Mental health conditions and medical schemes – what’s covered?

South Africans are often called resilient – we’ve weathered a pandemic, political instability, rampant unemployment, and load shedding – and potential water issues are often on the horizon.

However, when it comes to mental health conditions, many suffer in silence, and may forgo a diagnosis. According to the South African Depression and Anxiety Group (SADAG), one in three South Africans will suffer from a mental illness at some point in their life.

This article explores which mental health conditions tend to be covered by medical aid, and what this cover entitles you to.

Tip: Being in debt can cause or exacerbate depression, anxiety and stress. Explore how debt consolidation can help. 

Prescribed minimum benefits

All medical schemes in South Africa, irrespective of the plan or option, are legally obliged to treat patients for the 271 Prescribed Minimum Benefit (PMB) conditions determined by the Council for Medical Schemes.

PMBs are conditions that warrant continuous care to improve members’ health, and the list includes certain mental health conditions.

All medical scheme members are entitled to in-hospital treatment and medical management for these conditions, says Jarrod Higgs, advisor sales team leader at Bestmed. However, it’s important to note that different providers have different approaches to treatment.

“There are various types of diagnoses that one has to recognise and treat, and for each diagnosis, there are numerous treatment plans to consider,” says Dr Noluthando Nematswerani, Head of Clinical Excellence at Discovery Health.

“The extent of cover depends on the member’s plan, the diagnosis, and the severity of that diagnosis.”

Which mental health disorders are covered? 

Higgs notes that medical scheme members can receive specific care in-hospital for particular mental health disorders such as anxiety, acute stress, delusions, psychosis, and affective disorders such as schizophrenia, and bipolar or depressive disorders.

“In addition, they can be admitted to hospital or sub-acute facilities as a result of the abuse of alcohol or chemical substances,” he says.

In addition, up to 15 outpatient psychotherapy sessions are included per year under the PMB provision, for more than 40 major affective disorders, including schizoaffective-, bipolar affective- and recurrent depressive disorders.

There are also 27 chronic disease list conditions that are covered. To register a chronic condition, members require a valid diagnosis by a psychiatrist or psychologist, says Higgs.

“As it stands, the only mental illness conditions that are mandatory for a medical scheme to cover in this list of 27 are schizophrenia and bipolar mood disorder.

“Other conditions, such as major depression, are usually only covered by medical schemes on more comprehensive options, with certain limitations. For example, there may be a rand limit, or a portion of the treatment cost that will be covered.”

Mental illness cover under PMBs

The table below indicates mental illness cover under PMBs and the limits applicable to each condition. All medical aids offer similar benefits, though networked facilities differ.

Who qualifies for treatment?

Anyone is covered in terms of PMBs, but if you require prolonged treatment you must register for the mental health programme offered by your medical scheme.

Compared to the day-to-day benefits members receive, the mental health programme offers more comprehensive benefits, says Michelle John, a medical aid and gap cover broker at Cooke Fuller Group.

What many members don’t know is that a medical broker can advocate for additional benefits on a member’s behalf – and will often succeed in securing them.

“Members are not always familiar with the rules, or with their rights,” says John. “Even members on lower-priced plans are entitled to receive extensive benefits with and without PMB – but bear in mind that the level of in-hospital care will depend on the diagnosis justifying admission.”

John says hospital cover is usually more than adequate - above R40,000 in total for a pre-determined number of days, depending on the plan. Mental health conditions are typically managed in hospital or in a psychiatric clinic, for a set number of days.

John says brokers don’t charge for their services as they receive commission from medical schemes.

How does gap cover help?

John says that gap cover – an insurance product – is particularly useful, as many specialists charge above medical aid rates.

“They honour only in-hospital treatments – and even then, some can charge up to 500% of the scheme rate,” she warns.

“While your medical aid may provide 100% cover, you will still be liable for the shortfall. On the plus side, your medical scheme will inform you beforehand if a specialist is not contracted to their network or charges higher rates.”

This sub-limit means that you may have to use your medical savings account - if you have one - to settle payments, especially if specialists charge upfront and ask you to claim directly from your medical scheme.

Can I join a medical scheme with a pre-existing mental health condition?

John says you can join but there’s a three-month waiting period to claim if you haven’t been diagnosed and you’re not on chronic medication - that is, medication you take every day for the foreseeable future.

If you have a diagnosis, you must disclose this when you apply to join a scheme. There will then be a 12-month waiting period before you can claim for your condition.

Challenging the mental health stigma

John says she has seen a huge increase in members applying for mental health benefits over the past 12 months.

“What’s more concerning is that many people are self-medicating and not addressing their mental health issues with a professional,” she says.

Higgs adds, “Mental illness is not something to be ashamed of – we need to learn to seek help, as mental health conditions can be managed and treated.”  

He notes that Bestmed funded more than R130 million in claims in 2022, for in-patient and out-patient psychotherapy or treatment, excluding the amount spent on chronic medication.

John says medical schemes are very understanding when it comes to mental health, and take the matter very seriously.

“They offer mental health assessments to members, who are then nudged into discovering if they have a treatable condition,” she says. “Sadly, so many people only reach out once they realise they can’t deal with their illness on their own.”

Tip: Don’t let over-indebtedness destroy your mental health. A debt counsellor can help you to work out a payment plan.