Mental Health Coverage in South Africa: What You Need to Know

Understanding your medical aid's mental health benefits can feel overwhelming. The language is often complex, the policies are long, and it's hard to know what you're actually covered for.

This guide is designed to help you, as a South African medical aid member, understand your mental health coverage in simple terms. We will explore what medical aids are legally required to cover, what additional benefits the top schemes offer, and how you can access these benefits to get the support you need.

This article is based on a comprehensive analysis of the 2024 and 2025 policy documents from the top six medical aids in South Africa, which collectively cover over 92% of the insured population. We have read the fine print so you don't have to. Our goal is to provide you with the clear, factual information you need to make informed decisions about your mental health care.

Table of Contents | Jump Ahead

Understanding the Basics: Medical Aid in South Africa

A Look at the Top Medical Aids: Mental Health Coverage at a Glance

What You Can Do Next

Global Helplines & Emergency Services

References

Understanding the Basics: Medical Aid in South Africa

Prescribed Minimum Benefits (PMBs)

By law, all medical aids in South Africa must cover the costs related to the diagnosis, treatment, and care of a specific list of conditions. These are known as Prescribed Minimum Benefits (PMBs). The aim of PMBs is to ensure that all medical aid members have access to certain minimum health services, regardless of the benefit option they have selected. [1] When it comes to mental health, there are several conditions that are included in the PMB list. This means that your medical aid must cover the costs of your treatment for these conditions, even if you are on a basic hospital plan.

If you are diagnosed with one of these conditions, your medical aid is legally obligated to cover some treatment. This includes consultations with psychiatrists and psychologists, as well as medication. However, there are often conditions attached, such as the requirement to use a designated service provider (DSP).

Designated Service Providers (DSPs)

A designated service provider (DSP) is a healthcare provider (like a doctor, hospital, or pharmacy) that has an agreement with your medical aid to provide services at a specific rate. To get the full benefit of your PMB coverage, you will usually need to use a DSP. If you choose to use a non-DSP, your medical aid may only cover a portion of the cost, and you will be responsible for the co-payment.

In-Hospital vs. Out-of-Hospital Benefits

Medical aid benefits are often split into two main categories: in-hospital and out-of-hospital. As the names suggest, in-hospital benefits cover you when you are admitted to a hospital, while out-of-hospital benefits cover day-to-day medical expenses like GP visits, medication, and consultations with specialists. Mental health benefits can fall into both categories. For example, if you are admitted to a psychiatric facility, this will be covered by your in-hospital benefits. If you are seeing a psychologist for weekly therapy sessions, this will be covered by your out-of-hospital benefits.

Pre-Authorization

A Look at the Top Medical Aids: Mental Health Coverage at a Glance

As you can see, while all schemes provide some level of mental health coverage, their approach and the extent of their benefits differ significantly. Some, like Discovery Health, have comprehensive programmes that are integrated across all their plans. Others, like Momentum Health, offer high benefit limits on certain plans. And some, like Fedhealth and Bestmed, provide valuable support through wellness programmes and apps that are accessible to all members. In the upcoming articles in this series, we will delve into the specifics of each of these medical aids, providing a detailed breakdown of their mental health benefits, how to access them, and what you can expect to be covered for.

What You Can Do Next

1. Know Your PMBs: If you have been diagnosed with a PMB condition like Bipolar Mood Disorder or Schizophrenia, make sure you are registered for these benefits with your medical aid. This will ensure you get the full extent of the coverage you are entitled to.

2. Find Your DSPs: Log in to your medical aid's website and find their list of Designated Service Providers (DSPs) for mental health. Using these providers will help you avoid co-payments.

3. Understand Your Plan: Take some time to read through your specific plan's benefits. Pay close attention to the limits for psychology and psychiatry, and whether you need pre-authorization for certain treatments.

4. Ask for Help: If you are struggling to understand your benefits, don't hesitate to call your medical aid and ask for clarification. They have teams dedicated to helping members navigate their benefits.

Global Helplines & Emergency Services

• Find a helpline, suicide hotline, or crisis line in your country: https://www.therapyroute.com/article/helplines-suicide-hotlines-and-crisis-lines-from-around-the-world
• Find an emergency ambulance number in your country: https://www.therapyroute.com/article/ambulance-emergency-numbers-worldwide-list-by-therapyroute

References

Council for Medical Schemes - Prescribed Minimum Benefits

Council for Medical Schemes - PMB Overview

Council for Medical Schemes - Mental Health PMB Circular 17 of 2023

Fedhealth Medical Scheme GCR Credit Rating Report 2021

Discovery Health - Mental Health Care Programme

Bonitas - Care Programmes



Disclaimer: The information in this article is based on 2024/2025 policy documents. Benefit amounts and contact details can change. Always verify current details with your medical aid scheme before making any healthcare decisions.