Unless expressly stated to the contrary, all Genesis members have the luxury to choose their preferred hospital, doctor or medical specialist along with a choice of funding model. Members are not forced to seek treatment in network hospitals, nor are they required to make use of network medical practitioners.
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 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.