What does a primary healthcare plan offer?

Quality medical care may seem a distant dream for approximately 85% of South Africans, who can’t afford medical scheme coverage. However, a primary healthcare plan may be a cost-effective solution.

We examine what primary healthcare (PHC) plans are, what they cover, and how to make sense of the benefits.

Tip: If you need to pay medical costs out of your pocket, it helps to have savings. Start contributing towards a savings plan today.

What is a primary healthcare plan?

Primary healthcare is an insurance plan that offsets the cost of access to essential healthcare services, such as visiting a doctor or clinic. It ensures that basic healthcare needs can be met in a private healthcare setting, removing some of the burden on state facilities.

“You don’t have to wait for two days to see a doctor at a state hospital – you can now see a doctor at a private practice immediately,” says Michael Emery, marketing executive at Unity Health, one of a dozen or so companies offering this type of insurance.  

This is good news for South Africans currently using the public health network who can’t afford to pay medical aid premiums, which usually cost R2,000-plus per month.

“Private medical costs have risen well above inflation for the past two decades,” notes Jessica Bates, general manager of Dis-Chem Health. “There is a growing demand for medical insurance policies that offer a rich set of day-to-day healthcare benefits, or cover in the event of medical emergencies.”

While other medical insurance products are often aimed at significant events, primary healthcare plans target day-to-day needs.

According to Humphrey Mkwebu, head of strategy at Old Mutual, PHC plans are mainly suitable for South Africa’s semi-skilled or unskilled workforce, as they reduce out-of-pocket expenses.

Why don’t medical schemes offer primary healthcare plans?

Medical schemes are non-profit organisations regulated by the Medical Schemes Act. Primary healthcare plans are insurance products that operate in the healthcare space without having to comply with the Medical Schemes Act. They are empowered to provide essential medical care, but can’t offer the full range of benefits that medical schemes do.

Conversely, medical schemes can’t offer the low-cost healthcare options that PHCs do, as they are legally required to cover a set of Prescribed Minimum Benefits (PMBs) – that is, emergency medical conditions, along with 271 listed medical conditions, and 26 chronic conditions. These comprehensive benefits come at a cost.

In addition, medical schemes usually offer comprehensive hospital cover, while primary healthcare plans offer greater day-to-day cover and minimal hospital cover, according to Damian McHugh, executive head of marketing for Momentum Health Solutions.

Tips when choosing a primary healthcare plan

Choose a reputable product provider

McHugh says it’s vital to choose a well-known product provider that has funds behind it, and is not likely to go bankrupt.

Smaller players in the market, who may, for example, market a R50 monthly premium, are unlikely to offer the cover you expect, or you may not be able to access all of the benefits. For example, you may be restricted to using a specific healthcare provider who is located in another town.

“While price is important, you should evaluate what you get for that price. There is no point paying for something that is too cheap and you cannot access the benefits when you need them, or they do not cover the benefit you need,” notes McHugh.

Your provider should ideally have experience in offering low-cost health solutions, and be willing to take the time to go through the terms and conditions, making sure you understand the benefits and exclusions of your chosen plan.

Consider cost versus benefits

McHugh recommends looking at what your budget will allow, while bearing in mind your specific needs. For example, your chosen plan may offer unlimited GP visits, but no chronic medicine or specialist consultations (see box below).

If not included in the day-to-day cover, you may also need to take out a separate hospital product covering accidental injury. Alternatively, your product provider may offer a cash lump sum per day in hospital, if you have a predefined emergency in your policy.

The table below compares the benefits offered by three established PHC providers.

Tip: Getting out of debt can help you on your journey to financial security. Consider debt consolidation if you have multiple debts.