Basic health cover plans differ on benefits offered

A generic image of a sick child in hospital.
A generic image of a sick child in hospital.
Image: 123rf

Healthcare plans that promise access to private doctors for out-of-hospital needs offer a broad range of benefits, making it difficult to identify those that offer value for money.

As medical scheme membership is expensive, providers have a range of plans that offer what is known as primary healthcare cover only for visits to general practitioners, for medicine, X-rays and  sometimes dentistry and optometry.

Some plans are combined with insurance policies that offer limited private hospital cover, but be sure you are aware of the limitations.

All primary healthcare plans, whether combined with private hospital insurance or not, have to operate under registration with the Council for Medical Schemes because they are regarded as doing the business of a medical scheme.

The Council for Medical Schemes says about 18 plans were granted exemptions from complying with all the provisions of the Medical Schemes Act until May next year.

The council will shortly publish a list of these plans. Plans sold without the exemption are not lawful, Stephen Mmatli, the general manager for compliance and investigations at the council, says.

The exempt plans do not have to provide all the minimum benefits schemes are obliged to. Many of these minimum benefits cover hospital admissions that increase contributions.

The council is reviewing the wide variety of benefits offered by primary healthcare plans and will come up with a standard set of minimum benefits they will all have to offer by the time the current exemption – or an extension of it – expires. These benefits are likely to include some hospital benefits for emergencies and maternity cases.

In the meantime, be careful when you make comparisons that you are comparing like with like.

A quick comparison by GTC healthcare consulting shows that benefits differ in the following key ways:

Consultations with a GP

The number of consultations covered ranges from three visits a year to unlimited visits.

In some cases, the first five visits are paid for in full but after that attract a co-payment (a part of the fee that you must pay – for example, R75).

Most GP consultations are provided for within a network – Mmatli says you should make sure GPs in the network are not so busy that you have difficulty getting an appointment.

Medication

Some plans offer a set amount for medicines prescribed by a doctor and over-the-counter medicines (without a prescription), while others do not cover over-the-counter medicines. Some offer combined limits.

When it comes to medicines for ongoing chronic conditions, some cover none, some a limited list and some cover all 27 common chronic conditions medical schemes have to.

Specialist visits

Some plans offer no benefits, others an amount such as R2000 or a limited number of consultations, for example three, per year per family.

Pathology and radiology

Most plans offer basic blood or glucose tests or pap smears, and black and white X-rays but expensive scans like MRI scans are unlikely to be covered. Some plans have no benefits for pathology or radiology.

Maternity

There may be no benefits or limited consultations, scans and tests before the birth and then a rand amount such as R25000 or R30000 for the costs of the birth in hospital.

There is typically no cover for a baby born with any major health problems.

Dentistry

Many plans offer basic dentistry covering simple fillings and extractions but nothing fancy like implants.

Some have rand limits and others have an extra benefit for dental work following an accident, but if you lose your teeth as a result of, for example, cancer, you will not be covered.

Optometry

Some plans do not offer these benefits, but others offer an eye test and basic frames every two years.

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