There are two main doctor networks that provide day-to-day medical services to the low-cost medical scheme options. Knowing how these networks operate is the key to understanding the benefits provided by low-cost options.
Members of medical schemes making use of the Prime Cure network have unlimited access to the services offered by the network's more than 50 medical centres around the country. Members do not make any co-payments to use the centres' services.
These centres offer consultations with general practitioners, acute and chronic medication, pathology, basic radiology (X-rays), basic optometry, basic dentistry, minor procedures, mother and child health, family planning, immunisation and ante-natal care, all under one roof.
In addition, members who live far from the centres can visit almost 1 000 general practitioners, dental practitioners and optometry practices with whom Prime Cure has contracts. The medical centres and the general practitioners tend to be situated in lower- to middle-income residential areas.
You can make an appointment to see a Prime Cure doctor or you can just walk in to a Prime Cure centre and wait until a doctor is available.
Doctors in the network are assisted by nursing sisters, which means you will see a nurse before you are referred to the doctor.
Basic optometry means you can have your eyes tested and can get single focal or bi-focal plastic lenses in a selection of frames.
Basic dentistry covers fillings, extractions, cleaning and abscess treatments.
If you need to receive more complex treatment, such as a bridge or a crown, or if you want contact lenses instead of spectacles, you are likely to have to pay for this yourself, unless your scheme offers additional benefits that cover this treatment.
In addition to access to the Prime Cure network, some low-cost schemes provide limited benefits for, for example, visits to specialists, but you must be referred by a Prime Cure doctor.
Although you can get medicines from Prime Cure doctors and centres, these medicines will usually be cheaper generics, rather than patent ones. Prime Cure has a list, called a formulary, of drugs it dispenses. If you want a drug that is not on the list, you will have to pay for it yourself.
The network started in 1998 and now serves about 170 000 patients from the schemes it has contracts with, other schemes and patients who are not members of schemes.
Prime Cure has contracts with 20 medical schemes. Among these are a number of open schemes including: Bonitas, Bestmed, Good Hope Medical Hope Society, Ingwe, NMP, Prosano, Pretmed, Topmed, Odyssey, Vulamed and ExpressCare.
Most doctors who work at the Prime Cure medical centres share part of the profits of the centres, while others earn a salary. Doctors who participate in the network are either paid a set fee for the patients they actually see or they are paid a fee to service a set number of patients, and in this case it is in their interest to keep you healthy and out of their rooms.
The quality of care provided by the contracted doctors is monitored to ensure patients receive the same level of care as they would when visiting a Prime Cure Medical centre.
If you need to consult a doctor outside of the medical centre's operating hours, you need to phone the call centre for a referral.
Members of schemes making use of the CareCross network have access to the network's more than 1 000 doctors, dentists and optometry practices countrywide. They do not need to make co-payments for these services.
Unlike Prime Cure, CareCross does not operate through medical centres. Doctors who sign contracts with CareCross operate from their rooms and also service patients who are not members of schemes and who use the CareCross network.
CareCross doctors can also dispense acute and chronic medicines, and CareCross members are also able to get basic blood tests and basic X-rays through the network's doctors and laboratories.
Dentists in the CareCross network will do fillings, extractions, cleaning and preventative treatment at no cost, but if you need anything else, you will probably not be covered, unless your scheme has extra benefits for this.
Optometry benefits are limited to the standard lenses in a basic frame every two years. You will have to chip in for anything more fashionable.
CareCross doctors tend to be situated in urban areas, across a variety of income groups.
You have to choose a doctor and always visit the same doctor in order to qualify for unlimited benefits.You have to make an appointment to see a CareCross doctor, and appointments are as easy to get as they are for other private patients. If there is an emergency and you are not near your regular doctor, you can visit another CareCross doctor or one of the major private hospital trauma centres, but you may only do this three times a year.
Medicines you get from CareCross doctors are limited to those on the network's list and are likely to be generics. If you want a drug that is not on the list, you will have to pay for it yourself.
In order to get chronic medication, your doctor will have to fill in an application form on your behalf. The medication you need will then be sent to the doctor's rooms or possibly to a pharmacy for you to collect.
The CareCross network started in 1998 and now serves about 90 000 members. This includes the members and their dependants of about 16 medical schemes. Among these 16 schemes are eight open schemes: Discovery; Oxygen; OpenPlan; Protector Health; Bestmed; Ingwe; Odyssey; and Express Care.
CareCross doctors are paid fees for the clients they see in terms of the contracts they sign with CareCross.
The quality of care provided is monitored by CareCross and random surveys are conducted among patients.
Reinder Nauta, the managing director of CareCross, says members are made to choose a single practice within the network so that the doctor will be familiar with your history and will be better able to treat you.
He says if members are unhappy with the service they get from the doctor, they can take the matter up with CareCross.
There are three other networks used by the schemes featured in the article What your options are.
Pathfinder has its own network of 340 general practitioners across the country.
Consultations are unlimited, as are acute and chronic medication through these doctors. Members are also entitled to two visits per beneficiary to non-network doctors.
Dentistry and optometry is through networks of 1 800 dentists and 1 600 optometry practices.
Pathfinder's low-cost options are initiatives of the South African Medical and Dental Practitioners' Association, representing black doctors from previously disadvantaged communities. The target market of these options is people who live in previously disadvantaged areas and the emerging market. The practices of the network doctors are mostly in central towns, but there are also some doctors in rural areas.
Sizwe medical scheme also has its own doctor networks, but so far they are only in the Port Elizabeth/Uitenhage area; in Gauteng; Mpumalanga; North West Province; and Limpopo. A new network has been launched in KwaZulu-Natal and there are plans for the Western Cape. The network includes 1 500 general practitioners. Dentist and optometry networks are still being developed, and in the interim members are able to use their own dentists and optometrists.
Some schemes limit your hospitalisation to certain hospitals. However, if there is an emergency, you will be covered to receive treatment at any hospital and then moved to a network hospital once you are stabilised
There are 27 Afrox hospitals, 44 Netcare hospitals and 36 MediClinic hospitals around the country.