Does Your Medical Aid Cover Drug Rehabilitation?

Does Your Medical Aid Cover Drug Rehabilitation?

Does your medical aid provide coverage for accredited inpatient drug rehabilitation and the prescribed minimum benefits you might need?


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Medihelp Medical Aid members can receive coverage for drug rehab for up to 21 days, including a 3-day medically supervised detoxification. To obtain the full extent of their plan coverage, members must use accredited inpatient rehab facilities, which ensures quality treatment for their substance use disorders. The coverage falls under the prescribed minimum benefits (PMBs), which all medical aid schemes must cover.

At Changes Addiction Rehab, our multidisciplinary team is equipped with the skills and experience to deliver quality treatment needed to help individuals struggling with substance use disorders and to equip them with practical skills to ensure long-term sustainable recovery.

Overview Of Medihelp Medical Aid

Medihelp Medical Aid provides comprehensive coverage for addiction treatment in South Africa. The scheme offers a range of options, including inpatient drug rehab, certain outpatient services, and medically supervised detoxes, ensuring that members have access to the care they need and can feel secure in their coverage.

Types Of Rehab Treatments Covered By Medihelp

Members can receive up to 21 days of inpatient drug rehab coverage, including a 3-day medically supervised detoxification. This treatment is covered at approved facilities.

Drug rehab treatment therapies may include:

  • Individual counselling
  • Group therapy
  • Family therapy

Outpatient program services are covered, but limits may apply. Members should review their plans to understand their options.

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Eligibility Criteria For Coverage

To access coverage for drug rehab, members must meet certain criteria. These include:

  • Having an active membership
  • Been approved through a pre-authorisation process
  • Using network providers

Medihelp implements a standard pre-authorisation procedure that must be adhered to. Failure to do so will result in being denied coverage for drug rehab.

Additionally, Some plans have waiting periods or co-payments upon admission.

Understanding Addiction Treatment Coverage

Medihelp members are covered in their substance use disorders at drug rehabs. However, certain limitations may apply.

Inclusions In Addiction Treatment

Medihelp Medical Aid covers large portions of addiction treatment programmes under their prescribed minimum benefits. Luckily, this extends to all plans offered by Medihelp.

This coverage may include:

  • Residential inpatient treatment
  • Medically supervised detoxification
  • Outpatient services
  • Counselling sessions
  • Group therapy

Plans cover up to 21 days of inpatient treatment, including a 3-day supervised detoxification.

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Limitations And Exclusions

While Medihelp may offer comprehensive coverage to its members, there are limitations and exclusions to consider when choosing a plan:

  • All treatments must be pre-authorised through Medihelp Medical Aid
  • Members must select a facility on the designated service providers list (DSPs) to receive the full extent of their benefits
  • Medihelp does not cover treatments that are not deemed medically necessary

Pre-Authorisation Procedure For Medihelp

A pre-authorisation is required to be admitted into a drug rehab treatment facility. Medihelp has put into place specific steps that must be followed sequentially for coverage to be approved.

Our admissions team at Changes Addiction Rehab will do the pre-authorisation procedure on your behalf to make admission into our facility more accessible; this is what it will look like:

  1. We will phone Medihelp Medical Aid and give them your ICD-10 codes, relevant documentation and our facility’s practice numbers.
  2. Most importantly, no referral letter from a medical professional will be needed for admission.

The process is uncomplicated and takes less than 10 minutes. Our aim is to get you the help that you need as quickly and efficiently as possible.

Network Providers And Treatment Facilities

Medihelp Medical Aid uses a network of facilities for addiction treatment; this system affects coverage for coverage and costs for members seeking care for their substance use disorders.

Preferred Providers

Medihelp Medical Aid has a list of Designated Service Providers (DSPs) for drug rehab treatment facilities. When members choose these facilities, their co-payments are less.

These network providers include various treatments for substance use disorders, such as:

  • Inpatient treatment
  • Outpatient treatment services
  • Detoxification
  • Counselling sessions

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Coverage In Non-Network Facilities

Medihelp Medical Aid may provide coverage in these drug rehab facilities; however, members will be liable to much larger co-payments upon admission; the exact amount will vary depending on the plan chosen by the member.

Member Support And Resources

Members struggling with substance use disorders can benefit from the comprehensive benefits offered by Medihelp Medical Aid plans, providing them with the support and resources they need to overcome their challenges.

Counselling Benefits

Medihelp provides counselling sessions to members struggling with addiction. These benefits include one-on-one sessions with professionally trained counsellors and psychologists in a safe and confidential environment.

Group therapy is another benefit that Medihelp offers its members, but it is plan-dependent. Group therapy provides a supportive environment where members can share their experiences, learn from others, and build a strong support network, which can be crucial for long-term recovery.

These benefits can be claimed while being treated in a drug rehab facility.

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Conclusion

Medihelp Medical Aid members can receive up to 21 days of inpatient drug rehab, including a 3-day medically supervised detoxification. To receive the full extent of their benefits, members must choose a facility on the designated service providers list.

Their plans range from basic to comprehensive, ensuring that all members with diverse needs and budgets are catered to and cared for.

