Medical Aid Cover For Inpatient Addiction Treatment

Medical Aid Cover For Inpatient Addiction Treatment

Does your medical aid plan provide the Prescribed Minimum Benefit of 21 days funded inpatient addiction treatment and preauthorisation?


Genesis medical aid addiction treatment

If you are searching for Genesis medical aid addiction treatment, your plan entitles you to in-patient rehab at accredited centres such as Changes Addiction Rehab in Johannesburg. Addiction is covered as a Prescribed Minimum Benefit (PMB), which guarantees a minimum of 21 days of funded treatment each year. This guide shows you how Genesis applies cover, what is included, and how to complete the pre-authorisation process.

This guide explains how Genesis medical aid pays for addiction rehab, what the 21-day rule means, and how to secure pre-authorisation for admission. It also clarifies what your plan covers for in-patient rehab, out-patient therapy, and aftercare. Use it as the only guide you need when considering treatment at Changes Addiction Rehab.

PMB’s and Genesis’s Obligation

Genesis, like every registered medical aid scheme in South Africa, must provide cover for PMBs. Substance Use Disorder (ICD-10 codes F10–F19) is included.

Key PMB cover rules:

  • 21 days in-patient care per year for detox and rehabilitation
  • Cover when treatment is medically necessary and supervised
  • Paid from risk funds, not your day-to-day savings

This ensures all Genesis members, regardless of plan option, are guaranteed a minimum standard of addiction treatment.Genesis-Medical-Aid-drug & alcohol rehab joburg

Genesis carries a proud legacy in the healthcare provider landscape within South Africa. Over the years, Genesis has introduced flexible plans to cater to its members’ diverse needs and budgets, making healthcare accessible. The scheme prides itself on maintaining high standards of customer service while catering to the vast audience of South Africa.

does-genesis-medical-aid-cover-drug-rehab-in-south-africa.

Substance Abuse Treatment Coverage

Genesis Medical Aid has set aside specific provisions for substance abuse treatment. Understanding these benefits helps members manage their expectations.

Inpatient Rehab Treatment

Inpatient rehab treatment is covered for up to 21 days, including a 3-day medically supervised detoxification. Inpatient treatment is where individuals receive the most intensive care for their substance use disorders.

At Changes Addiction Rehab, our multidisciplinary team works with our clients to create tailored programs to suit their needs to ensure long-term recovery.

Detoxification 

The detoxification process is a critical part and the first step of the inpatient treatment program. Detoxes manage withdrawal symptoms, reduce the risk of complications and increase the likelihood of long-term sustainable recovery.

Individual Counselling

Individual counselling is a cornerstone in mental health treatment centres. Members of Genesis Medical Aid can claim individual counselling sessions during their stay in residential inpatient drug and alcohol rehab.

Individuals will learn to identify their triggers and combat maladaptive addictive behaviours through intensive individual therapy during their inpatient rehab treatment stay. 

At Changes Addiction Rehab, we employ different therapeutic modalities, including:

  • Cognitive Behavioral Therapy (CBT)
  • Dialectical Behavioural Therapy (DBT)
  • BrainWorking Recursive Therapy (BWRT)
  • Motivational Enhancement Therapy
  • Family Therapy
  • Occupational Therapydoes-genesis-cover-inpatient-treatment

 

Pre-Authorisation For Substance Abuse Treatment

The pre-authorisation process for Genesis Medical Aid is simple; however, members must ensure that the correct information is handed over to the scheme to avoid delay.

Pre-Authorisation For Genesis Medical Aid

Before being admitted into an inpatient rehab facility, a pre-authorisation process must be followed to be approved for treatment coverage from Genesis Medical Aid. This step ensures the treatment aligns with the scheme’s terms and conditions and covers the prescribed minimum benefits.

With your permission, our admissions team at Changes Addiction Rehab will do the pre-authorisation procedure on your behalf. We will phone Genesis and provide them with your ICD-10 codes, our facility’s practice numbers and any additional relevant information. 

We prioritise the well-being of our patients and want your admission into our facility to be as efficient and stress-free as possible. 

