Does Medscheme Cover Addiction Treatment In South Africa?
Medscheme Medical Aid covers 21 days of inpatient addiction treatment, including a 3-day medically supervised detoxification.
Medscheme Medical Aid covers 21 days of inpatient rehabilitation care, including a 3-day medically supervised detoxification.
Medscheme Medical Aid is legally bound to cover addiction treatment as it falls under the premium prescribed benefits (PMBs). This obligation applies to all their medical aid plans, guaranteeing that every member, regardless of their plan, will receive the necessary treatment for their substance use disorders.
At We Do Recover, we prioritise the safety and care of our patients. Working with the admission and pre-authorisation process with medical aids can be a taxing experience, which is why we are here to help. This informative article will delve into the benefits, exclusions, and limitations of the Medscheme Medical Aid plans, ensuring members know exactly what to expect when seeking treatment for their addiction.
Types of Plans And Coverage
Medscheme Medical Aid offers various plans to suit their member’s wide range of budgets and individual needs.
They have several plans to choose from, ranging from basic to comprehensive. The basic plans cover the essentials, while the more comprehensive plans will cover more extensively. For example, comprehensive plans might cover specialist visits like psychiatrist consultations, while basic plans might not.
While comprehensive plans may include more benefits, the basic plans are more affordable for those on a budget and still seeking addiction treatment coverage.
Addiction Treatment Coverage
Addiction has been classified as a chronic and severe brain disease and, if left untreated, can have detrimental psychological, physical and emotional consequences. Medscheme recognises this and offers comprehensive coverage to treat substance misuse to its members.
In the subsections listed below, we will discuss in depth what Medscheme Medical Aid members can expect from their coverage.
Inpatient Rehabilitation Treatment
Residential inpatient treatment care is covered for 21 days under the Medscheme Medical Aid Plans. Inpatient treatment aims to provide a safe and secure environment so that individuals can receive intensive care for their substance use disorders.
The coverage of inpatient rehab typically includes a 3-day medically supervised detoxification, which is the initial first step in treatment centres. The detox process aims to remove substances safely from the body in a controlled environment.
Coverage limitations, such as the cost ceiling or the total length of stay, will depend on the plan chosen by the member.
Outpatient Treatment Program Services
Medscheme Medical Aid also provides coverage for specific services offered at the outpatient program. This option is ideal for members with commitments like work, school, and relationships.
Members can claim for individual counselling sessions during the outpatient program. It is crucial to understand that Medscheme only covers part of the program.
Therapy And Counselling
Counselling is the hallmark of addiction treatment in inpatient rehab centres. The purpose of counselling is to allow individuals to combat their maladaptive addictive behavioural patterns and develop healthy coping mechanisms to deal with everyday stressors to sustain long-term recovery.
Our multidisciplinary clinical team has adopted a holistic approach to treating addiction at We Do Recover. We incorporate different therapeutic modalities to ensure that each client’s individual needs are met.
The following therapeutics we employ include:
- Cognitive-Behavioural Therapy (CBT)
- Dialectical Behavioural Therapy (DBT)
- Motivational Enhancement Therapy (MET)
- Group Therapy
- Family Therapy
Members of Medscheme Medical Aid can claim therapy sessions through their medical aid plans; the extent of their coverage will vary depending on the type of plan they are enrolled in.
Process For Claims For Medsheme Medical Aid Members
Claiming for treatment costs may seem like a daunting task. However, it is a simple and straightforward process.
These steps include obtaining a pre-authorisation for the chosen facility and submitting all the supporting documentation.
Pre-Authorisation Procedure
Members must follow a pre-authorisation process before being admitted into an inpatient treatment facility and get approval.
It is imperative to receive approval before being admitted, as Medscheme Medical Aid will only cover treatment that has been approved through a pre-authorisation procedure.
At We Do Recover, members can contact us, and we will direct you to our admissions department, which will start the pre-authorisation process on your behalf.
They will contact Medscheme Medical Aid and provide them with your ICD-10 codes for your specific addiction and our facility’s practice numbers.
Claims Procedure
After completing their treatment, members can submit claims to Medscheme for reimbursement. When submitting a claim, all necessary documentation must accompany it.
The typically includes:
- A detailed invoice from the addiction treatment facility
- Proof of payment (if already settled)
- Completed claim forms provided by Medscheme Medical Aid
Exclusions And Limitations
Members are subject to limitations and exclusions, regardless of which plans they are enrolled on.
Substance Abuse Treatment Limitations
Medscheme Medical Aid only covers drug and alcohol addiction. Process addictions like gambling, porn and sex addictions will not be treated under addiction therapies. If a member wishes to be treated for behavioural addictions, they will need to be referred to a psychiatric facility.
Additionally, Medscheme Medical Aid covers only primary care facilities; secondary and tertiary care facilities do not receive coverage, and members are liable to pay privately.
Coverage Caps
Medscheme Medical Aid imposes coverage cap limits on all their plans concerning substance use disorders. For example, Medscheme only covers 21 days of inpatient treatment and a 3-day medically supervised detox per year.
A member may also be limited to a certain number of therapy sessions per year that they may claim before they are liable to pay out-of-pocket.
Conclusion
Medscheme Medical Aid offers comprehensive coverage for drug and alcohol abuse rehabilitation to its members, offering 21 days of inpatient treatment and a 3-day medically supervised detox per year.
Members can also claim additional benefits, such as individual counselling and specialist care, such as psychiatric appointments.
At We Do Recover, we prioritise the welfare of our clients and ensure that they receive the highest level of care for their substance use disorders. Call us today at 081-444-700 so we can start the pre-authorisation process on your behalf.
FAQS
Medical aid schemes are legally obligated to cover 21 days of inpatient rehabilitation services, including a 3-day medically supervised detox. Depending on the type of plan chosen by the member, certain services in the outpatient program may also be covered. No, Medscheme does not cover halfway houses, and members would be liable to pay for that service out-of-pocket. No, If a member wants to be treated for a process addiction, they will need to be referred to a psychiatric facility.What Types Of Addiction Treatments Are Covered By Medical Aid Schemes In South Africa?
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