Description
Mental health disorders comprise a broad range of diagnoses, with different symptoms. However, they are generally characterised by some combination of abnormal thoughts, emotions, behaviour, and relationships with others. Examples of mental disorders are schizophrenia, depression, mental retardation, and disorders due to substance abuse. Most of these disorders can be successfully treated.
Bipolar affective disorder and schizophrenia are mental health conditions which are classified as part of the 26 Chronic Disease List Prescribed Minimum Benefit conditions and will therefore be covered in accordance with your chosen chronic provider. Medication is covered as part of the 26 Chronic Disease List conditions.
Depression, drug and alcohol rehabilitation, and acute stress disorder, accompanied by recent significant trauma, are mental health conditions which are classified as part of the 271 Prescribed Minimum Benefit conditions. Medication for these conditions is not covered. Benefits to treat these conditions are either 21 days in-hospital treatment or 15 outpatient consultations. These conditions will be covered at network providers in accordance with your chosen hospital provider, subject to the overall annual limit, where applicable. For outpatient benefits, members are encouraged to use Associated specialists to avoid having to pay for shortfalls when using non-Associated specialists who charge above the Momentum Medical Scheme Rate.
For more on your chronic benefits and where to obtain chronic medicine and treatment, click here.
General rules regarding the mental health benefit
- Benefits are available at Designated Service Providers in accordance with your benefit option.
- Pre-authorisation is required for in and out-of-hospital benefits.
- A treatment plan from your treating doctor will be required.
- Scholastic/educational assessments, disability assessments, forensic investigations and marriage counselling do not form part of the mental health benefit.
Ingwe | Evolve | Custom | Incentive | Extender | Summit |
Bipolar affective disorder: Forms part of the 26 Chronic Disease List Prescribed Minimum Benefit (PMB) conditions | |||||
Medication | |||||
| Benefits available from applicable chronic network providers | Benefits available from applicable chronic network providers | Benefits available from applicable chronic network providers | Benefits available from applicable chronic network providers | Benefits available from applicable chronic network provider | Benefits available from any provider |
Doctors, pathology and radiology | |||||
| Limited to PMBs at State facilities | Limited to PMBs | Subject to the treatment plan | Subject to the treatment plan | Subject to the treatment plan | Subject to the treatment plan |
Schizophrenia: Forms part of the 26 Chronic Disease List Prescribed Minimum Benefit (PMB) conditions | |||||
Medication | |||||
| Benefits available from applicable chronic network providers | Benefits available from applicable chronic network providers | Benefits available from applicable chronic network providers | Benefits available from applicable chronic network providers | Benefits available from applicable chronic network providers | Benefits available from any provider |
Doctors, pathology and radiology | |||||
| Limited to PMBs at State facilities | Limited to PMBs | Subject to the treatment plan | Subject to the treatment plan | Subject to the treatment plan | Subject to the treatment plan |
Summary of benefits per condition, per option
Ingwe | Evolve | Custom | Incentive | Extender | Summit |
Depression, acute stress disorder accompanied by recent significant trauma, alcohol and drug rehabilitation: Form part of the 271 Prescribed Minimum Benefits (PMBs) | |||||
Medication | |||||
| No benefit | No benefit | Subject to HealthSaver+ if available | Subject to available Savings and/or HealthSaver+ | Covered from the chronic benefit up to R12 400 per family per year (combined limit for the 36 additional conditions) | Covered from the chronic benefit (accumulates to overall day-today limit of R31 300 per beneficiary per year) |
In-hospital | |||||
| Limited to PMBs at State facilities | Limited to PMBs at Evolve Network hospitals | 21 days at private facility DSP Subject to mental health limit of R43 000 per beneficiary. Alcohol and drug rehabilitation forms part of this 21-day limit (must complete the full 21 days at a SANCA facility) Or out-of-hospital see below. | 21 days at private facility DSP Subject to mental health limit of R46 000 per beneficiary. Alcohol and drug rehabilitation forms part of this 21-day limit (must complete the full 21 days at a SANCA facility) Or out-of-hospital see below. | 21 days at private facility DSP Subject to mental health limit of R46 000 per beneficiary. Alcohol and drug rehabilitation forms part of this 21-day limit (must complete the full 21 days at a SANCA facility) Or out-of-hospital see below. | 21 days at private facility DSP Subject to mental health limit of R46 000 per beneficiary. Alcohol and drug rehabilitation forms part of this 21-day limit (must complete the full 21 days at a SANCA facility) Or out-of- hospital see below. |
Out-of-hospital | |||||
| Limited to PMBs at State facilities | Limited to PMBs | 15 outpatient psychotherapy consultations (this is not in addition to the in-hospital benefit and limit) | 15 outpatient psychotherapy consultations (this is not in addition to the in-hospital benefit and limit) | 15 outpatient psychotherapy consultations (this is not in addition to the in-hospital benefit and limit) | 15 outpatient psychotherapy consultations (this is not in addition to the in-hospital benefit and limit) |
Who is eligible for mental health benefits?
