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.
Medical Aid Rate (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.
Benefits are subject to Genesis issuing a hospital admission reference number.
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 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 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.
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.
