus removal & stent insertion grommets Repair wound lesions (scalp/ Excision of superficial benign
Scope and pyelogram General Surgery Nasal bleeds (control) hands/neck/feet/face) tumours
Second stage urethroplasty post stage 1 Anal dilatation/Anoscopies/ Reduction of nose fracture Excision of benign lesions Superficial foreign body removal
Testicular biopsy for infertility fissures and fistula repair Rhinoplasty (scalp/neck/hands/feet/trunk/ Nasal plugging for epistaxis
Urethrocystoscopy for bladder outlet Breast biopsy/ removal lump Septoplasty limbs) Cauterisation of warts
obstruction Colonoscopy Sinus related surgery (ethmoid- Excision of malignant lesions (+ Bartholin cyst excision
Varicocelectomy for varicocele Drainage of abscesses/hae- ectomy/sinusotomy and flap if required)
Vasectomy matomas/cysts (subcutane- lavage)
Vasostomy ous/submucosal) Tonsillectomy Procedures performed in a
Paediatrics Excision lipoma/cysts/tu- Turbinectomy doctor’s room or suitably
Circumcision for intact prepuce mours Tympanoplasty equipped procedure room
Glandulo-cavernous shunt for priapism Excision of sweat glands The following procedures will
Hydrocelectomy for congenital (axilla/inguinal) and simple
GO BACKflexiFED in-hospital benefit
flexiFED in-hospital benefit
flexiFED 1 flexiFED 2 flexiFED 3 flexiFED 4 flexiFED 1 flexiFED 2 flexiFED 3 flexiFED 4 flexiFED 1 flexiFED 2 flexiFED 3 flexiFED 4
Overall annual limit Unlimited at net- Unlimited at negotiated tariff. Alternatives to hospitalisation: Oncology: oncologist Unlimited at cost at R300 200 at designated service R480 400 at
(OAL) work hospitals only. consultations, visits, PMB level of care at provider* and paid from Level 1 designated
R7 000 co-pay- On flexiFED 2GRID, flexiFED 3GRID and flex- Nursing services, Unlimited at negotiated tariff
treatment and designated service treatment protocols. service provider*
ment on voluntary iFED 4GRID members must use network private nurse
materials for provider* and paid and
use of non-network hospitals and network day clinics. There is a practitioners & chemotherapy and from Level 1 paid from
hospital. R12 500 co-payment on use of non-network nursing agencies radiotherapy, treatment protocols. Level 1 treatment
R2 000 co-pay- hospitals and a R2 000 co-payment on use Sub-acute facilities, Unlimited at cost up to PMB level of care approved medication, protocols.
ment on voluntary of non-network day clinics. physical radiology and
use of non-network A 40% co-payment applies where a DSP is not used
rehabilitation pathology
day facility. On flexiFED 2Elect, flexiFED 3Elect and flex-
On flexiFED 1Elect, iFED 4Elect there is a R12 500 excess on facilities
there is a R12 500 all hospital admissions except emergency Appliances, Paid from Savings/ Wallet or self-funded. Paid from Organ transplant in- Unlimited at cost at R300 200 (See HPT) R480 400 (See
excess on all hos- admissions. external accesso- Accumulates at cost to Threshold level Savings/ cluding immunosup- PMB level of care HPT)
pital admissions ries and orthotics Wallet or pression medication
except emergency self-funded. Corneal graft No benefit R35 000 per
admissions. Does not beneficiary
Healthcare Professional Tariff in hospital (HPT) accumulate Pathology, radiology Unlimited at Fedhealth Rate
Fedhealth Network Covered unlimited. Paid in full. to threshold. (general)
GPs and Specialists Paid from
Physiotherapy Subject to referral by a medical practitioner, pre-authorisation and treat-
Non-network GPs Paid up to Fedhealth Rate threshold up
ment
Non-network Paid up to Fedhealth Rate to protocols
Specialists R12 500 per
family per Psychiatric services: Unlimited at cost at R25 500 (see R27 000 (see HPT)
Other Healthcare Paid up to Fedhealth Rate accommodation in PMB level of care HPT)
Professionals year. (R4
680 sub-limit a general ward,
Prescribed Min- To have the treatment for PMB conditions covered in full, you will procedures, ECT,
per benefi-
imum Benefits have materials and
ciary for foot hospital equipment,
(PMB): Treatment to use Fedhealth Network GPs, Specialists, Hospitals and DSPs
orthotics) consultations and
for PMB conditions where
can be funded in applicable. Blood, blood Unlimited visits, medicines and
two ways: equivalents and injection material
Should you choose not to make use of network providers, the blood products Renal dialysis (chron- Unlimited at cost at R300 200 up to the Fedhealth R480 400 up to
Scheme Immune deficiency Unlimited (see HPT) ic): consultations, PMB level of care at Rate at Designated Service Pro- the Fedhealth
will only refund treatment up to the Fedhealth Rate and you will related to HIV visits, all services, Designated Service vider (DSP). Rate at Desig-
have a co-payment should the healthcare professional charge materials and Provider (DSP). nated Service
infection
more medicines associated Provider (DSP).
