What is the Scheme Tariff”?
Scheme tariff (“Genesis Rate”) 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.
Will I get a waiting period?
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||–||–|
Will I pay a Late Joiner Penalty (LJP)?
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:
Who are your network hospitals and / or doctors?
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 Medical Aid Rate, 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 Medical Aid Rate.
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 addition, Genesis has Designated Service Provider (DSP) agreements with the Western Cape and Gauteng Departments of Health.
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.
If in any doubt, please call our Client Services Department on telephone number 0860 10 20 10 or via email to firstname.lastname@example.org.
When will I receive my membership card?
Physical membership cards are no longer printed. Members and dependants are encouraged to use their electronic membership card(s) on their Genesis Smartphone App(s).
The electronic membership card is accepted by the four major hospital groups (MEDICLINIC, NETCARE, NATIONAL HOSPITAL NETWORK and LIFE Health Care) in South Africa, as well as the majority of pharmacies or other service providers.
In addition, the card can be emailed directly from your smartphone to a service provider for their record keeping or admission purposes. Alternatively, a photocopy of the electronic membership card can also be made by placing your smartphone directly on a photocopy machine (do not close the lid).
For further assistance regarding your membership card(s), please direct your query to email@example.com.
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.
My child is still studying. Will I pay child rates for him / her?
The Rules provide that any person over the age of 21 years no longer qualifies as a child dependant.
Can I add my grandson / -daughter as a dependant on my medical scheme?
Yes, you may, if you are liable for his / her care and support. Unless he / she is placed in your legal custody, you will however pay adult contributions for your grandchild.
I am pregnant. Will I have a waiting period?
If you are not a member of a medical scheme at the time of falling pregnant, your membership may be subject to a 3 months general waiting period, as well as a 12 months waiting period on your pregnancy and confinement. Read more
Are my contributions based on my monthly salary?
No. Contributions are not based on monthly salary bands. Depending on the selected benefit option, all adult members pay the same monthly contribution.
Do you cover extreme sport?
Generally speaking, most sport injuries will be covered, provided that the necessary safety precautions were followed at the time of an accident, however, medical expenses incurred in respect of the following extreme sport shall not be covered by Genesis.
► Motorised speed contests
► Speed trials or the use of quad bikes and the like (*)
Savings account / Self Managed Fund (SMF) facilities, where applicable and to the extent available, may be used to cover expenses where indicated.
(*) The Board may, in its sole discretion and on such terms and conditions as it may alone determine, grant exemption from the operation of this rule, in periods not.exceeding 12 months at a time to any beneficiary after suitable motivation requesting such exemption.
Will you cover the cost of an ambulance or helicopter?
Yes, if the preferred provider (ER 24) is used in the event of an emergency medical condition. In this regard, the condition has to be sudden and, at the time an unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such medical or surgical treatment, could result in serious impairment of bodily functions or serious dysfunction of a bodily organ or part, or could place the person’s life in serious jeopardy.
Do you offer gym membership?
As part of our continuous drive to offer real value to our members, Genesis and Planet Fitness have agreed to a deal that offers Genesis members a tailored opportunity to take care of their extended health and welfare needs. All Genesis members qualify for a 20% discount on gym membership at any Planet Fitness club in South Africa.
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.
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 Savings or Self Managed Fund (SMF) Account.
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.
Is Genesis financially sound?
The best measure of this is the solvency requirement as required by the Medical Schemes Act. The Act requires a minimum solvency of 25% to be maintained by all medical schemes. Currently Genesis has built up reserves far in excess of the legal minimum requirements and is able to boast a very high claims paying ability to help put your mind at rest.
What is a “solvency ratio”?
The Medical Schemes Act requires medical schemes to have reserves of at least 25% of the total contributions paid by members in a year. The higher the solvency ratio, the greater the ability of the scheme to pay your claims.
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.
How does my Self Managed Fund (SMF) benefit work?
Unless expressly stated to the contrary, members on the Private Comprehensive benefit option may use their SMF benefit to pay for their and / or their registered dependants’ day-to-day medical expenses.
At the beginning of each three months period in any financial year, the Scheme will make available a SMF benefit not exceeding three times the monthly SMF contribution that is included in your monthly contribution. In addition, any amount unused from a previous three month period in the same financial year, will be added to your available SMF balance.
