- Benefits are subject to Genesis issuing a hospital admission reference number, however, payment is not guaranteed if clinical protocols and the terms and conditions as per the Scheme Rules are not met.
- Beneficiaries on all options share the benefits of adult members unless expressly stated to the contrary. Prescribed Minimum Benefits (PMBs) cannot be limited beyond the limits prescribed by law. For further information contact Genesis.
- Genesis does not provide any kind of healthcare service or treatment. Treatment can only be provided by / in a registered healthcare practitioner(s) and / or institution(s). The function of the Scheme is therefore to provide the funding for such treatment and will accordingly reimburse members’ claims in terms of its Rules.
- Genesis covers all approved conditions, including Prescribed Minimum Benefits (“PMBs”), in private hospitals, where the benefits and limits, as set out in the Scheme Rules, apply. Hospital accounts will usually be paid in full in terms of tariff agreements with the hospital. In private hospitals, the charges of attending doctors/specialists and other healthcare service providers will be reimbursed at 100% or 200% of the Scheme Tariff, depending on which benefit option you are on.
- This funding applies to all claims for treatment in private hospitals, even if the condition is listed as a PMB. Shortfalls relating to treatment received in private hospitals usually pertain to charges for attending doctors/specialists if they charge more than 100% or 200% of the Scheme Tariff. To this end, should your claim be listed as a PMB and you want it to be paid according to the law as provided for in section 29(1)(p) of the Medical Schemes Act (“paid in full subject to PMB level of care”), then treatment must be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply. Genesis has selected all public hospitals in South Africa as its Designated Service Providers (DSPs).
- In short, PMB treatment in private hospitals is reimbursed in terms of the Rules where limits may apply. PMB treatment in public or state hospitals will be reimbursed subject to PMB level of care as prescribed in the Medical Schemes Act. This means that you will receive the same entitlement to treatment that applies to a public or state hospital patient as set out in the regulations of the Act.
- The cost of medical services rendered outside the Republic of South Africa is excluded from the risk benefits on all options.
- The Scheme Rules, including a list of excluded conditions, procedures and services for all benefit options are available on the website or on request from the Scheme.
Comprehensive
Medical Aid Plan
Apart from peace of mind and knowing that your in-hospital medical aid coverage offers excellent in-hospital healthcare funding benefits, this plan also offers generous day-to-day and dentistry benefits.
Our Unique
Medical Aid Plan Benefits
Why we are
This plan is ideally suited for individuals/families who require in-hospital cover for planned and emergency hospital admissions, as well as generous day-to-day benefits by means of a Self Managed Fund.
Includes some out-of-hospital cover for X-rays, MRI / CT scans and diagnostic endoscopy (i.e. colonoscopy & gastroscopy). Doctors and specialists are covered at 200% of the Scheme Tariff.
Also includes substantial benefits for basic dentistry – an additional benefit covered by Genesis and not from your own pocket.
You may use any private hospital and doctor or medical specialist in South Africa (no networks).
Our Medical Aid
Package
MED-200 Plus
Hospital Plan
Generous day-to-day Benefits
IN HOSPITAL COVER
(including maternity benefits)
- Cost up to 200% of Scheme Tariff
- Cost up to 100% of Scheme Tariff
- Benefits limited to PMBs
- Claims will be paid in full when obtained from a DSP
- When treated in a non-DSP claims will be paid up to 200% of Scheme Tariff when hospitalised, or the lower of cost or an R1,350 per contact out of the hospital, further limited to R54,000 per beneficiary p.a.
- 100% of cost up to R35,000 per beneficiary p.a.
- The lower of cost or R20,000 per beneficiary p.a. when used for the treatment of fractures
- Subject to approval
- Cost up to 100% of Scheme Tariff
(plain radiography)
- 100% of the lower of cost or Scheme Tariff
- 100% of the lower of cost or Scheme Tariff
- Subject to approval
- Scans related to conservative treatment of back/neck conditions covered up to 50% of the lower of cost or Scheme Tariff, further limited to R8,400 per beneficiary p.a.