Maternity - Healthcare Professional Tariff in-hospital (HPT) with the cost of renal
Hospitalisation Unlimited at Unlimited at Unlimited at Unlimited at A 40% co-payment applies where a DSP is not used
Fedhealth Network Covered unlimited. Paid in full. dialysis
costs: negotiated tariff at negotiated negotiated negotiated
accommodation network tariff tariff. Private tariff. Private GPs and Specialists Childhood illness No benefit Childhood illness specialised drug benefit for chil-
(e.g. Gynaecolo- specialised drug dren up to the age of 18
in a general ward, hospitals only. ward ward
gists & Paediatri- benefit (up to the
high care ward and cover for cover for
cians) age of 18)
intensive care unit, maternity maternity
theatre fees, admissions admissions Non-network GPs Paid up to Fedhealth Rate Specialised radiology Unlimited at Unlimited at Fedhealth Rate. First R2 380 for non-
medicine, material Fedhealth Rate. PMB MRI/ CT scans for the member’s account
Non-network Paid up to Fedhealth Rate First
and hospital Specialists R3 310 for
apparatus
Other Healthcare Paid up to Fedhealth Rate non-PMB MRI/ CT
Additional medical Paid from Savings/ Wallet or self-funded. Accu- In and scans for the
Professionals
services (dietetics, mulates at cost to Threshold level out-of-hospi- member’s account
occupational tal: Paid from Dentistry
Spinal surgery No benefit unless Conservative Back & Neck No benefit unless
therapy and speech Savings/ Maxillo-facial Unlimited, subject to approval (see HPT) Rehabilitation Programme has been completed. Mem- Conservative
therapy) Wallet or surgery ber pays a co-payment of R8 000 on the hospital bill Back & Neck
self-funded. Rehabilitation
Does not Surgical extraction You pay a co-payment of R4 600 on the hospital bill
of impacted wis- Programme has
accumulate been completed.
to Threshold. dom teeth
Member pays a
Paid from In-hospital den- No benefit We cover the hospital and anaesthetist co-payment of
Threshold up tistry benefit for costs from the in-hospital benefit. The R6 000 on the
to R12 500 hospital bill
children under 7 dentist account will be paid from Savings/
per family per Wallet or self-funded Terminal care benefit R33 300 at Fedhealth Rate
year
GO BACKflexiFED co-payments & prosthesis benefit
flexiFED in-hospital benefit
Co-payments Prosthesis benefit
Co-payments may apply on certain in-hospital procedures, which will be for the member’s account. Under this benefit, we cover internal prosthesis like pacemakers and spinal plates.