The SMF benefit of those members joining the Scheme during a financial year, will be prorated to the end of the applicable three month period of that financial year.
At the end of each financial year, any unused balance in the SMF will be forfeit to the Scheme after first settling any qualifying expenditure, relating to treatment / service rendered in the particular year, submitted to the Scheme within four (4) months after that particular financial year end.
When are my benefits pro-rated?
When you join Genesis during the financial year (e.g. not in January), certain stated benefits, such as your Self Managed Fund (SMF) (Private Comprehensive option), in-hospital dental treatment, internal medical / surgical appliances or prosthetics, etc., will be pro-rated.
An example of this is your SMF benefit. If you join the Scheme on 1 July, you will effectively have half of the annual SMF benefit.
What benefit do I get for internal prosthesis?
The benefit for internal medical / surgical appliances or prosthetics is limited to R30 000 per beneficiary per annum on the Private and Private Comprehensive options.
The benefit for internal medical / surgical appliances or prosthetics is limited to 50% of the cost up to R20 000 per beneficiary per annum on the Private Choice option.
What benefit do I get for external prosthesis?
The benefit for external medical / surgical appliances only applies to certain external appliances such as a Taylor spatial frame and is further limited to 75% of the cost up to R19 000 per member family per annum on all benefit options.
When does Genesis pay for MRI / CT Scans?
Genesis Medical Scheme will cover the costs of MRI / CT scans at 100% of the lower of cost or Scheme Tariff if you are hospitalised with an acute / emergency medical condition and where, in the opinion of the Scheme, the motivation from the attending practitioner confirms that the scan is clinically indicated for the urgent assessment and treatment of that condition.
Scans related to the conservative treatment of back / neck conditions, or which, in the opinion of the Scheme, could otherwise have been done out of hospital, will be covered at 50% of the lower of cost or Scheme Tariff, further limited to R7 600 per beneficiary per annum on the Private and Private Comprehensive benefit options.
If you are a member of the Private Choice option you will have a co-payment of R 2 750 per scan (if done in hospital) with a limit of 2 scans per family per annum. Scans will further be limited to a benefit of R7 350 per scan. There is no benefit for out-of-hospital scans. Expressly excluded from payment on the Private Choice benefit option, are scans related to dental conditions, conservative back treatment, migraine and diagnostic purposes.
Requests for all scans need to be clinically motivated by the attending practitioner and authorised by the Scheme before commencement of the investigations.
How does the Major Medical Illness (“MMI”) benefit work?
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 hospital, or post-operative. The MMI benefit on the Private and Private Comprehensive options has an overall limit of R550 000 per beneficiary per annum, with sub-limits for certain treatment protocols.
The in-hospital MMI benefit on the Private Choice option are limited to R50 000 per beneficiary per annum. Out-of-hospital MMI benefits on the Private Choice option is further limited to statutory Prescribed Minimum Benefits (PMBs).
Should membership be subject to a 3 months general waiting period and the member has access to Prescribed Minimum Benefits (PMBs), these benefits will only be available from a public / state facility. Should you have specific questions about this benefit, please contact Genesis directly.
Are scaling and polishing covered as part of the dental benefit?
Am I covered for a vasectomy?
All forms of sterilisation are funded from your available Self Managed Fund (SMF) balance (members on the Private Comprehensive option).
Am I covered for mammograms as a preventative measure?
All forms of preventative screening are funded from your available Self Managed Fund (SMF) balance (members on the Private Comprehensive option).
How do I register for chronic medication?
The prescribing doctor must first contact our Chronic Medication department on 0860 10 62 03 to register you.
At what rate will my claims be paid?
Hospital and related accounts for all approved conditions (e.g. theater costs, X-rays, pathology, physiotherapy, blood transfusion, medicines, etc.) will be covered at 100% of Scheme Tariff for a general ward or intensive and high care wards of a private or provincial hospital, day clinic or the recovery room charges of an unattached operating theater.
Whilst in hospital, the Scheme will reimburse general practitioners and specialists at cost up to 100% of Scheme Tariff on the Private Choice option.
On the Private and Private Comprehensive options, general practitioners and specialists will be reimbursed at cost up to 200% of Scheme Tariff.
Statutory Prescribed Minimum Benefits (PMBs) in private hospitals are covered as per the Scheme Rules; in public or state hospitals, benefits are covered as prescribed by law.