How Genesis Medical Aid Covers Rehab

Genesis is a self-funded medical aid scheme with transparent benefit rules. Here’s how cover works:

1. In-Patient Addiction Treatment

  • Genesis pays a set scheme rate for in-patient rehab, including accommodation, meals, detox, and therapy
  • PMBs guarantee 21 days of funded treatment per calendar year
  • Additional days depend on your plan limits and authorisation

2. Out-Patient and Aftercare

genesis medical aid scheme addiction treatment rehab

Why Pre-Authorisation is Essential

Genesis medical aid addiction treatment requires pre-authorisation for addiction rehab admissions. Without it, claims are declined.

The 4-step process at Changes Rehab:

  1. Contact admissions. Our team knows exactly how to work with Genesis.
  2. Clinical assessment. We confirm diagnosis and required level of care.
  3. Submission. We send a treatment plan with ICD-10 codes (F10–F19) to Genesis Managed Care.
  4. Authorisation number. Genesis approves the admission and issues a number that guarantees funding for the approved stay.

Important: Always use the clinical term Substance Use Disorder. This ensures claims are treated as medical, not lifestyle, cases.Genesis medical aid addiction rehab drugs and alcohol joburg changes rehab

What Genesis Funds at Changes Rehab

With pre-authorisation, Genesis medical aid typically funds addiction treatment:

  • Medically supervised detox
  • In-patient rehab with counselling, groups, and medical oversight
  • Relapse prevention and coping skills training
  • Family therapy where benefits apply
  • Discharge planning and structured aftercare

At Changes Rehab we:

  • Bill Genesis directly for approved benefits
  • Align all treatment to recognised medical aid codes
  • Advise you in advance about any possible co-payments

Changes Addiction rehab genesis medical aids pays for treatment

Maximising Your Genesis Benefits

Addiction treatment often requires more than 21 days. Here’s how to get the most from your medical aid:

  • Use out-patient mental health benefits for follow-up therapy
  • Check gap payments. If the facility charges more than the scheme rate, we tell you upfront
  • Explore secondary or extended care where clinically justified. Our team negotiates with Genesis for additional approval

Why Genesis Medical Aid Addiction Treatment at Changes Rehab

  • Accredited by Department of Health, fully compliant with PMBs
  • Experienced in Genesis claims, with proven authorisation success
  • Comprehensive treatment, including detox, therapy, relapse prevention, and aftercare
  • Family support services, guiding loved ones through the process
  • Direct liaison with Genesis, so you focus on recovery while we handle admin

Does Genesis cover substance abuse treatment?

Yes. SUD is a PMB condition. Genesis funds at least 21 days of in-patient treatment each year.

Do I need pre-authorisation?

Yes. Without it, claims are declined. Our team secures approval before admission.

Which Genesis plans cover rehab?

All options cover PMBs. Specific limits vary by plan type.

Will I face a co-payment?

Sometimes. Genesis pays scheme rates. If facility rates exceed this, a gap may apply.

Does Genesis cover aftercare therapy?

Yes. Out-patient psychology or psychiatry sessions are usually funded from savings or day-to-day benefits.

What codes are used for addiction claims?

ICD-10 codes F10 to F19 for Substance Use Disorders are submitted in treatment motivations.

Does Genesis cover addiction rehabilitation and detox?

Yes, but only under Prescribed Minimum Benefits (PMBs). Genesis excludes rehabilitation services in its standard benefits, except where required by PMB law. Genesis Medical

How many days of rehab does Genesis cover under PMBs?

Typically up to 21 days of inpatient rehabilitation + detoxification may be covered under PMB entitlements (per scheme and plan limits).

Are outpatient counselling or therapy services covered?

No. Genesis excludes rehabilitation and related outpatient services from its non-PMB benefits. Only PMB entitlements apply. Genesis Medical

Is pre-authorisation required?

Yes. For any claims under PMB entitlement, you must follow the scheme’s authorization process, supply ICD-10 codes, and obtain approval before admission.

Related Questions

How will my medical scheme decide that my case meets the Prescribed Minimum Benefit for 21 days of inpatient addiction treatment?

Schemes don’t base PMB eligibility on good intentions—they want clinical justification. Expect them to ask for a formal diagnosis (ICD-10 or DSM-5 code), clear evidence of acute risk (severe withdrawal, suicide risk, medical instability) or a recognised dependency syndrome, and a treating clinician’s motivation that describes why inpatient care is clinically required now. Psychiatrist involvement or a specialist report strengthens the case; contemporaneous clinical notes, a withdrawal risk score, medication lists and any prior failed outpatient interventions are useful. The facility must submit a treatment plan with daily goals and an estimated length of stay tied to medical necessity. If these pieces aren’t documented up front, preauthorisation will stall—get the diagnosis, the risk statement and the consultant’s plan before you admit.

