Question 1

Will my medical aid scheme cover the full cost of rehab?

Accepted Answer

Coverage varies among different medical aid schemes and plans. You can contact your broker, review your scheme or call us and we can pre-authorise on your behalf. If we call us to pre-auth on 081-444-7000, it’ll give us all the info and it’s really quick.

Question 2

How do I find a rehab facility that accepts my medical aid scheme?

Accepted Answer

Rehab centres accredited by the DSD (Dept. of Social Development) and the DOH (Dept. of Health), as well as the BHF (Board of Healthcare Funders), can claim from various medical aid schemes in South Africa. Be aware that rehabilitation centres that cannot claim from your medical aid are likely to be unlicensed.

Question 3

Is inpatient or outpatient rehab covered by my medical aid scheme?

Accepted Answer

Both inpatient and outpatient rehab programs may be covered, depending on your specific medical aid plan. Usually, your medical aid will cover 21 days of inpatient rehabilitation each year, for every family member on the policy. The comprehensive plans will cover 15 outpatient sessions with a psychologist too. Comprehensive medical aid plans may also cover other HPCSA registered addiction professionals.

Question 4

Can I access rehab services even if I have a pre-existing condition?

Accepted Answer

Many medical aid schemes in South Africa do cover rehab services for pre-existing conditions, but this coverage may be subject to waiting periods or other restrictions.

Question 5

What is the process for getting approval for rehab from my medical aid scheme?

Accepted Answer

The process may vary among different schemes. Any quality rehab that medical aids pay for will be able to take your details and get pre-authorisation very quickly. There’s no need for a referral from a healthcare professional like a GP, psychologist or psychiatrist. The rehab will provide your details along with the ICD-10 codes and clinic practice numbers for quick pre-auth. and approval.

Question 6

Does Discovery Health cover inpatient rehab and detox?

Accepted Answer

Yes. Discovery Health covers in-hospital detoxification and rehabilitation under Prescribed Minimum Benefits (PMB).

Question 7

How many days does Discovery Health fund rehab?

Accepted Answer

Discovery typically pays for up to 21 days of inpatient rehabilitation per year, plus up to 3 days of medical detox, subject to plan rules and pre-authorisation.

Question 8

Are outpatient or aftercare services covered?

Accepted Answer

Outpatient rehab services (counselling, therapy, etc.) are generally excluded under Discovery unless explicitly included in your plan beyond PMB provisions.

Question 9

Do co-payments or DSP rules apply?

Accepted Answer

Yes. If you receive treatment from a facility outside Discovery’s Designated Service Providers (DSPs), you may incur co-payments. Discovery may reimburse only up to a portion of the provider’s rate, leaving you with the balance.

Question 10

Will my medical aid pay for residential, outpatient or medication-assisted treatment?

Accepted Answer

Short answer: sometimes — but “cover” is not one-size-fits-all. Schemes differentiate between medically managed detox (usually treated as an acute hospital admission), inpatient residential programmes, outpatient therapy and medication-assisted treatment (MAT) such as methadone or buprenorphine. Approval depends on the clinical diagnosis, documented risk (suicidality, medical instability, failed outpatient attempts), correct ICD-10/DSM coding, a specialist referral (psychiatrist or medical practitioner) and whether the provider is a Designated Service Provider (DSP) for your scheme. Many schemes will pay fully for a medically necessary admission or acute detox; residential rehabilitation for psychosocial rehabilitation or long-term therapy often attracts limits, day caps or co-payments. MAT can be funded inconsistently — some schemes cover it under chronic medication or specialised programmes, others exclude certain drugs. Before admission get a written pre-authorisation number, confirm which services and medications are covered, and ask how in-network versus out-of-network rates affect payment.

Question 11

Exactly what clinical paperwork does the scheme want to approve an admission?