Are all claims always settled in full?
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 that 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 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 Medical Aid Rate. 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. If in any doubt, please call our Call Centre for further information.
When does a claim become stale?
Claims received by Genesis later than the last day of the 4th month following the month in which the service was rendered, will be regarded as stale and will not be paid. Members must check their statements for missing claims. The Scheme cannot be held responsible for postal delays.
How must I submit a claim?
Genesis will accept signed claims by the principal member via e-mail, fax, post or by hand. Where a member has paid an account, please attach the receipt to the claim. Claims can be scanned and e-mailed to firstname.lastname@example.org or faxed to 021 447 4707.
Alternatively, a good quality photo (image) of the claim, clearly indicating your membership details, may also be emailed to email@example.com, or sent to the Scheme directly from your Smartphone App.
Always ensure that you insert your membership number in the “Subject line” of claims that are sent via email.
Monthly statements will be sent to each member that has claimed in that month. Alternatively, members can login to the secured member section on our website or mobile app to view the status of their claims.
We encourage members to check that the services were in fact rendered to them or their dependants.
How often does Genesis pay claims?
Claims are paid at the end of each month.
Must I pre-notify Genesis of hospital admission?
Yes. In-hospital benefits are always subject to Genesis issuing a hospital admission reference number.
This policy is in place to help members who are subject to waiting periods and to assist the Scheme in managing costs associated with the hospital event.
Contact the Scheme on 0860 10 62 05, seventy two (72) hours prior to admission.
In the event of an emergency, or after hours, members must notify the Scheme by no later than the first working day following such admission.
A co-payment of R7 500 will be levied on all qualifying hospital events that were not pre-approved (excluding emergencies).
Must I pay the pharmacy and claim a refund from the Scheme?
No. Approximately 97% of all pharmacies are linked electronically to Genesis and they are able to verify your membership online. The pharmacy will claim directly from Genesis.
Other medical providers are able to confirm benefits with Genesis and there should be no need to pay upfront. Some doctors however do not accept any medical schemes and will insist on payment upfront. Genesis will refund you for qualifying expenses.
When are contributions reviewed?
Generally contributions are adjusted to cater for inflation etc. on the 1st of January each year.
What are the contributions for 2021?
|Hospital cover medical aid plans||Comprehensive medical aid plan|
|Main member||R1 340||R1 850||R2 640|
|Adult dependant||R1 340||R1 850||R2 640|
On what date do you collect my debit order?
Debit orders are collected on the first day of every month, other than a Sunday or a public holiday.
Can my debit order be deducted before the 1st of every month?
No. Should you wish to pay your contribution on or before the 1st of every month, you may action a stop order with your bank.
What must I do to change my debit order details?
Can I change my benefit option during the year?
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 before 30 September of the previous year.
I have not claimed once from the Scheme. I now want to cancel my membership. Do I get my contributions refunded to me?
No. Your medical scheme is a form of insurance providing cover in case you need it. Even if you do not claim, the Scheme is still at risk in case you do claim.
My spouse / partner / dependant / principal member died. What should I do?
If a dependant dies then we only require the death certificate. If the principal member dies then Genesis would require a new application form.
How do I go about adding a dependant?
You need to complete the “Dependant Form” (found on the Forms page). If you are adding a newborn baby Genesis would require a copy of the birth certificate.
Am I covered for overseas travel?
No, but most major credit card companies include emergency insurance when their card is used for payment of overseas travel. Check with your credit card company or travel agent.
If I leave my employer must I resign from Genesis?
Your membership of Genesis is in your individual capacity and your employment has no effect on your membership. When you leave your employer, you may continue your membership of Genesis by simply advising us of this fact and making suitable arrangements for payment of your contribution.
What do I need to do should I wish to cancel my membership?
A member may terminate his / her membership of the Scheme by giving one month’s written notice. All rights to benefits cease after the last day of membership (Rule 13.1.1).
Will I owe the Scheme money if I cancel my membership during the year?
Yes in the event that your savings facility has been depleted before you resign. This will result in the facility being overdrawn.
Do you offer Gap cover?
No. Gap cover is a short-term insurance product which falls outside the ambit of the Medical Schemes Act. It is a separate insurance product that may be purchased in addition to medical aid cover.