Does Netcare Pay For Substance Abuse Treatment?

Netcare Medical Aid, a trusted healthcare service provider in South Africa, offers its members comprehensive healthcare coverage, including 21 days in an inpatient treatment facility and a 3-day medically supervised detoxification. Understanding the coverage for substance use disorders is not just important; it’s crucial. 

Addiction is a chronic disease that, if untreated, can have severe consequences. Netcare Medical Aid strives to provide its members access to top-notch medical and drug and alcohol rehabilitation treatment. However, it’s important to note that their plans have exclusions, benefit caps, and eligibility requirements that must be met. By understanding these, you can make informed decisions about your healthcare.

Netcare Medical Aid covers treatment for substance abuse, but the extent to which that coverage depends on the plan chosen by the member; some plans offer more comprehensive coverage than others, making it particularly important for members to review their plans before making a decision.

At We Do Recover, we understand how exhausting the pre-authorisation process can be, which is why we are here to help. This informative article will tell you everything you need to know about Netcare Medical Aid and the pre-authorisation process for an addiction treatment centre. Remember, you’re not alone in this process. We’re here to guide you every step of the way.

Overview Of Netcare Medical Aid

Netcare Medical Aid is a South African medical aid scheme that provides comprehensive addiction treatment to its policyholders. It offers various plans to suit its members’ specific budgets and needs.

Netcare Medical Aid is well-known for its expansive network of hospitals and healthcare providers, conveniently located throughout South Africa.

Types Of Plans

Netcare offers its members several plans, including network, hospital, and comprehensive plans. These plans vary in their extent of coverage and cost, allowing members to choose the one that best suits their needs and budget. However, it’s important to note that treatment for drug and alcohol abuse is included in all of them, ensuring that you have access to the care you need.

Extent Of Coverage

Netcare Medical Aid offers a wide range of coverage for different medical treatments, including addiction. 

As mentioned above, the extent of coverage a member will receive will vary depending on the type of plan the member has chosen. For example, network and hospital plans will have limited coverage compared to the comprehensive plan.

It is advised that policyholders carefully review their plans before deciding on their addiction treatment facility and plan. At We Do Recover, we can help you better understand your benefits, limits, and exclusions; don’t hesitate to reach out and call us.

Addiction Treatment Coverage

Netcare Medical Aid provides members with comprehensive coverage for addiction treatment benefits, including inpatient treatment, outpatient services, and therapy sessions.

Inpatient Services

Members in an inpatient treatment facility will receive coverage for the 21-day inpatient program and a 3-day medically supervised detoxification. Depending on the member’s chosen plan, they may also receive coverage for individual counselling, group therapy sessions and certain medications.

By law, Netcare Medical Aid must cover addiction treatment under the premium prescribed benefits (PMBs). These are defined benefits that all medical schemes must cover, regardless of the chosen plan or option. However, policyholders may still be liable for a co-payment upon admission. 

Outpatient Services

Netcare Medical Aid covers certain outpatient services but not the entire program. Services members can claim for include:

• Individual Counselling
• Group Therapy

Therapy And Counselling

Members receive comprehensive coverage through their Netcare Medical Aid Plans. Policyholders can claim individual counselling sessions with licensed psychiatrists,  therapists, psychologists, social workers, and occupational therapists.

However, specific plans are subject to exclusions and do not cover all therapeutic modalities. Members must review their plans to better understand their benefits.

Pre-Authorisation Process

Before admission, members must adhere to a quick and straightforward pre-authorisation procedure to be eligible for coverage.

At We Do Recover, we can start the pre-authorisation process on your behalf. This means we will handle the paperwork and communication with Netcare Medical Aid, making your admission process more manageable. 

The pre-authorisation procedure looks like this:

• We will give Netcare Medical Aid a call on your behalf, giving them your medical aid details and your ICD-10 codes for your addiction.
• We will provide them with our practice numbers.
• Lastly, there will be no need for a referral letter from a doctor.

It is important to be aware that members who have not undergone a pre-authorisation process and have not been approved by Netcare Medical Aid for substance abuse treatment will not be covered.

Moreover, members may be liable to a co-payment upon admission. 

Claims And Reimbursements

Submitting A Claim

Netcare Medical Aid’s coverage for addiction treatment is comprehensive; however, the extent of coverage is subject to the policy’s terms and conditions. Members can submit claims to Netcare Medical Aid for reimbursements.

To receive a reimbursement, members must submit a claim with supporting documentation, including the treatment and relevant medical reports from healthcare professionals. It’s also important to check that the facility is registered with the Council For Medical Schemes. 

Once your claim has been submitted, Netcare Medical Aid will review it and determine whether it is eligible for reimbursement under the policy. If the claim has been approved, you will be reimbursed for the cost of the treatment.

Reimbursement Process

Once a claim has been submitted, Netcare Medical Aid will review it and determine whether it is eligible for reimbursement under the policy. If the claim has been approved, the member will be reimbursed for the cost of the treatment.

Exclusions And Limitations

Specific Exclusions

Although Netcare Medical Aid generally covers a wide range of services to treat substance use disorders, members must be aware of some limitations and exclusions. For example, Netcare Medical Aid does not provide coverage for process addictions like gambling and sex addiction.

Additionally, Netcare will only provide treatment for an inpatient rehab facility that has been approved through a pre-authorisation process. 

Benefit-Caps

Like all medical aid and hospital plans, Netcare Medical Aid has benefit caps. These are limits on the number of treatment sessions or the total amount of benefits you can claim for a specific service. The number and types of sessions will vary depending on the plan chosen by the member. 

It is paramount that members be aware of these limits when seeking out treatment for their substance use disorders. 

Conclusion

Netcare Medical Aid understands the severity of substance use disorders and, because of this, offers its members comprehensive coverage for addiction treatment.

Netcare Medical Aid offers different plans to suit its members’ budgets and specific needs. These plans cover substance abuse treatment; however, their benefits, limits, and exclusions will vary.

At We Do Recover, we have partnered with Netcare Medical Aid to provide their members with high-quality treatment and ensure they receive professional help from our multidisciplinary team of registered healthcare professionals.

Contact us today today to start your pre-authorisation process at 081-444-7000.

FAQS