flexiFED 1 flexiFED 2 flexiFED 3 flexiFED 4 flexiFED 1 flexiFED 2 flexiFED 3 flexiFED 4 flexiFED 1 flexiFED 2 flexiFED 3 flexiFED 4
Co-payments per event applicable on the hospital/ facility bill only Laparoscopic hernia repairs R6 800 R4 600 External Unlimited at R11 780 at R12 500 at cost
(bilateral inguinal, repeated in- cost at PMB cost
Adenoidectomy, R6 800 No co-payment
guinal hernias & Nissen/ Toupet level of care
bunion procedures,
diagnostic hernia repairs only), laparo- Internal
cystoscopy, scopic procedures Aorta Stent Grafts Unlimited at cost at PMB R63 100
gastritis/ dyspepsia/ Bone lengthening level of care See combined benefit limit for
Laparoscopic varicocelectomy R6 800 No co-payment
heartburn, nasal devices, carotid all
procedures, skin Rhizotomies and facet pain No benefit R4 600 stents, embolic unlisted internal prosthesis*
biopsy/ excision blocks (limited to 1 of either protection devices,
procedure per beneficiary other
All open hernia R6 800 R4 600 No co-payment
per year) approved spinal
surgery
implantable
Arthroscopic R8 500 R2 600 Spinal surgery** R8 000 R6 000
devices and in-
procedures - knee, Surgical extraction of R4 600 tervertebral discs,
shoulder, ankle and impacted wisdom teeth peripheral arterial
other stent grafts, spinal
Varicose vein procedures R6 800 R4 600 No
Arthroscopic No benefit R8 500 R2 600 plates and
co-payment
procedures: hip screws
Tonsillectomy Cardiac pacemakers, Unlimited at R29 900
Arthroscopic Unlimited at cost R8 500 R2 600
procedures: wrist at PMB level of Under the age of 12 No co-payment cardiac stents, cardi- cost at PMB
care ac valves level of care
12 and over R6 800 No co-payment Detachable platinum R54 600
Back & neck R6 800 R4 500 R2 500 coils
** No benefit unless Conservative Back & Neck Rehabilitation Programme has been completed.
procedures
Elbow, hip, knee and See combined R29 900
Cataract surgery Unlimited at cost at PMB level of care shoulder replace- benefit limit
with CP** ment for all unlisted
Colonoscopy, upper R6 800 R4 600 R2 600 internal pros-
GI endoscopy thesis*
Total ankle replace- No benefit See com-
Dental admissions No benefit R6 800 No co-payment
ment bined benefit
Hysterectomy R4 000 No co-payment limit for all
(unless for cancer) unlisted inter-
Inguinal hernia R6 800 R4 600 No co-payment nal prosthe-
sugery sis*
Intraocular lenses Unlimited at cost at PMB R3 400
Joint replacements
(per lens) level of care
Single hip and knee Unlimited at cost at PMB level of No co-payment * Combined benefit R26 900
replacements with care limit for all unlisted
CP* internal prosthesis
Single hip and knee Unlimited at cost at PMB level of R28 400
replacements- care
voluntary non-use
of CP*
Other joint Unlimited at cost at PMB level of R6 800 R4 600
replacements and care
involuntary non-use
of CP* for single
hip and knee
replacements
* Contracted Provider: Must use ICPS Hip and Knee network or JointCare for single non-PMB hip and knee joint replacements.
Non-use of Contracted Provider (CP) will result in co-payment.
** Contracted Provider: Must use ICPS Cataract network for cataract surgery. Non-use of Contracted Provider (CP) will result in
co-payment of R6 000.
GO BACKExamining our Oncology Disease Management
Fedhealth supports cancer patients in their time of need, and
diagnosed members are encouraged to register on the Fed-
provided a valid authorisation has been obtained. The treating
doctor must submit a treatment plan to Oncology Disease Manage-
ment, cancerinfo@fedhealth.co.za. Once treatment has been au-
Specialised radiology
Specialised radiology (e.g. CT scans, MRIs, angiography, radioiso-
topes) requires a separate pre-authorisation. These pre-authorisa-
cancer cover health Oncology Programme by calling 0860 100 572. The
Scheme offers all members the opportunity to change to a
higher option within 30 days of a life-changing event or diag-
thorised, the member and doctor will receive an authorisation letter.
Treatment for conditions not directly related to the treatment of
the cancer (e.g. depression) as well as treatment for the long-term
tions must be obtained from the Authorisation Centre. Specialised
radiology is paid from Risk. A co-payment for non-PMB MRI/CT
scans will apply on all options.
nosis. This ensures that those with cancer can get access to conditions that may develop as the result of chemotherapy or radi-
medication that will help them to remain economically active, otherapy, will be funded from an alternative benefit (i.e. the Chronic PET scans
with all the support they need to deal with this stressful diag- Disease Benefit or the Savings Account/ Wallet). PET scans are limited to two per family per annum restricted to
nosis. staging of malignant tumours. PET scans are paid from the oncolo-
On flexiFED 1, flexiFED2GRID and all Elect options: Chemotherapy, gy benefit. flexiFED 1 does not have a PET scan benefit.
