Psst: did you know your medical aid plan *has* to pay for trauma-related treatment?

If you or anyone you know have been a victim of significant trauma, including physical or sexual abuse, and are suffering from acute stress disorder as a result, please know that if you are on medical aid, the scheme has to pay for either 3 days of in-hospital treatment or 12 outpatient consults for psychotherapy or counselling out of its “own” pocket.

Need more information on PMBs?

Huh? How does that work? I’m only on a hospital plan!

So this is how it works: The government has identified 270 conditions that have to be treated in and out of hospital, to a minimum level of care, regardless of what medical aid plan you have. So, even if you are just on a hospital plan, your scheme has to pay for your out-of-hospital consults with your pulmonologist if you have asthma (for example). These 270 conditionsa are known as PMBs (Prescribed Minimum Benefits) and you can read more about them here.

You can also see a full list of the 270 PMB conditions here.

So, how does mental health fit into this?

These PMB mental conditions must be covered by medical aids without charging the member out-of-pocket expenses, assuming that protocols and DSPs (Designated Service Providers) are followed.

CODE CONDITION TREATMENT
182T Abuse or dependence on Psychoactive substance, including alcohol Hospital-based management up to 3 weeks/year
910T Acute delusional mood, anxiety, personality, perception disorders and organic mental disorder caused by drugs Hospital-based management up to 3 days
901T Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse Hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts
910T Alcohol withdrawal delirium; alcohol intoxication delirium Hospital-based management up to 3 days leading to rehabilitation
908T Anorexia Nervosa and Bulimia Nervosa Hospital-based management up to 3 weeks/year or minimum of 15 outpatient contacts per year
903T Attempted suicide, irrespective of cause Hospital-based management up to 3 days or up to 6 outpatient contacts
184T Brief reactive psychosis Hospital-based management up to 3 weeks/year
910T Delirium: Amphetamine, Cocaine, or other psychoactive substance Hospital-based management up to 3 days
902T Major affective disorders, including unipolar and bipolar depression Hospital-based management up to 3 weeks/year (including inpatient electro-convulsive therapy and inpatient psychotherapy) or outpatient psychotherapy of up to 15 contacts
907T Schizophrenic and paranoid delusional disorders Hospital-based management up to 3 weeks/year
909T Treatable dementia Admission for initial diagnosis; management of acute psychotic symptoms – up to 1 week

I can benefit from this! What do I do now?

The best course of action is to speak to your doctor or psychologist, and to your medical aid as soon as possible. The medical aid will probably require your doctor to fill in forms, or motivate treatment. Once that is done, and if your condition meets the above criteria, you should be presented with a treatment plan by your scheme.

If you are an Argentum/rehealth client, we can help you with the process. (There is no extra cost to being a client. Just fill out this form to get started.)

Please spread the word!

These are extremely important benefits, that can be literally life-saving, and yet they are not very well known. Please share them far and wide (you can always link to this page if you want) so that more people are aware that they have help at their fingertips, already paid for by their medical aid premium.

Need more information on PMBs?