- Epidural injection for conservative back and/or neck (spinal/vertebral) condition paid up to 75% of the cost, further limited to R7,500 per beneficiary per annum (all inclusive)
(must be directly related to the reason for admission)
- Cost up to 100% of Scheme Tariff
- Cost up to 200% of Scheme Tariff
Required as a result of major trauma or accident
(excluding tooth implants, conservative dental treatment, fillings, X-rays, tooth extractions, root treatment, dentures, orthodontics, perio-dontal services and related costs)
- Subject to approval
(part of “Basic dentistry” benefit)
- Cost up to 100% of Scheme Tariff for the surgical removal of impacted wisdom teeth, limited to the lower of cost or R15,000 per case
- Cost up to 100% of Scheme Tariff for child beneficiaries, prior to attaining the age of 9 years, for extractions and fillings (once only, lifetime limit), limited to the lower of cost or R10,000 per case
- Subject to Genesis protocols and approval
- Limited to 1 hospital admission per beneficiary p.a.
- Cost up to 100% of Scheme Tariff for material, apparatus and operator’s fees
- 100% of cost up to R300,000 per beneficiary p.a. at Scheme Tariff
- 100% of legislated cost
- Cost up to 200% of Scheme Tariff for qualifying surgical procedures that would otherwise necessitate admission to a hospital
- 100% of cost subject to available SMF balance
Including treatment for obesity & elective or planned procedures not directly caused by or related to illness, accident or disease.
- 100% of cost subject to available SMF balance
- 100% of cost subject to available SMF balance
- In private hospitals, benefits and limits as above
- In public or state hospitals, benefits as prescribed by law
AUXILLARY SERVICES
Whether in hospital or out the following limits apply for diagnostic procedures:
- COLONOSCOPY – The lower of cost or R7 900 per procedure
- GASTROSCOPY – The lower of cost or R5 300 per procedure
- COLONOSCOPY and GASTROSCOPY performed at the same time – R10 300 per event
- All procedures listed above are further limited to two claims per year.
- Pathology services (biopsies) performed during endoscopic procedures will be covered at 100% of the lower of cost or scale of benefits, further limited to R1 750 per beneficiary per annum.
Exception: Where, as a result of any of the procedures listed above, an illness or disease is diagnosed that requires hospitalisation and treatment that qualifies as a benefit in terms of these rules, the Scheme will reimburse the total cost of the procedure/s limited to the lower of cost or Scheme Tariff.
- 100% of cost when using the preferred provider (ER24)
100% of the lower of cost or scale of benefits, subject to the following conditions:
1. Females – 39 years and younger; one such claim per annum
when prescribed by a gynaecologist or general practitioner.
2. Females – 40 years and older; one such claim per annum.
100% of the lower of cost or scale of benefits, subject to the following conditions:
(i) Cervical (PAP) smears – Females 18 years and older; limited to one such test per annum to be done by a gynaecologist or general
practitioner.
(ii) Prostate Specific Antigen (PSA) test – Males 50 years and older; one test per annum.
CHRONIC COVER
- Limited to the extent of the therapeutic algorithms
- 100% of the cost of formulary drugs
OUT OF HOSPITAL COVER
- R10,800 per adult p.a.
- Pro-rated and advanced quarterly
- 100% of legislated cost subject to available SMF balance
- 100% of cost subject to available SMF balance
General practitioners & medical specialists
Speech therapy & audiology
Chiropractic services
Dietician’s services
Psychologist
Social worker
Physiotherapy / Biokinetics
Optometrist
Alternative treatments
Homeopath & related services
- Cost up to 200% of Scheme Tariff subject to available SMF balance
- 100% of cost subject to available SMF balance
- Cost up to 200% of Scheme Tariff subject to available SMF balance
- 50% of the lower cost or Scheme Tariff, limited to R5,800 per beneficiary p.a.
- 50% of the lower cost or Scheme Tariff, limited to R8,400 per beneficiary p.a.
Covered at the lower of cost or Scheme Tariff for the following qualifying dental benefits (per beneficiary p.a.) when obtained from a registered Dental Practitioner:
- Three (3) dental oral examinations
- Six (6) fillings
- Tooth extractions
- Plain X-rays and/or wide angle or Panorex imaging as required in the ordinary course for conservative dentistry limited to the lower of cost or scale of benefits further limited to R750 per beneficiary per annum.
