Medshield is considered one of the leading medical aid service providers in South Africa. Addiction is regarded as a severe and chronic brain disease that requires professional treatment. Yes, Medshield covers 21 days of inpatient treatment, including a 3-day medically supervised detox per member each year. 

At We Do Recover, we want to ensure that you understand what your coverage will entail so that you can maximise your treatment plan and achieve the best possible outcome for long-term recovery.

Overview Of Medshield Medical Aid Scheme

Medshield Medical Aid understands that each member’s needs and budgets are unique. That’s why they offer a variety of plans with different premiums and benefits, ensuring that members find the one that best suits their specific requirements. 

These plans provide access to quality healthcare services, including coverage for treating drug and alcohol addictions. 

Let’s explore the eligibility criteria, services covered, limitations and exclusions, claims, and the pre-authorisation process, equipping you with the knowledge to make the most of your treatment plan.

Eligibility For Rehab Treatment Coverage

Members need to meet specific criteria to be eligible for addiction rehab coverage. 

The following subsections outline requirements for membership status and medical criteria.

Membership Status

Members must have an active Medshield Medical Aid plan and up-to-date payments to be approved for drug and alcohol rehab coverage.

Members who are still on their waiting period will not be approved for coverage.

Medical Necessity Criteria

Legally, Medshield is required to cover addiction treatment services under the Premium Prescribed Benefits (PMBs) package. The PMB package is a set of benefits covered by all Medical Aid Schemes under the law.

Under the PMB regulations of the Medical Schemes Act, medical aid schemes must cover the diagnosis and treatment of substance use disorders.

Addiction Rehab Services Covered

Medshield Medical Aid covers a comprehensive range of addiction rehab services. These services are specifically designed to help individuals struggling with alcohol and drug addictions achieve long-term recovery.

Inpatient Treatment Services

Medshield Medical Aid Schemes cover residential inpatient treatment, including an extended stay in a facility where members receive 24-hour care and support, meals, individual counselling and group therapy sessions, depending on the plan chosen by the member.

During their time in inpatient rehab treatment, members will receive medically supervised detoxification, counselling, and therapy sessions to address their addiction challenges. Services include Cognitive Behavioural Therapy (CBT), Motivational Enhancement Therapy (MET),  Dialectical Behavioural Therapy (DBT)

Outpatient Treatment Sevices

Members can claim individual counselling benefits through their Medshield Medical Aid plan. However, if their benefits were capped during a stay in an inpatient facility, they may be liable to pay out-of-pocket.

Therapy And Counselling

Medshield Medical Aid covers a broad range of counselling and therapy modalities for addiction rehab, such as individual counselling, group therapy, and family therapy sessions.

Individual counselling is designed to help people identify their maladaptive addictive thoughts and behaviour patterns associated with their substance use disorder and to develop healthy coping mechanisms and practical strategies to sustain long-term recovery.

At We Do Recover, we have a multidisciplinary clinical team of psychiatrists, psychologists, registered counsellors, addiction counsellors, social workers, and occupational therapists who provide an integrated approach to recovery. 

Pre-Authorisation And Claim Process

Before undergoing addiction treatment, members need to follow a pre-authorisation procedure to ensure that they fulfil the claims submission guidelines. Medshield Medical Aid will not provide coverage for any therapy or treatment that has not been approved.

Pre-Authorisation Procedure

The pre-authorisation procedure is a quick and easy process. You can either go through Medshield directly or contact us at We Do Recover, and we can do it on your behalf.

Claims Process

Members must adhere to submission guidelines and a specific procedure if they want to submit a claim to Medshield Medical Aid.

Exclusions And Limitations 

Members of Medshield Medical Aid are subject to certain limitations and exclusions, which may vary depending on the plan chosen by the policyholder. 

Rehab Treatment Exclusions

Medshield Medical Aid does not cover all types of addiction. For example, substance use disorders such as drug addiction and alcoholism will receive coverage at a rehab centre. Behavioural addictions like gambling, sex and porn, as well as eating disorders, will need to be treated in a psychiatric clinic under Medshields’ psychiatric benefit.

Coverage Limitations

Members do not have unlimited benefits regarding coverage for addiction treatment; this is true for all plans. It is crucial to be aware of these limits before seeking treatment to avoid surprise costs. 

Medshield provides the most extensive coverage for inpatient treatment, including residential stay. Outpatient treatment services are limited to specific therapies for coverage.

Should these benefits be capped, members will be liable to pay for any out-of-pocket costs.

Conclusion

Medshield Medical Aid is a trusted medical aid provider that offers a variety of plans to suit its members’ specific needs and budgets. While plans may have exclusions and limitations, there are an overwhelming number of benefits available that members can claim for addiction treatment.

Members are advised to review their plans so that they are equipped to make an informed decision when choosing a rehab treatment centre.

At We Do Recover, we recognise that the process behind pre-authorisation may be confusing and overwhelming, so we can do it on your behalf. Contact us today at 081-444-7000.