What is Primary Care?
The first pillar of health insurance is the benefit that pays for various day to day expenses, also known as Primary Care. These claims include GP consults, blood work, x-rays, acute medication, ER visits, dentistry, optometry and chronic condition cover.
You can use the Primary Care benefit as a standalone insurance plan (with no hospital cover), or as an addition to your “hospital only” medical aid plan.
Note: not all these benefits are available on all the plans.
GP Visits
There are usually two types of benefits for GP consults:
- You have unlimited consults available, from a network of doctors or (Example: Discovery Flexicare, Episodic, Stratum, Healh4Me)
- You have a Rand limit per consult, and can choose any GP (Example: Affinity, Oneplan)
Some plans will give you both of these options (Example: Unity Health).
There might be implied limits, even in “unlimited” benefits. For example: OnePlan Core plan pays up to R400 for a GP consult, but has an overall R13,465 per family limit for all primary healthcare services.
Other things to consider:
Q: When will the claim be paid? If you are seeing a network doctor, chances are they will claim from the insurer directly. But if you are seeing a non-network GP, you would need to pay out of pocket first and be reimbursed later.
Oneplan gives you a debit card which they top up with funds prior to you seeing the doctor, so you are not out of pocket.
Q: Are minor procedures covered? Some plans include minor in-room treatments like stitches, and casts. (Example: Affinity Health, Flexicare).
Some insurers offer unlimited nurse consults at clinics like Clicks (Example: Elixi).
Medication
Your plan can cover prescribed medication, over-the-counter medication and even chronic medication (Example: Dischem MyHealth Plus Plan, EssentialMed, Health4me).
Even with this benefit, the insurer will have a list of medicine it is obliged to pay for (this is known as the formulary), and any medicine not on the list needs to be paid out of pocket.
Watch out for waiting periods and exclusion of pre-existing conditions, especially if claiming for chronic medicine.
Specialist Consults
Not all plans offer this benefit.
If this is a benefit on your plan, you are usually able to choose your own specialist, but must be referred by a GP. There are always strict limits on the maximum claim allocated to specialists. In addition, check if the limits are per person or per family. (Example: Kaelo Health, Unity Health)
Blood tests and X-rays
Insurers often cover basic blood tests and black and white x-rays under the Primary Cover benefit, although these will most likely need to be requested by your GP first and be obtained from specific providers. Primary care plans rarely cover specialised radiology, such as MRI or CT scans but accident and illness policies might do so.
Vaccines
This can include the first immunizations for children and flu shots for adults (Example: Flexicare).
Some plans offer more extensive vaccine cover, including a combination of pneumococcal vaccination, hepatitis A and B vaccination, and tetanus vaccination. There are usually limits to the frequency of these. (Example: Stratum, GetSavvi)
Preventative Benefits
Some plans pay for a pap smear and prostate screening (Example: Stratum, Elixi, Unity Health).
Wellness
Your plan might include an annual wellness check. This can consist of checks of blood pressure, blood glucose (blood sugar), cholesterol and body mass index (BMI). (Example: GetSavvi, Flexicare, Kaelo Health).
Dentistry
Premium primary plans often cover standard dentistry, with a “per consult” limit, as well as an overall limit per year. Standard dentistry most often includes consults, fillings and extractions. (Example: Stratum, Health4Me).
Specialized dentistry like crowns, implants and dentures are rarely covered on a standard plan, although you can sometimes upgrade your cover at an additional cost. (Example: EssentialMed)
If you need hospitalization for your dental issues (due to trauma or cancer, for example) this would only be potentially covered under an accident or illness insurance plan.
Stratum offers cover for root canal as part of a primary care plan. Kaelo MyHealth Plus pays for dentures.
HIV Treatment
This benefit includes a regular HIV test, and can include treatment, antiretroviral drugs as well as counselling. (Example: Kaelo Health, Affinity Health )
Optometry
With this benefit, you can get cover for annual standard eye tests and a set of glasses, once every 24 months. There is often a 12 month waiting period for this benefit, and you will need to use network providers. (Example: Unity Health, Elixi)
Maternity
This does not include paying for the delivery of the baby. But you can get extra benefits such as 2D or 3D scans, blood tests, prescribed medication and consults with gynaecologists. (Example: Affinity Health, Unity Health, One Plan)