At Changes Addiction Rehab, we provide our patients with the highest level of care, which is why we have partnered with Medihelp. This partnership ensures that their patients receive the best care possible. Call us today to start your pre-authorisation.

Are Drug Rehabs Covered Under Medihelp Medical Aid Plans?

Yes, Medihelp Medical Aid is legally obligated to cover addiction treatment under all its plans as it falls under the prescribed minimum benefits (PMBs).

What Aspects Of Addiction Treatments Are Included In Medihelps’ Benefits?

Medihelp benefits include inpatient treatment, certain outpatient services, counselling and group therapy sessions.

Does Medihelp Medical Aid Cover Secondary Treatment?

No, members will be liable to pay private fees for secondary drug rehab treatment.

Related Questions

Can a medical aid be compelled to pay for an inpatient detox or rehab under Prescribed Minimum Benefits?

Short answer: sometimes — it depends on how the admission presents clinically. Under the Medical Schemes Act, schemes must fund PMBs for emergency medical conditions and certain listed diagnoses regardless of your plan option. An acute, life‑threatening withdrawal or overdose that requires hospital-level care is an emergency PMB and should be funded from the scheme’s risk pool. Chronic, planned admissions for long-term residential programmes are not automatically PMBs unless the specific ICD diagnosis and treatment protocol fall under the PMB definitions. Practically, that means if detox is clinically urgent (severe withdrawal signs, suicidal ideation, uncontrolled comorbidity) the scheme should cover an accredited inpatient level of care; if it’s elective residential rehabilitation, coverage will depend on your plan’s hospital and mental health benefits, DSP rules and pre-authorisation. Always get a clear clinical motivation from a treating medical practitioner and request PMB consideration in writing.

What exact clinical evidence will a scheme demand before authorising inpatient addiction treatment?

Schemes want medical detail, not slogans. Expect a psychiatric or medical assessment with documented diagnosis using ICD/DSM codes, a clear account of recent substance use and complications, risk assessments for suicide and medical instability, physical examination and relevant blood tests, a detox protocol if withdrawal is likely, and a multidisciplinary treatment plan with objectives, expected length of stay and planned aftercare. The admission letter should include the admitting practitioner’s HPCSA registration, facility accreditation status, tariff estimate and justification for inpatient care versus outpatient alternatives. Without that clinical sheet, pre-authorisation will be refused or delayed — and retrospective PMB claims are harder to win. If you’re in Johannesburg, get this packed by a GP or psychiatrist who knows scheme language; a bland referral won’t cut it.

My preferred rehab in Johannesburg isn’t on my scheme’s DSP list — does that kill my chance of cover?

No — but it complicates things. If the claim qualifies as a PMB (for example, an emergency detox), the scheme must fund it even if the facility is not a DSP, though they may apply tariffs or co-payments and will require clinical motivation and often retrospective review. For non-PMB admissions, many schemes only pay fully for treatment at their DSPs and will either refuse or apply a large co-payment for non‑DSP facilities. Practical steps: ask your scheme for a written explanation of DSP rules and potential co-pay amounts, get a detailed cost estimate and clinical motivation from the rehab, and request pre-authorisation. If the scheme refuses, you can escalate through internal appeal, involve your broker, or lodge a complaint with the Council for Medical Schemes — but while you do that, negotiate with the facility for deferred payment or a reduced rate so treatment isn’t delayed.

Which parts of addiction care do families typically have to pay for out of pocket despite medical aid membership?

Expect gaps. Common out‑of‑pocket items include long-term residential therapeutic community fees beyond scheme day limits, non-medical 'holistic' add-ons (equine therapy, expensive detox supplements, private family therapy sessions), transport to and from the facility, accommodation for family visits, and aftercare sober-living placements that aren’t registered as clinical services. Pharmacies and outpatient psychotherapy after discharge often fall under day‑to‑day or chronic benefits with separate limits; opioid substitution therapy (methadone) coverage varies widely and may not be fully covered unless prescribed and funded correctly. Also budget for co-payments when the facility charges above scheme tariff. Always get an itemised quote up front and a written statement from the scheme about what line items they will or won’t fund.

My scheme has rejected an admission — what realistic steps get treatment approved or funded in the short term?

Move fast and advocate rigorously. First, obtain a full clinical motivation from the treating medical practitioner that addresses why inpatient care is clinically necessary now and asks explicitly for PMB consideration if appropriate. Request urgent pre-authorisation or retroactive cover if already admitted. Escalate to the scheme’s case manager and your broker; ask for a written reason for rejection and the applicable scheme rule. If the matter is time-sensitive and life‑threatening, insist on emergency PMB cover and document all communication. If the scheme stands firm, lodge an internal appeal immediately and prepare supporting records from specialists. If internal appeal fails, you can submit a complaint to the Council for Medical Schemes while negotiating payment plans with the facility. In Johannesburg many families combine a short bridge payment to secure admission with simultaneous appeals — don’t accept "no" without clinical justification, and use the CMS complaints process if the scheme’s refusal contradicts clinical evidence.

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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.