What is a primary healthcare plan?

Key takeaways

  • A primary healthcare plan offers cover for your day-to-day healthcare needs – visits to a general practitioner and prescribed medicines, basic dentistry and optometry.
  • Primary healthcare plans are provided by insurers under an exemption from the Medical Schemes Act. The intention is that they will in future become low-cost medical scheme options.
  • Primary healthcare plans may be offered with limited hospital insurance, but they do not offer cover as comprehensive as that of a medical scheme.

A primary healthcare plan is an insurance policy that can offer you cover for a basic package of day-to-day medical expenses.

These plans typically offer:

  • Unlimited general practitioner (GP) and nurse consultations;
  • Acute medication from a list of medicines; and
  • Basic radiology (such as x-rays) and pathology (such as blood tests).

They may also offer one or more of the following:

  • Limited specialist consultations if you are referred by a GP;
  • Chronic medication for listed conditions only – these vary across plans;
  • Basic and emergency dentistry;
  • Basic optometry (a specific set of benefits every two years);
  • Pre-birth maternity care; and
  • Wellness screenings such as those for blood pressure, blood glucose (blood sugar), cholesterol.

What kind of cover is it?

These plans are offered by insurers as insurance policies. They are currently not medical schemes – they are operating under an exemption from the Medical Schemes Act. The government’s intention is that these plans will be converted to low-cost medical scheme benefit options under the Medical Schemes Act once a legal framework for these options has been established.

The current exemption for these products, which has been extended a number of times, will expire in April 2024.

The only primary healthcare plans currently in the market are ones that were in place in 2017. In that year, the latest regulations under the Short Term and Long Term Insurance Act that demarcate medical schemes from health insurance policies became effective. A revised definition of a medical scheme under the Medical Schemes Act became effective at the same time.

No new primary healthcare plans have been allowed to launch since then.  

What is not covered?

Primary healthcare plans cover you for day-to-day out-of-hospital medical benefits when these are in line with the benefits stated in the policy.

Hospital cover is generally excluded, but these policies may be sold in combination with a hospital cash plan and/or cover for your stabilisation in hospital in an emergency or after an accident. Read more: What is a hospital cash plan?

You should not expect the cover for primary health care to be as comprehensive as you can expect from a medical scheme, as you will not enjoy the protection of the prescribed minimum benefits (PMBs). The PMBs are benefits that all schemes must provide to ensure you are covered for all emergencies and conditions that could affect the quality of your life. Read more: What is a prescribed minimum benefit?

Even after these policies are converted to medical scheme options, they may be offered under legislation that enables them to reduce the PMB cover.

The network is key

Primary healthcare plans offer cover through networks of doctors, pharmacies, dentists, optometrists, pathologists and radiologists. You will have to use these providers to enjoy cover. You will not be able to use your own doctor or dentist unless he or she participates in the network.

The insurer negotiates rates with these providers in order to keep the cost of cover lower and the services that will be provided are defined.

Who can use it?

Anyone can use a primary healthcare plan but they are typically targeted at consumers who cannot afford medical scheme membership and the networks are designed to serve people in certain target areas. You therefore need to check the providers in the network to ensure they are providers you can get to conveniently.

Key things to check

The insurer must be one of the insurers granted an exemption from the Medical Schemes Act and must be able to offer such a product. The Council for Medical Schemes has a list of these insurers.

Can you use a primary healthcare plan with a medical scheme?

Currently you can use a primary healthcare plan with a medical scheme option offering hospital cover. However, if primary healthcare plans are converted to medical schemes as low cost benefit options, you will not be able to use them with another medical scheme option as you may not belong to more than one medical scheme.

What else should I know?

If you use a primary healthcare plan to provide cover for your day-to-day healthcare needs, it will not count as cover from a medical scheme and if you join a medical scheme after the age of 35 you could be made to pay a late-joiner penalty. Read more: Will I pay a late-joiner penalty if I join a medical scheme?

How are the premiums set?

Insurers are obliged to set premiums on these policies for groups, but premiums can differ depending on which group you belong to. So the premium set by an insurer for a group of employees from one employer may be different to that set for employees from another employer or the premium set for any individual who signs up for cover.

Are there any waiting periods

Insurers can impose waiting periods, but only the ones that medical schemes are allowed to apply. This means a general waiting period – on all benefits - of up to three months or a 12-month waiting period for any condition you have been diagnosed with or treated for in the past 12 months. Read more: What waiting periods can my medical scheme apply?

Waiting periods can be applied both when you join and again if you upgrade to a policy offered by the same insurer with higher benefits.

Can a late-joiner penalty be applied?

Yes, you can be made to pay a late-joiner penalty if you sign up for cover after the age of 35, without having enjoyed cover previously for a certain number of years. Read more: Will I pay a late-joiner penalty if I join a medical scheme?

Tax and primary healthcare plans

If your employer pays the premium for you to belong to a primary healthcare plan, the premium will be regarded as a taxable fringe benefit and added to your income for tax purposes.

You will not be able to claim the medical tax credit if you are paying for a primary healthcare plan and you can also not claim any medical expenses that the plan pays for as a medical expense for tax purposes. Read more: What is a medical tax credit? and What is the additional medical tax credit and who qualifies for it?