DESIGNATED SERVICE PROVIDERS (DSP)

DSP agreement with Western Cape Government

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.

Availability of beds in the public sector

Where you have elected to seek treatment in a public sector facility and there are no beds available, then you must obtain a letter from the medical manager of the hospital, stating that there is no bed available for you on a particular day.  This letter must be sent to Genesis and you may then select a private hospital to have your PMB condition treated.  Your claim will then be paid in full, subject at all times to the treatment being at the same level of care as that available to a public hospital patient.

NAME OF HOSPITAL PLACE
Alan Blythe Hospital Ladismith
Alexandra Hospital Maitland
Beaufort West Hospital Beaufort West
Caledon Hospital Caledon
Ceres Hospital Ceres
Citrusdal Hospital Citrusdal
Clanwilliam Hospital Clanwilliam
Eerste River Hospital Eerste River
False Bay Hospital Fish Hoek
GF Jooste Hospital Manenberg
Groote Schuur Hospital Observatory
George Hospital George
Helderberg Hospital Somerset West
Hermanus Hospital Hermanus
Karl Bremer Hospital Bellville
Khayelitsha Hospital Khayelitsha
Knysna Hospital Knysna
Laingsburg Hospital Laingsburg
Lentegeur Psychiatric Hospital Lentegeur, Mitchells Plain
Lapa Munnik Hospital Porterville
Mitchells Plain Hospital Lentegeur
Murraysburg Hospital Murraysburg
Montagu Hospital Montagu
Mossel Bay Hospital Mossel Bay
Mowbray Maternity Hospital Mowbray
NAME OF HOSPITAL PLACE
New Somerset Hospital Green Point
Otto Du Plessis Hospital Bredasdorp
Oudtshoorn Hospital Oudtshoorn
Paarl Hospital Paarl
Prince Albert Hospital Prince Albert
Radie Kotze Hospital Piketberg
Red Cross Children’s Hospital Rondebosch
Riversdale Hospital Riversdale
Robertson Hospital Robertson
Stellenbosch Provincial Hospital Stellenbosch
Swartland Hospital Malmesbury
Stikland Psychiatric Hospital Bellville
Swellendam Hospital Swellendam
Tygerberg Hospital Tygerberg
Tygerberg Hospital Oral Health Centre Tygerberg
Mitchells Plain Oral Health Centre Lentegeur, Mitchells Plain
Uniondale Hospital Uniondale
Valkenburg Psychiatric Hospital Observatory
Victoria Hospital Wynberg
Vredendal Hospital Vredendal
Vredenburg Hospital Vredenburg
Western Cape Rehabilitation Centre – Lentegeur Hospital Lentegeur, Mitchells Plain
Westfleur Hospital Atlantis
Worcester Hospital Worcester

Emergencies

Please note that the information above does not apply to emergency treatment.

An emergency is any life-threatening condition which, without immediate treatment, will or may result in the loss of your life. Note that there is a difference between urgent treatment and an emergency. A condition that requires urgent treatment is not necessarily an emergency. An emergency is a condition that requires immediate treatment. In the case of an emergency, you will be admitted to the nearest hospital, regardless of whether it is private or public and Genesis will cover the claim in full.