Understanding primary healthcare products

Primary healthcare helps South Africans get access to affordable healthcare by putting private health cover within reach.

What are primary healthcare products?

Primary healthcare products are affordable healthcare solutions that offer access to primary healthcare services at private health practitioners. These products are insurance products and are not medical schemes. Primary healthcare products do not offer Prescribed Minimum Benefits or comprehensive private hospitalisation as would be available through a medical scheme.

The benefit of having such a product is the lower monthly premium in comparison to medical scheme premiums. In addition these products usually offer day-to-day benefits, which may include; unlimited GP consultations at designated network providers, basic pathology and radiology, basic dentistry and basic optical benefits. Some primary healthcare products may also offer limited specialist and maternity benefits.

The other differentiator between primary healthcare products and medical scheme options is that primary healthcare products do not offer private hospitalisation. However, they may offer limited private hospital cover consisting of private emergency transportation, stabilisation, trauma and/or accident benefits subject to the relevant terms and conditions.

In recent years we have seen a steady increase in the take-up of primary healthcare products by employer groups with employees earning below R10 000 per month.

It is important to note that Primary healthcare products are not a substitute for a medical scheme option, instead they offer basic day-to-day medical cover for those who cannot afford medical scheme premiums.

Demarcation Regulations

Insurers who provide primary healthcare products must apply for exemption from the Council of Medical Schemes (CMS) under the demarcation regulations that govern the business of a medical scheme. The current exemption period ends on 31 March 2022. The extension is conditional on insurers complying with the defined exemption conditions.

In the near future all primary healthcare insurance products will probably transition into the Low Cost Benefit Option framework that is being developed by the Council for Medical Schemes in consultation with various healthcare stakeholders. Existing primary healthcare service providers who also offer medical scheme products are at an advantage as they have an existing platform to allow a seamless transition within the Medical Schemes Act once the framework is finalised.

Although primary healthcare products are not a substitute for medical schemes, they offer reasonable cover for day-to-day health services within a private setting at an affordable cost.

ENDS