Accepted Answer

Don’t hand over a single GP note and expect approval. Schemes typically require a specialist referral, a documented psychiatric/substance-use assessment with DSM/ICD diagnosis, medical history, current medications, risk assessment (suicide, withdrawal risks, comorbid medical conditions), a clear multidisciplinary treatment plan (expected level of care, goals, length of stay), recent lab work/urine drug screen and a cost estimate from the facility. For detox there must be documentation of physiological dependence and withdrawal risk. For complex cases include prior treatment attempts and a psychiatrist’s motivation detailing why outpatient care is unsafe or insufficient. After admission you must submit regular progress reports and a discharge/aftercare plan to maintain funding. If you’re unclear, ask the facility’s case manager to compile the submission — they do this daily and can accelerate approval.

Question 12

My scheme approved admission but I still owe money — how do I avoid surprise shortfalls?

Accepted Answer

Authorisation ≠ full payment. Schemes pay according to tariff schedules (the scheme rate) and many providers charge higher private rates, creating a shortfall. Shortfalls can also come from annual limits, day caps, co-payments or exclusions for specific therapies. To avoid surprises obtain a written cost estimate from the facility, ask your scheme for the applicable scheme rate for that provider and the expected out-of-pocket amount, and check whether the provider is a DSP (DSP use often reduces or removes shortfalls). Consider gap cover only if it explicitly covers mental-health and addiction shortfalls. If there’s a projected shortfall, ask the treating clinician to submit a clinical motivation for higher rates based on complexity — schemes sometimes authorise a portion of the excess for medically complex patients.

Question 13

The scheme denied pre-authorisation. What are the fastest, most effective next steps?

Accepted Answer

Act immediately. First get the denial reason in writing and the author who made the decision. Ask your treating specialist to prepare a formal appeal: a focused clinical motivation referencing the specific denial grounds, supporting assessments, risk factors, and why the requested level of care is clinically necessary. Request an urgent peer-to-peer review between your psychiatrist and the scheme’s medical advisor. Lodge the scheme’s internal appeal within their timeline while continuing any necessary emergency care and documenting it clinically. If the scheme still refuses and the case meets PMB criteria or you suspect incorrect application of scheme rules, escalate to the Council for Medical Schemes (CMS) complaint process and consider legal advice; time is critical where risk to life or severe withdrawal is present, so document everything and push for expedited review.

Question 14

Do Prescribed Minimum Benefits (PMBs) mean I automatically get inpatient rehab paid?

Accepted Answer

No — PMBs provide mandatory cover for specific defined conditions and emergency treatment, but they don’t automatically pay for every inpatient rehab admission. PMB entitlement can apply where an acute episode or a recognised chronic condition meets the criteria and is treated under the relevant Diagnostic and Treatment Pair, and where clinical necessity is demonstrated. Many psychosocial or long-term residential programmes fall outside PMB parameters unless the condition and treatment meet the PMB definitions. Always check if your case can be considered under PMB rules, ensure correct ICD-10 coding and specialist involvement, and submit a PMB motivation if applicable. If the scheme rejects PMB application, you still have the right to appeal through the scheme and to lodge a complaint with the Council for Medical Schemes if you believe your statutory entitlements were wrongly denied.

Benefits of Medical Aid Paying for Rehab	Without Medical Aid Paying
Quick access to evidence-based therapies and a tailor-made treatment plan	Limited treatment options due to financial constraints
Full-time inpatient programme: GP, detox, psychologists, psychiatry, nursing, group and individual therapy and lectures	Out-of-pocket expenses for inpatient or outpatient treatment
Financial support for inpatient and outpatient programs	Struggling to afford necessary treatment programs
Reduced financial burden	Potential debt for rehab expenses
Opportunity to focus on healing and personal growth	Stress about treatment costs hindering recovery progress
Access to professional, individualised help and guidance	Difficulty finding appropriate support and resources
Reinforcement to seek addiction treatment sooner	Delay in seeking help due to cost concerns
Potential coverage for aftercare services	Access to aftercare services and dependent on finances
Possible longer treatment adding too recovery commitment	Higher risk of relapse due to inadequate treatment
Improved chances of long-term success and lasting recovery	Lower chances of long-term success and lasting recovery

Most South African Medical Aids Provide Rehab Coverage