Hospital Plans

Our affordable hospital plans provide excellent healthcare funding benefits for mainly in-hospital benefits and also include generous dentistry benefits.
Hospital Plans

Our unique
HOSPITAL PLAN benefits

Our hospital 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.

Both hospital plans include substantial benefits for basic dentistry – an additional benefit covered by Genesis and not from your own pocket.

Our MED-200 option provides some out-of-hospital benefits for X-rays, MRI / CT scans and diagnostic endoscopy (i.e. colonoscopy & gastroscopy).

Our HOSPITAL PLAN Packages

MED-100

Hospital Plan
Some day-to-day Benefits

(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 R1,100 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.
  • 75% of cost up to R19,000 per member family 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 R2,750 per scan
  • Up to two (2) scans per member family p.a., further limited to R7,750 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 authorisation

(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

Including treatment for obesity & elective or planned procedures not directly caused by or related to illness, accident or disease.

  • No benefit
  • In private hospitals, benefits and limits as above
  • In public or state hospitals, benefits as prescribed by law

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.

  • Limited to the extent of the therapeutic algorithms
  • 100% of the cost of formulary drugs

  • 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

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 R5,500
  • Surgical removal of impacted wisdom teeth, where pathology and pain are directly associated with wisdom teeth
  • One (1) scale and polish
  • 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

(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 R1,100 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.
  • 75% of cost up to R19,000 per member family 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 R5,000 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 authorisation

(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 member family 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

Including treatment for obesity & elective or planned procedures not directly caused by or related to illness, accident or disease.

  • No benefit
  • In private hospitals, benefits and limits as above
  • In public or state hospitals, benefits as prescribed by law

  • R7,000 per procedure for colonoscopy (all inclusive)
  • R4,500 per procedure for gastroscopy (all inclusive)
  • R9,000 per event when colonoscopy and gastroscopy are performed at the same time (all inclusive)
  • R1,500 per beneficiary p.a. for pathology services related to endoscopy benefits.

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.

  • Limited to the extent of the therapeutic algorithms
  • 100% of the cost of formulary drugs

  • 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
  • 50% of the lower of cost or Scheme Tariff, limited to R5,250 per beneficiary p.a.
  • 50% of the lower cost or Scheme Tariff, limited to R8,000 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 Medical Aid Rate, further limited to R5,500
  • Surgical removal of impacted wisdom teeth, where pathology and pain are directly associated with wisdom teeth
  • One (1) scale and polish
  • One (1) dental implant is limited to R10,000 per three-year financial year cycle of membership.

(i.e. orthodontic work)

  • 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 R250,000 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 HOSPITAL 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.

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

This means the fixed tariff determined by Genesis for the payment of relevant health services/benefits in accordance with the Rules of the Scheme or the fee determined in terms of any agreement between the Scheme and a service provider(s) in respect of the payment of relevant health services.

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You don’t have to make use of any network hospitals or doctors. As a member of Genesis, you have the freedom to choose any private hospital in South Africa. You may also be treated by any doctor or specialist that is registered by the Health Professions Council of South Africa.

It is important to note, however, that the use of private providers (even for PMBs), may have limits on the reimbursement of doctors.

Genesis covers all approved conditions, including Prescribed Minimum Benefits (PMBs), in private hospitals, where the benefits and limits, as set out in the Rules, apply. Hospital accounts, including treatment for PMBs, 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, even for PMBs, will be reimbursed at 100% or 200% of the Scheme Tariff, depending 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 hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply.

In addition, Genesis has selected every public hospital in the country as its DSP.

View the full list of 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.

Bear in mind that this does not mean that you must or can only be treated in a public sector hospital. PMB treatment in public hospitals simply protects Genesis and its members from health service providers who charge excessively for their services when the condition is a PMB. The choice, however, remains yours.

Waiting periods are not always imposed when joining Genesis. It is done at the Scheme’s discretion after assessing the health profile of the applicant and is used as a measure to prevent people from joining the Scheme purely because they have to go to the hospital in the near future. There are two kinds of waiting periods, i.e.:

  • General waiting period of up to three months – during this period, members have to pay their normal monthly contributions, but are not entitled to claim any benefits whatsoever, except in certain instances with claims relating to PMBs and in which instance the treatment and / or service have to be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply.

  • Condition-specific waiting period of up to 12 months – during this period, members have to pay their normal monthly contributions, but any pre-existing health condition(s) will be excluded and all medical costs associated during the first 12 months will be for the member’s own pocket, except in certain instances with claims relating to PMBs and in which instance the treatment and / or service have to be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply.

The table below provides a summary of the provisions applicable to waiting periods as per the Medical Schemes Act:

Category 3-Months General Waiting Period 12-Months Condition Specific Waiting Period
New applicants who are currently members of another registered SA medical scheme for more than 2 years, and / or who have not cancelled their membership for more than 90 days preceding the date of application Yes
New applicants who are members of a registered SA medical scheme for less than 2 years Yes
New applicants, or applicants who are not members of a registered SA medical scheme for at least 90 days preceding the date of application Yes Yes
Change of benefit options
Child dependants born during the period of membership

Genesis may apply premium penalties to applicants who have not been a member(s) of a recognised SA medical scheme after the age of 35. These premium penalties shall not exceed the following bands:

genesis-medical-scheme-late-joiner-penalties-table

The MMI benefit (for the treatment of cancer, stroke, motor neuron disease and organ transplant(s)) is designed to provide cover for expenses that are both in and out of the hospital, or postoperative.

The MMI benefit on the MED-200 and MED-200 Plus options will cover costs related to in and out of hospital oncologist consultations, chemotherapy, radiotherapy (including brachytherapy), oncology related MRI/CT/PET and bone scans, pathology tests, medication and materials used in treatment, limited to R250 000 per beneficiary per annum.

Out of hospital MMI benefits on the MED-100 option are limited to PMBs in public hospital only.

Unfortunately not. Option changes are allowed once a year only and the change must be effective from the 1st of January, providing the Scheme is notified in writing within the notice period stipulated by the Scheme.

No.  All approved conditions are covered in terms of the benefits and limits as set out in the Scheme Rules.  Where service providers charge more than the Scheme Tariff, you may have a co-payment(s).

Genesis covers all approved conditions, including Prescribed Minimum Benefits (PMBs), in private hospitals, where the benefits and limits, as set out in the Rules, apply. Hospital accounts, including treatment for PMBs, 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, even for PMBs, 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. 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 to the Act.