My scheme refused preauthorisation—what realistic steps get treatment funded fast or force a reassessment?

Start by demanding the exact reason for denial in writing and ask the scheme to reconsider with an enhanced clinical motivation within their internal appeal window. Immediately obtain a consultant psychiatrist’s clinical motivation and recent clinical notes; a second clinician’s supporting letter often flips decisions. If the case is urgent, push for emergency PMB funding on the grounds of acute risk—schemes must consider that. If internal appeal fails, lodge a complaint with the Council for Medical Schemes (CMS) and get legal advice if needed; that can be slow, so simultaneously explore short-term alternatives: negotiated self-pay blocks with the facility, family bridging loans, or staggered admission while pursuing the appeal. Keep records of every call, email, report and preauthorisation reference—administrative chaos is often their defence, and your paperwork is the counterargument.

My scheme approves only part of the 21 days or wants a co-payment—who covers the rest and how do I limit out-of-pocket exposure?

Partial approvals and co-payments are common; schemes pay according to their tariff structures, network rules and benefit rules, not necessarily the provider’s rate. The shortfall is usually for the patient or family unless you have gap cover or top-up benefits. Mitigate cost by requesting a full preauth cost estimate in writing, asking the scheme to justify the co-payment, and checking if you can use your Medical Savings Account for the balance. Negotiate a reduced self-pay rate with the facility, ask for phased admissions to limit upfront costs, or request an ex-gratia funding review from the scheme. If the co-payment is arbitrary or unexplained, escalate to the scheme’s clinical committee and, if necessary, the CMS—documented clinical necessity can sometimes overturn co-pay demands.

Does being admitted to a private centre outside my scheme’s network automatically mean I lose PMB cover?

No—PMBs are about clinical need, not network loyalty. Schemes may prefer network providers and can request transfer, but they cannot lawfully withhold PMB funding simply because you used a non-network facility if the treatment meets PMB criteria and a network provider cannot deliver equivalent care in time or place. You must show why the non-network centre was necessary: lack of suitable network beds, specific specialist expertise, or immediate risk that required admission. Expect the scheme to request motivation and proof that equivalent network care was unavailable; keep admission notes, bed availability correspondence and specialist recommendations to hand. If the scheme persists in refusing, escalate the clinical motivation and consider a CMS complaint while negotiating with the facility about interim self-funding arrangements.

What exact paperwork and clinical information should I bring to an admission in Johannesburg to avoid a paperwork rejection from my medical aid?

Bring the basics plus clinical detail: ID and medical aid card, the referring clinician’s letter with diagnosis and ICD-10/DSM-5 code, a consultant psychiatrist’s motivation or assessment, a current medication list, recent bloods and ECG if available, urine drug screen results, and any discharge summaries or outpatient notes showing prior treatment attempts. Include the facility’s written treatment plan, estimated daily tariff, and the admitting clinician’s contact and HPCSA number. Record the scheme contact name and preauthorisation reference during admission calls and insist on a written preauth or provisional authorisation number before bedside paperwork is finalised. Missing one of these documents is the fastest route to an administrative rejection—bring everything that proves clinical necessity, urgency and the facility’s proposed cost structure.

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© 2025 Changes Addiction Rehab PTY LTD (‎2013/152102/07) of 216 Weltevreden Road. Northcliff, Johannesburg, South Africa

Changes Addiction Rehab is licensed by the South African Department of Social Development (Practice No. 0470000537861) and the Department of Health, and is a registered detox facility and practice with the Board of Healthcare Funders. Our treatment programme is led by counsellors registered with the HPCSA, working alongside a multidisciplinary team of medical professionals under a unified practice. We are proud, standing members of the International Certification & Reciprocity Consortium (IC&RC), the Occupational Therapy Association of South Africa, the South African Council for Social Service Professions, the South African Medical Association, the South African Nursing Council and the South African Society of Psychiatrists. Changes Addiction Rehab has been in continuous professional operation since 2007, when it was founded by Sheryl Rahme, who has worked in the addiction treatment field since 1984. Our core clinical team brings over 100 years of combined professional addiction recovery experience.