Hospital Plans
Our affordable hospital plans provide excellent healthcare funding benefits for mainly in-hospital benefits and also include generous dentistry benefits.
Our Unique
Hospital Plan Benefits
Our hospitalisation plans will cover you in hospital for planned and emergency hospital admissions.
You may use any private hospital and doctor or medical specialist in South Africa (no networks).
Doctors and specialists are covered at 100% of the Scheme Tariff on the MED-100 option and at 200% of the Scheme Tariff on the MED-200 option.
Our Hospital Plan
Packages
Med-100
Hospital Plan
Some day-to-day Benefits
IN HOSPITAL COVER
(including maternity benefits)
- Cost up to 100% 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 100% of Scheme Tariff when hospitalised, or the lower of cost or an R1,250 per contact out of the hospital, further limited to R42,000 per beneficiary p.a.
- 50% of cost up to R20,000 per beneficiary p.a.
- The lower of cost or R19,000 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
- Member has a co-payment of R3,000 per scan
- Dento-alveor procedures and conservative treatment of back/neck conditions excluded
- No benefit
(must be directly related to reason for admission)
- Cost up to 100% of Scheme Tariff
- Cost up to 100% 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
- No benefit
- 100% of the legislated cost
- Cost up to 100% of Scheme Tariff for qualifying surgical procedures that would otherwise necessitate admission to a hospital
- No benefit
Including treatment for obesity & elective or planned procedures not directly caused by or related to illness, accident or disease.
- No benefit
- No benefit
- In private hospitals, benefits and limits as above
- In public or state hospitals, benefits as prescribed by law
AUXILLARY SERVICES
- No benefit
- 100% of the 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.
- No benefit
- 100% of the 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
- Limited to the extent of the therapeutic algorithms
- 100% of the cost of formulary drugs
OUT OF HOSPITAL COVER
- No Benefit
General practitioners & medical specialists
Speech therapy & audiology
Chiropractic services
Dietician’s services
Psychologist
Social worker
Physiotherapy / Biokinetics
Optometrist
Alternative treatments
Homeopath & related services
- No Benefit
- No Benefit
- No Benefit
- No Benefit
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 limited to R10,000 per three year financial year cycle of membership.
(i.e. orthodontic work)
- No Benefit
Med-200
Hospital Plan
Some 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 R1,250 per contact out of the hospital, further limited to R42,000 per beneficiary p.a.
- 100% of cost up to R30,000 per beneficiary p.a.
- The lower of cost or R19,000 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 R8,000 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 the legislated cost
- Cost up to 200% of Scheme Tariff for qualifying surgical procedures that would otherwise necessitate admission to a hospital
- No benefit
Including treatment for obesity & elective or planned procedures not directly caused by or related to illness, accident or disease.
- No benefit
- No benefit
- 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 500 per procedure
- GASTROSCOPY – The lower of cost or R5 000 per procedure
- COLONOSCOPY and GASTROSCOPY performed at the same time – R9 750 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 Scheme Tariff, further limited to R1 650 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 the 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.
Whether in hospital or out the following limits apply for diagnostic procedures:
- COLONOSCOPY – The lower of cost or R7 500 per procedure
- GASTROSCOPY – The lower of cost or R5 000 per procedure
- COLONOSCOPY and GASTROSCOPY performed at the same time – R9 750 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 Scheme Tariff, further limited to R1 650 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 the 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
- Limited to the extent of the therapeutic algorithms
- 100% of the cost of formulary drugs
OUT OF HOSPITAL COVER
- No Benefit
General practitioners & medical specialists
Speech therapy & audiology
Chiropractic services
Dietician’s services
Psychologist
Social worker
Physiotherapy / Biokinetics
Optometrist
Alternative treatments
Homeopath & related services
- No Benefit
- No Benefit
- No Benefit
- No Benefit
- 50% of the lower of cost or Scheme Tariff, limited to R5,500 per beneficiary p.a.
- 50% of the lower cost or Scheme Tariff, limited to R8,000 per beneficiary p.a.
- 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)
- No Benefit
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
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Important information
on our HOSPITALISATION PLANS
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
Find out more
- 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.
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
Does a hospital plan fall under medical scheme cover?
YES – in South Africa a hospital plan (sometimes called a hospitalisation plan) does fall under medical aid cover. It is one of the options or benefit types that a registered medical aid scheme can offer. Hospital plans typically cover medically appropriate in-hospital treatment in line with the registered benefits of each plan option, for example, if you are admitted to a hospital for planned or emergency treatment, your hospital plan will cover the cost of doctors, specialists, theatre, medication, X-rays, blood tests, etc.
What is usually covered by a hospital plan?
Hospital cover plans in South Africa will provide cover for mainly in-hospital and related expenses. It does not typically provide cover for out-of-hospital (day-to-day) benefits like doctors’ visits, acute medication, physiotherapists, etc.
Some hospital plans may also cover certain out-of-hospital expenses, for example both our MED-100 and MED-200 hospital plans offer generous out-of-hospital dental benefits, as well as cover for preventative screening tests such as mammograms, cervical smears and PSA tests. In addition, our MED-200 hospital plan also provides cover for X-rays / MRI / CT scans, as well as diagnostic scopes such as colonoscopies and gastroscopies.
Are hospital cover plans more affordable?
YES – hospital plans in South Africa are generally more affordable that comprehensive medical aid benefit options because “everyday” out-of-hospital expenses, such as GP visits, medication, spectacle frames and lenses, physiotherapy, etc. are not included in the cover. Hospital plans, however, do provide excellent financial healthcare funding for what is best described as primarily catastrophic cover – that is, the big accident or unexpected illness or disease.
Hospital and related accounts, such as theatre costs, X-rays, medication, blood tests, blood transfusions, etc., will usually be covered in full, even on the cheapest hospital plan in South Africa. Hospital cover plans will reimburse doctors’ and specialists’ fees at the medical scheme rate, i.e. 100% or 200%.
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.
Is Genesis a new generation scheme?
Yes. A new generation 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 costs, while the Scheme provides for the higher costs associated with hospital care.
Who provides financial backing for Genesis?
The Medical Schemes Act prevents a medical scheme 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; hence the solvency requirements of a scheme as required by the Medical Schemes Act.