Genesis Private medical aid plan: 2017

Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB. Pay for all children.

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • Scans related to conservative treatment of back and neck covered up to 50% scheme rate, and limited to R6,000 per person
Supplementary Services: (Physio, etc)
Transplants:
  • Limited to R550,000 per person for admissions related to cancer, stroke, motor-neuron disease and organ transplant
  • Cost of immunosuppressants: R84,000
Co-payments:
  • External medical appliances: 25% of cost copayment
Alternatives to hospitals:
  • Hospice: 100% of cost
  • Home care visits: R200 per day
  • Home visits by medical practitioner: 100% scheme rate

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Surgical procedures in doctor's rooms: covered for qualifying procedures that would otherwise necessitate admission to hospital
  • Otherwise, no benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • Scheme pays 50% of scheme rate, limited to R6,000 per person
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Consultations:
  • No benefit
Scans:
  • No benefit

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • Oncologist consults, chemotherapy, radiotherapy, MRI/CT/PET and bone scans, pathology and materials: R210,000 per person
  • Subject to overall limit of R550,000 for cancer, stroke, motor-neuron disease and organ transplant

Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry: R25,000 per person. Includes:
  • Consultations, fillings, extractions, plain x-rays, root canals, wisdom tooth removal
  • Crowns, dentures or bridges: Sub-limit of R3,200
  • In-hospital removal of wisdom teeth: R9,000 per case
  • In-hospital: extractions and fillings for children under 9yrs. Once per lifetime, limited to R9,000
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • Paid by scheme if due to major trauma or accident at 200% Scheme Tariff

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • No benefit
Notes:
  • Scheme pays 100% of cost for medicines on the formulary

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OPTOMETRY:
Optometry:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • 3 days per person in hospital and 18 days in registered health establishment
  • Limited to R36,000 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:

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OTHER BENEFITS:
General Appliances:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport: ER24
International Coverage:
  • No benefit
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Pneumonia vaccines:
  • No benefit
Back Rehabilitation Programme:
  • No benefit
Biometric Screening:
  • No benefit
Child Immunisation:
  • No benefit
Pap Smear:
  • No benefit
Mammogram:
  • No benefit
PAS Test:
  • No benefit
HIV Test:
  • No benefit

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Sub-limits:

    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised