Question 1

Does Fedhealth cover inpatient addiction treatment and detox?

Accepted Answer

Yes. Fedhealth provides cover for in-hospital detoxification and rehabilitation for substance use disorders under PMB rules, subject to plan limits and pre-authorisation.

Question 2

How many days of rehab does Fedhealth typically fund?

Accepted Answer

Most schemes (including Fedhealth) fund up to 21 days of inpatient rehabilitation per year, with up to 3 days for medically supervised detox, depending on your plan option.

Question 3

Are outpatient counselling or aftercare services covered?

Accepted Answer

Generally, outpatient counselling and therapy are limited or excluded unless your specific Fedhealth option provides additional benefits beyond PMBs. Check your plan rules and any DSP requirements.

Question 4

What is required for pre-authorisation with Fedhealth?

Accepted Answer

Pre-authorisation is mandatory. We’ll submit your practice numbers and ICD-10 codes, confirm availability with the facility, and obtain approval before admission.

Question 5

Exactly what clinical papers does my medical scheme want before it will authorise 21 days of inpatient rehab?

Accepted Answer

Don’t send a sentence and hope for the best — schemes want a clinical file. At minimum you’ll need a referral from a GP or psychiatrist, a current psychiatric/substance-use assessment (ICD‑10 codes F10–F19), a clear statement of acute risk (suicide, medical complications, severe withdrawal), a day-by-day treatment plan showing why inpatient care is necessary, results of recent bloods and any ECGs, a medication list, and a written cost estimate from the facility. If there are comorbid medical problems (HIV, TB, liver disease) include those reports. Ask the facility to package this into a single PDF and to add the treating clinician’s motivation — schemes respond to clinical rationale, not to promises of behaviour change.

Question 6

Will the scheme actually pay for all 21 days, or will they only fund detox and leave psychosocial therapy unpaid?

Accepted Answer

Most schemes split the claim into “medical/hospital” components and “non-medical” rehabilitation programmes. Acute detox and admissions for a psychiatric risk are usually covered under hospital benefits if properly motivated, but the extended psychosocial therapy days that follow are commonly limited or excluded, especially if the facility is not contracted as a hospital. Expect partial approvals: they may fund the first 5–10 medically necessary days and reject the rest, or approve only a hospital tariff that is lower than the facility’s private rate. Always get the authorisation in writing with the number of approved days and which tariff/benefit it comes from — that’s what you’ll fight or plan around.

Question 7

We need an urgent admission — how fast does prior authorisation happen and what if the scheme stalls while withdrawal is imminent?

Accepted Answer

Tell the scheme it’s an emergency and ask for telephonic or “immediate” authorisation; many schemes provide provisional approvals over the phone if the facility’s doctor phones in a motivated case. The facility must then follow up with full documentation within 24–72 hours. If you’re past that and the scheme refuses retroactively, the family can be left paying. Practical moves: get a written provisional authorisation number, have the hospital social worker or treating psychiatrist submit the full clinical file urgently, and if the scheme still refuses, escalate immediately to the scheme’s case manager and lodge an internal appeal. If the clinical risk is high, make sure the treating psychiatrist documents imminent harm — schemes are likelier to approve admissions where delay would be unsafe.

Question 8

My relative has depression and heavy alcohol dependence — does a dual diagnosis make funding more likely, and how should clinicians present it?

Accepted Answer

Yes — complexity helps. Dual diagnosis shifts the claim from “lifestyle” to clear medical necessity when you document interaction effects: medication instability, suicide attempts, medical decompensation, failed outpatient treatments, or increased risk during withdrawal. The treating psychiatrist should spell out how the mental disorder and the dependence exacerbate each other, list prior interventions that failed, and show why inpatient, multidisciplinary care is needed now. Use objective markers (suicide ideation, liver function, repeated ER visits) rather than vague language — schemes respond to clinical severity, not to moral arguments.

Question 9

If the scheme refuses the full 21 days, what practical and legal steps can families take quickly in South Africa?

Accepted Answer

Start with an internal appeal: get an independent or second psychiatrist to write a focused clinical motivation, submit it with any missing tests, and ask the facility to negotiate a time-limited package while you appeal. Ask the scheme for an itemised reason for the refusal and the benefits they will cover in writing — that’s required under the Medical Schemes Act. If internal appeal fails, lodge a complaint with the Council for Medical Schemes (CMS). Meanwhile, negotiate a reduced private rate with the facility or a split-payment plan; many centres will accept a deposit and bill the scheme directly for the remainder. Litigation is possible but slow and costly; in practice the fastest wins are a strong clinical re-motivation, an interim private admission negotiated with the provider, and escalation to the CMS if the scheme’s refusal is inconsistent with the scheme rules or statutory obligations.

Medical Aid Covers 21 Days Of Addiction Rehabilitation

Key Take-Aways

Fedhealth’s Coverage for Addiction Rehabilitation

Does Fedhealth Pay for Addiction Rehabilitation?

Finding the Right Rehab Center

If You Need More Information About Medical Aid Coverage

FAQ: Fedhealth Medical Aid Rehab Cover