We require a clinical summary of each member’s case: this as well as medicine and consumables directly associated with the
must include the history, ICD–10 codes, the clinical findings of treatment of cancer, should be obtained from the Oncology Phar- Surgery and hospitalisation
the doctor, as well as the test results confirming the cancer macy Network and in accordance to the oncology Preferred Prod- Claims for surgery and hospitalisation will be paid from the in-hospi-
and the specific type of cancer. The proposed treatment plan uct List (PPL) – non-use of these will result in a 25% co-payment. tal benefit, provided that the member obtains a valid authorisation
must be submitted so that the oncology team can approve the from the Authorisation Centre.
appropriate therapy. Our Radiotherapy
caring agents will guide the member through the process. Radiotherapy will be paid from the oncology benefit, provided a Stoma therapy
valid authorisation has been Stoma therapy will be paid from Risk. Pre-authorisation is not re-
Members can access the oncology benefit by obtaining obtained. The treating doctor must submit a treatment plan to On- quired.
pre-authorisation from the Oncology Disease Management cology Disease Management. Once treatment has been authorised,
team. The team comprises highly skilled healthcare profession- the member and doctor will be sent an authorisation letter. Terminal care and private nursing
als who work in conjunction with the treating doctor to ensure Accommodation in a hospice or terminal care facility for the care of
that treatment provided is both clinically appropriate and Specialised medication patients in terminal stage of life will be covered from the Terminal
cost-effective. A set of cancer guidelines and protocols are Specialised medication is medication that is focused on a defined Care Benefit covered up to R33 300 per family per year. Pre-au-
used during the pre-authorisation process. These guidelines group of patients, diseases, skills, or philosophy e.g. biologicals – thorisation must be obtained from the Hospital Authorisation Cen-
are continually updated as new products are launched and oncology and non-oncology. Specialised medication is covered on tre. Private nursing will be paid from the Alternatives to Hospitalisa-
new treatment protocols are established. In addition, our team our maxiFED options only. tion benefit, where this is available.
is supported by a number of oncologists and haematologists
from the private, public and academic sectors. Consultations and visits Post-active treatment
Oncologist consultations and hospital visits are paid from the oncol- Post-active refers to the time when the member actually had last
On flexiFED 1, oncology is covered unlimited at PMB level of ogy benefit while the member has either an active chemotherapy or active treatment (e.g., hormone therapy, chemotherapy or radio-
care at the designated service provider, ICON, subject to Level radiotherapy authorisation. Hospital visits are pre-authorised at the therapy). “For life” means that the member will remain on the oncol-
1 treatment protocols. A 40% co-payment applies where a DSP same time as the authorisation for chemotherapy or radiation treat- ogy programme as long as the cancer is in remission. Whilst in re-
is not used. ment. You will receive an authorisation letter detailing the number mission, a list of appropriate consultation, radiology and pathology
of visits authorised and the period for which these visits are author- codes has been defined and claims for these services are automat-
On flexiFED 2 and flexiFED 3, oncology is covered up to R300 ised. ically paid for life from the oncology benefit. Should the condition
200 per family per year at the designated service provider, regress, the active treatment benefit will be reinstated upon
ICON, subject to Level 1 treatment protocols. A 40% co-pay- Pathology submission of a new treatment plan.
ment applies where a DSP is not used. Oncology-related pathology claims are paid from the oncology
benefit while the member is receiving treatment (either chemother-
On flexiFED 4, oncology is covered up to apy or radiotherapy), provided that the member has a valid author-
R480 400 per family per year at the designated service pro- isation. A list of appropriate pathology codes has been defined and
vider, ICON, subject to Level 1 treatment protocols. A 40% claims for these services are automatically paid from the oncology
co-payment applies where a DSP is not used. benefit (a separate pre-authorisation is therefore not required).
At Fedhealth you can Independent Clinical Oncology Network (ICON) Radiology
upgrade your option ICON provides Fedhealth’s active oncology treatment. ICON
is a network of oncologists that includes 75% of all practicing
General radiology
General oncology-related radiology claims are paid from the oncol-
any time of the year on oncologists in South Africa. To find an ICON network special-
ist, you can call 0860 002 153.
ogy benefit while the member is receiving treatment (either chemo-
therapy or radiotherapy), provided that the member has a valid
diagnosis of cancer. Chemotherapy and associated medicine
authorisation. A list of appropriate radiology codes has been de-
fined and claims for these services are automatically paid from the
Chemotherapy and medicine directly associated with the oncology benefit (i.e. a separate pre-authorisation is not required).
treatment of cancer will be paid from the oncology benefit,
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