- Two (2) root canal treatments, excluding root canal treatment on wisdom teeth
- Crowns, bridges or dentures limited to the lower of cost or Scheme Tariff, further limited to R5,750
- Surgical removal of impacted wisdom teeth, where pathology and pain are directly associated with wisdom teeth
- Two (2) scales and polishing
- One (1) dental implant is limited to R10,000 per three-year financial year cycle of membership.
(i.e. orthodontic work)
- 100% of cost subject to available SMF balance
MAJOR MEDICAL ILLNESSES COVER
- In- and out-of-hospital benefits for oncologist consultations, chemotherapy, radiotherapy (including brachytherapy), MRI / CT / PET and bone scans, pathology tests, medication and materials up to R275,000 per beneficiary p.a.
- Cost of immunosuppressant medication up to R84,000 per beneficiary p.a.
Accommodation, Homecare visits, Home visits by a medical practitioner
- 100% of the cost
- R200 per day
- Cost up to 100% of Scheme Tariff
Why we are
#thesmartchoice
Premium benefits
at fair rates
We are the
people’s choice
Known for
lowest increases
Choose your trusted
doctor / hospital
Important information
on our Medical Aid Plan
Benefits reflected in this schedule are for the full benefit year and will be pro-rated for those members joining Genesis during the benefit year.
Our Scheme Tariff
What our
members say
Let's clear things up and give you
Peace of mind
Get in touch
Please feel free to contact us by filling the form below
Can any person belong to Genesis?
Yes. Membership of Genesis is open to any person who is a citizen of South Africa or permanently residing in South Africa.
Foreign students wishing to study in South Africa and who wish to apply for membership in order to get a visa, are not eligible for membership of the Scheme.
Are my contributions based on my monthly salary?
No. All our benefit options provide significantly more coverage than the basic cover that are provided on some of the income-based options in the market. Genesis contributions are therefore not based on monthly salary bands and, depending on the selected benefit option, all adult members pay the same monthly contribution.
Cheap medical aid cover may be available on certain income-based medical cover options from some of the other medical aid schemes in South Africa. Although income-based medical aid options in South Africa can be good choices, their suitability depends on your healthcare needs, budget and expectations.
Is Genesis a Company registered in terms of the Companies Act?
No. Genesis is a medical scheme registered during May 1995 in terms of the Medical Schemes Act.
Who owns Genesis?
As with all medical schemes, Genesis is owned by all its members. Members elect Trustees who act on their behalf. The Trustees form the management committee of the Scheme and are elected to serve in the best interest of all the members.
Can any person belong to Genesis?
Yes. Membership of Genesis is open to any person who is a citizen of South Africa or permanently residing in South Africa.
Foreign students wishing to study in South Africa and who wish to apply for membership in order to get a visa, are not eligible for membership of the Scheme.
Is Genesis a new generation scheme?
YES. A new generation medical aid scheme differs from a traditional scheme in that the scheme is primarily concerned with the costs associated with in-hospital treatment and procedures. Most out-of-hospital medical costs are paid from your day-to-day credit facility via a Self Managed Fund (SMF).
Essentially out-of-hospital costs are for your account and the Scheme merely provides the credit facility and administers the claims on your behalf.
As a member of a new generation scheme, you are responsible for managing most of your out-of-hospital medical cover and costs, while the Scheme provides for the higher costs associated with hospital care.
Who provides financial backing for Genesis?
The Medical Schemes Act prevents medical aid schemes in South Africa from borrowing money. It follows that no medical scheme has financial backing. The success of a scheme is dependent on various factors, including the structure of its benefits, pricing of its premiums, management of its day-to-day activities, the risk of its members and its solvency reserves.
All medical schemes maintain a pool of funds that is used to pay claims. The success of any scheme lies in the ability of a scheme to maintain that pool of funds at a level that is sufficient for its members’ claims.
In South Africa, medical schemes are legally required to maintain a minimum solvency level of 25% of their annual contributions – this is stipulated in Regulation 29 of the Medical Schemes Act.