SABC Medical Aid, a leading healthcare provider in South Africa, recognises addiction as a brain disease. In line with this understanding, they provide comprehensive coverage for the treatment of substance use disorders. This includes a 21-day residential inpatient treatment program and a 3-day medical detoxification. Rest assured, SABC Medical Aid is committed to supporting your journey to recovery. However, it’s important to be aware of the specific coverage terms.

To fully understand the coverage for addiction treatment provided by SABC Medical Aid, it’s vital to know the eligibility criteria, limits and exclusions, and claims process. Therefore, it’s strongly advised that members review their plans thoroughly to determine their coverage level and maximise their benefits.

At We Do Recover, we’ve partnered with SABC Medical Aid to ensure you receive the highest level of care for your substance use disorder. We understand that navigating the pre-authorisation and admissions process can be daunting. This article aims to address any lingering questions you may have, providing clarity and peace of mind.

Understand SABC Medical Aid

Overview Of SABC Medical Aid

SABC Medical Aid, a popular South African healthcare provider, offers its customers a comprehensive range of benefits. These include hospitalisation, chronic medication, preventative care, psychiatric, and substance abuse treatment. This scheme is open to all Broadcasting Employees and their dependents, providing a broad scope of coverage for various healthcare needs. 

Drug And Alcohol Abuse Coverage Basics

SABC Medical Aid is legally required to cover 21 days of inpatient rehab treatment, including a 3-day medical detoxification per year for substance use disorders under the prescribed minimum benefits (PMBs). This means that SABC Medical Aid recognises that addiction is accepted as an illness and not a moral failing.

It is essential to know that most medical aid plans require a co-payment for inpatient treatment facilities. This means that members must pay a portion of their treatment out-of-pocket; the co-payment amount will vary depending on the specific plan the member has chosen.

Eligibility For Addiction Treatment Coverage

SABC Medical Aid is committed to delivering quality, comprehensive coverage to its members. It covers treatment for substance use disorders, but coverage is subject to certain membership criteria and conditions.

Membership Criteria

Members must have up-to-date paid membership premiums to be eligible for drug and alcohol treatment coverage. Membership criteria may vary depending on the specific plan chosen by the member. Members are advised to review their plans to determine their eligibility for coverage.

Conditions For Coverage

SABC Medical Aid covers treatment for drug and alcohol abuse but is subject to certain conditions; the type of addiction treatment covered, the duration of treatment, and the number of treatments covered may differ from plan to plan. SABC Medical Aid covers treatment plans provided by registered healthcare professionals accredited by appropriate regulatory bodies.

Additionally, SABC has partnered with accredited addiction rehabilitation facilities, but you will receive addiction coverage as long as the clinic is licensed. The SABC Medical Aid list might have designated service providers (DSPs) that differ from your preference; luxury rehab treatment facilities are available; however, the co-payment will be excessive.

Your medical aid can provide you with a list of DSPs, or you can call us at We Do Recover to find out what your co-payment will be. It’s crucial to choose a rehab centre that not only treats addiction but also co-occurring mental health conditions.

Extent Of Treatment Coverage

SABC Medical Aid provides coverage for a wide range of addiction treatment services. These services will vary depending on what plan the member has chosen. 

Inpatient vs Outpatient Services

SABC Medical Aid covers both inpatient and outpatient addiction treatment services. Inpatient services include the cost of the 21-day residential day, including the 3-day medical detoxification. Inpatient treatment also involves coverage for several individual counselling sessions and group therapies. 

SABC Medical Aid does not cover the entire outpatient program. Still, a few select services, such as individual counselling and group therapy sessions, can be claimed under the prescribed minimum benefits (PMBs). 

It is important to note that members must pay out-of-pocket for these additional services if these benefits have been exhausted.

Counselling And Support Groups

Counselling and group therapy are the crux of rehab treatment programs. These therapeutic approaches offer members a safe and supportive environment to share their experiences and struggles with addiction. 

SABC Medical Aid understands this and covers both individual and group therapy sessions, ensuring that their members get the best level of care that they need to combat their addiction to drugs or alcohol and ensure long-term recovery.

Duration Of Treatment

SABC Medical Aid must legally pay for 21 days of inpatient rehab treatment, including a 3-day medical detoxification per year, under the prescribed minimum benefits (PMBs). Not all inpatient addiction treatment services will be covered by every plan; members are encouraged to check their plans to determine what will be covered.

Types of Addiction Covered

Substance Use Disorders

The SABC Medical Aid Scheme covers substance use disorders such as drug addiction, prescription drug abuse, and alcoholism.

Inpatient and outpatient rehabilitation programs are used to treat these disorders and include cover for therapy, detoxification, and certain medications, depending on the plan chosen by the member.

Claims Process For Drug And Alcohol Abuse Treatment 

Documentation Requirements

To claim back from SABC Medical Aid, the member will need to provide them with specific documentation. This includes a document that will provide proof of admission into the rehab treatment facility and a detailed outline of the rehab program.

Exclusions And Limitations

SABC has extensive coverage for substance and alcohol use disorders. However, there are exclusions and limitations that members should be aware of.

Non-Covered Treatments

SABC Medical Aid does not cover some all addiction treatments. These treatments include non-medically necessary therapies and treatments not provided by a registered healthcare professional. 

Some of these exclusions include:

• Process addictions like gambling and porn addiction.
• Treatments that were not pre-authorised by SABC Medical Aid
• Treatment centres that are not registered or are not on the designated service providers list (DSP)

Coverage Caps And Limits

Like all medical aids, SABC has annual limits to its benefits, and these maximum limits will vary depending on the plan chosen by the member. These limits include the number of therapy sessions, inpatient stays, and specific treatment modalities covered, including Cognitive Behavioural Therapy (CBT), Motivational Enhancement Therapy (MET), Family Counselling, and medically supervised detoxification.

Members can contact us at We Do Recover, and we can talk to SABC on their behalf to find out what benefits and extent of coverage they are eligible for and, if appropriate, start the pre-authorisation process.

Conclusion

SABC Medical Aid covers rehab treatment for substance use disorders under the premium prescribed benefits (PMBs), which means they are legally obliged to offer 21 days of inpatient treatment and 3 days of medically supervised detoxification per year. However, most medical aid plans require a co-payment before admission for a 21-day inpatient program.

Members should be aware that rehab treatment coverage varies depending on the plan chosen and should review accordingly. Understanding your plan’s benefits, coverage, limitations, and exclusions will allow you to make an informed decision when selecting your inpatient treatment program.

We understand that the admin behind pre-authorisation and admissions can be taxing at We Do Recover. We are committed to helping you through the process step by step. Contact us today at 081-444-7000.