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Claiming from Medical Aid?

One of the most common questions that psychologists receive is whether medical aid will cover therapy. Many people who are seeking therapy are concerned with whether their medical aid plan will pay for counselling sessions, how much will be covered and whether they have to pay upfront. These questions can unfortunately become barriers towards finding a therapist or affording therapy, as it may be difficult to negotiate the different terms and to know what to expect. This blog post aims to clear up some of these matters and help you take the first step towards booking a session.

Will My Medical Aid Cover Therapy?

Yes. Probably. Well, generally speaking, yes. The answer is that most medical aids cover my therapy rates (and the rates of many other psychologists). To consider this question fully, we need to consider several factors: the specific medical aid and plan, the cost of therapy, and the mental health professional. I will to answer the following questions:

What is Covered?

Medical aids only cover professionals who are registered with the HPCSA, such as clinical social workers, registered counselors and psychologists. As a Counselling Psychologist who is registered with the HPCSA, almost all medical aids consider therapy that I provide to be part of the services that qualify for their cover. Dependents or adult spouses on medical aid plans are also covered for therapy, typically from a joint medical aid savings. This cover then includes adults, teenagers and children, as I see individuals across a range of ages at my private practice. Medical aids normally cover only in-person as well as online therapy, Generally, the provided diagnosis does not affect whether medical aids pay or how much they pay, unless there is a specific benefit or PMB application.

Tree growing in money, symbolising the monetary investment in therapy and medical aid

Who Pays?

Some practices work as a cash practice, while others do not. In simplest terms, a cash practice means that a person or client will pay the practice directly and subsequent claim from the medical aid themselves. The medical aid then pays the client rather than the practice. I operate a cash practice, and have typically found that this suits many clients. Typically, payments come through quickly from medical aids, and they can then track their sessions and medical aid savings, and generally this is a painless process. Other practices operate by claiming from the medical aid on behalf of the client, and are paid directly by the medical aid. The client may then be responsible for a 'co-payment', such as sessions that are partially covered, missed sessions which medical aids to not reimburse, or when medical aid savings are finished.

How Much is Covered?

Having clarified how the payment works, you may wonder whether medical aids will pay the full amount. Each medical aid rate differs in terms of how much they cover, for example fro a 51-60 minute session, Bonitas covers up to R1173.40, while Discovery covers a maximum of R1135.60. This is similar to seeing specialist doctor – depending on the rate charged, different medical aids will cover different amounts of the fee. Many psychologists might indicate that they charge within medical aid rates, while others may offer a reduced rate or charge above medical aid rates. I charge within medical aid rates, so the cost of a therapy is R1030 per session, which lasts just over 50 minutes. This rate is within the amount covered by almost all medical aids. Next, I will consider where this rate is paid from, whether it is a separate benefit or medical savings.

Prescribed Minimum Benefits (PMBs)

What is a PMB?

Medical aids may pay for therapy sessions in a variety of ways, through medical aid savings. specific benefits such as a Prescribed Minimum Benefit (PMB). I am frequently asked how PMBs work and what they are. The greatest misconception about PMBs is that anyone wishing to have therapy can get a PMB. However, a PMB is specifically for severe and/or chronic mental illnesses, which each medical aid has to provide a minimum level of cover for. Mental disorders listed as PMBs include major depression, bipolar disorder, forms of psychosis and schizophrenia, but do exclude other diagnoses such as more minor depression, anxiety, some trauma and relationship challenges. Some motivation can be provided outside of these diagnoses, but unfortunately this is not often allowed for.

A psychologist or psychiatrist needs to make an application for a PMB, as this benefit is not granted automatically, but requires approval by the medical aid. For example, Discovery would require that the member and psychologist or psychiatrist completes this form. Where the mental illness is not listed as a PMB, motivation can be supplied for a PMB application on a case-by-case basis. The limit for this is 15 therapy sessions, but the application can be renewed again the following year. Prescribed Minimum Benefit sessions are covered as a separate benefit, and do not deplete medical aid savings. Once the 15 PMB sessions are finished, psychotherapy can continue either out of pocket, or by using medical aid savings.

Some Considerations

A PMB can be a wonderful way to allow people suffering with significant mental health problems, such as debilitating depression, to access treatment. However, there can be some implications of a PMB application (and some of these are also true of a diagnosis of these conditions even without a PMB application).

Firstly, there is a total of 15 sessions for in-patient and out-patient care. So, if the 15 sessions are used for therapy it may limit an in-patient admission later in the year, as some or all of the benefit may have been used. The total number of sessions may also need to be shared between the treating psychologist and psychiatrist. Secondly, the application requires a disclosure of the psychiatric condition, so sensitive information is provided to the medical aid. This information is kept on a medical record (sometimes for life), which can be accessed. Specifically, this may impact them in the future in a few areas, such as new or existing life insurance policies, immigration challenges, or even limits on some career choices. Ultimately, a PMB is for severe psychiatric illness and should be done with due consideration.

Medical Aid Savings & Alternatives

In addition to PMBs, there may be other very specific benefits for mental health. Select medical aids have a mental health benefit, which may be yearly or once-off. There are also incident related benefits, which can even come from other insurers, such as motor vehicle insurance or house insurance may offer a limited cover following a traumatic incident. Beyond these benefits, all counselling is covered by medical aid savings. This does mean, that for any plans which do not have savings (i.e. hospital plans), therapy is only covered where there is a specific benefit or must be paid for out-of-pocket.

In Summary

Most medical aids cover therapy with me, and my rate is normally reimbursed in full to you once paid. As a therapist, I provide a relationship to explore your mental health, but am also able to assist when it comes to medical aids and application for benefits. When we meet you we can always discuss this and consider this further, or you can contact me to find out more about this. Medical aids can be a helpful tool to afford therapy, but I also work with many people who do not have medical aids. While therapy is a considerable expense, it is an investment in your future and mental well-being. If you're ready to take the next step you can book a session with me.



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