Sometimes. What your medical aid covers, however, depends on your particular plan, the type of treatment, and how the claim is processed. Understanding how your benefits work before you begin can help you avoid unexpected costs and give you a clearer picture of what your medical aid may contribute towards. Understanding which one applies to you can be the difference between a handful of sessions and a properly funded course of treatment.
The two routes
In South Africa, psychological treatment may be paid for through your medical scheme benefits or privately by the person receiving treatment. Which route applies, and what is covered, depends on your medical scheme, plan and clinical circumstances.
| Medical savings | Prescribed Minimum Benefits | |
|---|---|---|
| Where the money comes from | Your own scheme savings account | The scheme’s risk pool — not your savings |
| Runs out? | Yes, and often early in the year | Yes, after the approved number of sessions run out. This varies per medical aid but is typically between 8–15 PMBs per year. |
| Needs a diagnosis? | No | Yes — a listed condition, confirmed by assessment |
| Application needed? | No | Yes, motivated and submitted by your psychologist, GP or psychiatrist |
Most people begin on savings without realising there is another option. If you have a qualifying condition, PMBs are usually the far better route.
What Prescribed Minimum Benefits actually are
Prescribed Minimum Benefits (PMBs) are not a discount or a favour from your medical scheme. They are a set of benefits that medical schemes are legally required to cover under the Medical Schemes Act, provided that the relevant condition and treatment meet the PMB requirements.1 The PMB list includes a number of mental health conditions, including major depression, bipolar mood disorder, and schizophrenia. Where your condition qualifies for PMB cover, the associated treatment is generally funded from your scheme’s risk benefit rather than from your day-to-day medical savings. This can make a significant difference: accessing treatment through PMB cover may mean that your medical savings are preserved for other healthcare expenses. PMB cover is, however, subject to the scheme’s clinical protocols, designated service provider arrangements and any required authorisation. The exact benefits and process therefore depend on your medical scheme and the condition being treated.
Where a condition qualifies, funding comes from the scheme’s risk pool rather than your savings. In practice, this may allow eligible treatment to be funded from your scheme’s risk benefit rather than your medical savings, preserving those savings for other healthcare expenses.
How the process works with us
You begin therapy
You meet with Kirsten or Karen for a first consultation to understand your concerns, your history, and what support is likely to help.
Clinical assessment, sessions 1–3
Over the first one to three sessions your psychologist completes a clinical assessment, which may include standardised screening measures.
We establish whether PMB criteria apply
If the assessment indicates that you meet the diagnostic criteria for a PMB condition, this is discussed openly with you. Not every diagnosis qualifies, and we will tell you if yours does not.
We apply on your behalf unless your medical aid requires a PMB application from another provider
Where it is clinically appropriate, your clinical psychologist completes and submits the PMB documentation to your scheme. Most South African medical aids accept PMB submissions from clinical psychologists. However, sometimes a medical aid will request that the PMB application is done by a GP or psychiatrist. It is recommended that you check with your medical aid to find out who they will accept a PMB application from prior to starting your therapy process.
The scheme decides
If approved, your fee changes from the practice fee to the medical aid rate for the duration of the approved sessions.
You pay the practice directly
We are a cash practice. Fees are payable to the practice on the day of your appointment, whether or not PMBs are approved.
You claim back
After payment we issue an invoice with the correct codes, which you submit to your scheme for reimbursement.
Approved session numbers vary by scheme and condition. Many clients receive somewhere between 8 and 15 fully covered sessions per year, though this is set by the scheme, not by us.
The honest limitations
What to ask your scheme before you start
A five-minute phone call to your scheme can save a great deal of uncertainty. Useful questions:
In short
Medical aid may pay for therapy from your savings, or, where you have a qualifying condition, through Prescribed Minimum Benefits (PMBs). PMB treatment is funded from your scheme’s risk benefit rather than your savings. Where appropriate, we can assist with the PMB application. Approval depends on your scheme’s clinical criteria and authorisation.
Talking to us about it
You are welcome to raise medical aid in your very first enquiry. It is a practical question, and knowing your circumstances early helps us make the best plan for your care. Our current fees are set out on the fees page, and you can send a confidential enquiry at any time.
This article is general information, not a substitute for individual professional advice, assessment or treatment. If you are in crisis, please see our emergency resources.
Sources
- Medical Schemes Act 131 of 1998, Regulation 8 and Annexure A (Prescribed Minimum Benefits).
- Council for Medical Schemes. PMB definition guidelines for mental health conditions.
