DESIGNATED SERVICE PROVIDERS (DSP)

Genesis has entered into a Designated Service Provider (DSP) contract with the Western Cape Government in May 2019.

The Medical Schemes Act (“the Act”) is the legislation governing all aspects of a medical scheme. This Act lists a set of some 270 mostly hospital-based conditions as Prescribed Minimum Benefits (PMBs). This means that, regardless of the option you have chosen to join, Genesis must provide benefits for these conditions. In addition to this list of 270 conditions are a further 25 chronic conditions which must also be covered by Genesis.

The Act prescribes that medical schemes are not allowed to limit reimbursement for the treatment of these conditions when they are obtained from a public hospital. In other words, a medical scheme must provide for cover for at least what is available in a public sector hospital. Where treatment for these conditions is obtained from a private hospital, then the limits set out in the rules of Genesis apply. These rules may differ, depending on your benefit option.

If you need treatment for one of these PMB conditions in a public hospital, then Genesis cannot limit the reimbursement, provided that the treatment you receive is the same treatment that is available to any patient that does not have medical aid. Under these circumstances, your claim from the hospital (including treatment by doctors) will be paid in full. Kindly note that the referral protocol is applied in the public sector at hospital level, unless it is an emergency.

If you, however, choose to be treated in a private hospital for one of the PMB conditions, then your claim will be subject (and may be limited) to the benefits that apply to your benefit option.

All Genesis benefit options make provision for all private hospital accounts relating to the treatment of PMB conditions to be paid in full (except for specific exclusions listed in the rules, or in the case of personal expenses).

It is important to remember that, unlike treatment received in a public hospital, your private hospital account does not include the treatment that you receive by doctors (or other healthcare providers). These charges are billed for separately by each and every doctor. Here too, the limits as set out in the rules of Genesis will apply. According to these rules, Genesis will reimburse claims at 100% of the Genesis tariff for members on the Private Choice Option and at 200% of the Genesis tariff on all other benefit options. This means that if you elect treatment in a private hospital and your doctor charges more than the Genesis tariff, you will be liable for the co-payment (difference in cost). Although the majority of doctors’ charges usually fall within the Genesis tariffs, there may be some doctors who will charge above these rates. It is therefore important that you find out from the doctor(s) that will be treating you in hospital as to what their charges will be and are aware of any co-payments that may apply.

Please note that the DSP arrangement with the Western Cape Government does not mean that you must or can only be treated in a public sector hospital. It simply protects Genesis and its members from health service providers in the private sector who charge excessively for their services when the condition is a PMB.