What benefits does my medical scheme offer for mental health?

Your mental health is as important to maintain as your physical health.

An increasing number of South Africans are experiencing and identifying mental ill-health amid heightened work, social, health and crime-related stress. The South African Depression and Anxiety Group says one in three South Africans will suffer from a mental health condition at some point in their lives.

Both government and private mental health professionals and facilities are in high demand in South Africa, making it extremely difficult to access care in public facilities, while waiting times and costs for private facilities are high.

Medical schemes are obliged to offer all members certain mental health benefits, but if your condition is not one of those listed, more comprehensive and expensive options typically provide the best benefits.

Mental health benefits schemes must provide

All medical schemes in South Africa are required to cover certain mental health benefits that are listed as prescribed minimum benefits (PMBs).

The PMB list includes 271 medical conditions, 26 chronic (ongoing) conditions and any emergency medical condition.

Mental health conditions listed as chronic conditions

Mental health conditions that are covered by the PMB chronic condition list include:

• Schizophrenia; and
  
  
• Bipolar affective disorder.

For these conditions, the diagnosis, care and ongoing medication must be covered by your scheme.

In order to enjoy these benefits, you may be expected to enrol in the scheme’s chronic medication programme – a process that may require you to get forms completed by your treating doctor.

Your scheme may also have a designated service provider you need to use in order to enjoy full cover for your condition and you may need to use medicines listed on the scheme’s formulary of medicines. If the formulary medicine is not suitable, your treating doctor needs to motivate for the use of an alternative medicine.

Mental health conditions listed as PMBs

A few other mental health conditions are covered as part of the 271 conditions and the treatment to which you are entitled is listed.

These conditions are:

• Alcohol withdrawal or intoxication delirium: up to three days of treatment in hospital;
  
  
• Anorexia nervosa and bulimia nervosa: up to three weeks treatment in hospital per year or 15 consultations as an outpatient;
  
  
• Attempted suicide: up to three days treatment in hospital or up to six consultations as an outpatient;
  
  
• Brief reactive psychosis: up to three weeks treatment in hospital per year;
  
  
• Amphetamine, cocaine or other psychoactive substance delirium: up to three days in hospital;
  
  
• Major depressive disorder (unipolar depression) or bipolar depression: up to three weeks treatment in hospital per year (including inpatient electro-convulsive therapy and psychotherapy) or up to 15 psychotherapy consultations as an outpatient;
  
  
• Schizophrenic and paranoid delusional disorders: up to three weeks treatment in hospital per year; and
  
  
• Treatable dementia: admission for initial diagnosis and up to one week for managing acute psychotic symptoms.

Unfortunately, benefits are often hopelessly inadequate for the treatment required for serious, often life-threatening, mental health conditions that require long periods in mental health facilities as well as ongoing outpatient consultations with both psychiatrists and psychologists.

The ongoing medication required to treat the condition is often not included.  

In order to enjoy these benefits you may need to apply for approval of the PMB, particularly if it is out-of-hospital treatment. Your doctor can also motivate for additional treatment, which may or may not be approved.

Remember if you have two conditions, for example anorexia and depression, you should be able to access benefits for both conditions.

More benefits on higher options

In addition to the PMBs, some schemes offer additional mental health benefits, but benefits for costly treatment are often only offered on more comprehensive and expensive medical scheme options.

• Some schemes offer mental health wellness benefits. Some just offer information to help you manage your mental health, while others offer support in accessing standard benefits, or access to social workers or counsellors. A few cover medicines and GP visits for depression, as well as online psychotherapy.
  
  
• Some schemes have allied, therapeutic and psychology benefit limits that pay from your day-to-day benefits or medical savings accounts. If you have above-threshold benefits, you have to pay out-of-pocket when you are in the self-payment gap but benefits are paid again at the scheme rate when your expenses exceed the threshold.
  
  
• Some more expensive options cover additional chronic conditions including some mental health ones, such as delusional disorder, generalised anxiety disorder, obsessive compulsive disorder, panic disorder and post-traumatic stress disorder.

Disease management programmes for mental health

Many schemes have disease management programmes (DMPs) that aim to help you manage chronic conditions or serious illnesses like cancer. Some disease management programmes cover mental health conditions giving you access to:

• Education about the condition;
  
  
• Help in managing your medication;
  
  
• Support groups;
  
  
• Counselling; or
  
  
• Psychotherapy.