If you have been diagnosed with a mental health condition by your family doctor, specialist psychiatrist or psychologist, you will be eligible for the mental health benefits.
How to register
1. Obtain a treatment plan from your treating doctor and/or facility.
2. For hospitalisation, you need to request pre-authorisation. You can do this by emailing us at [email protected], sending us a WhatsApp message or calling us on 0860 11 78 59 and providing the following details in the letter of motivation from your treating doctor:
- The diagnosis and ICD-10 code;
- The current clinical condition;
- The estimated length of stay if you are being admitted to a facility;
- The completed assessment or DSM form (diagnostic assessment and treatment plan report);
- The treatment plan, including the duration of the treatment with tariff codes to be charged by all healthcare providers, such as psychologists, psychiatrists, etc;
Requests for children under the age of 14 must be accompanied by a referral letter from the child’s GP, paediatrician or psychiatrist.
3. Submit a letter of motivation or completed DSM form from your treating doctor for in-hospital benefits for depression, drug and alcohol rehabilitation, and acute stress disorder to us, via email at [email protected], for evaluation.
4. For out-of-hospital psychotherapy sessions (for Prescribed Minimum Benefit conditions) instead of hospitalisation, submit a letter of motivation or treatment plan from the treating psychiatrist or psychologist to us via email at [email protected].
5. Registration for mental health chronic benefits (for bipolar affective disorder and schizophrenia) must be done by the treating psychiatrist via the chronic registration process. The contact number for chronic medication registration is 0860 11 78 59. Once authorised, you need to obtain your chronic medication monthly and make sure that you take your medication according to the dosage and quantity prescribed by your doctor. Make sure that you do not miss a dose, not only from a compliance perspective, but more importantly because it can have serious implications for your health and wellbeing.
Glossary of terms used in this document
| Term | Description |
| Chronic Disease List (CDL) | A list of 26 chronic conditions for which all medical schemes in South Africa have to provide cover in terms of the Medical Schemes Act No 131 of 1998. |
| Designated service provider (DSP) | Momentum Medical Scheme uses a network of designated service providers, such as Associated GPs and Specialists, as well as State facilities, depending on the circumstances, to diagnose and treat our members for the Prescribed Minimum Benefits. See definition of Prescribed Minimum Benefits below for more information. |
| DSM form | The DSM form is a diagnostic assessment and treatment plan report that is universally used as per the Diagnostic Statistical manual |
| ICD-10 code | This is a system of coding that notes various medical records including diseases, symptoms, abnormal findings and external causes of injury. It is your diagnosis code. |
| Prescribed Minimum Benefits (PMBs) | Prescribed Minimum Benefits (PMBs) is a list of benefits for which all medical schemes in South Africa have to provide cover in terms of the Medical Schemes Act No 131 of 1998. The Prescribed Minimum Benefits include life-threatening emergency medical conditions, a defined set of 271 diagnoses and 26 chronic conditions. Benefits are covered in full if you use the Scheme’s Designated Service Providers (DSPs). If you voluntarily choose to use non-designated service providers, the Scheme will pay benefits up to the Momentum Medical Scheme Rate and relevant co-payments will apply. If you use non-designated service providers in a life-threatening emergency, it is deemed involuntary, and co-payments are therefore waived. |
| Tariff codes | These are the codes that are billed by the healthcare provider for services rendered. |
| HealthSaver+ | HealthSaver+ is a voluntary complementary product available from Momentum. You may choose to make use of additional products available from Momentum Metropolitan Holdings Limited (Momentum), to seamlessly enhance your medical aid. Momentum is not a medical scheme and is a separate entity to Momentum Medical Scheme. |
Disclaimer: +Momentum Medical Scheme members may choose to make use of additional products available from Momentum Group Limited and its subsidiaries as well as Momentum Multiply (herein collectively referred to as Momentum). Momentum is not a medical scheme and is a separate entity to Momentum Medical Scheme. Momentum products are not medical scheme benefits. You may be a member of Momentum Medical Scheme without taking any of the products offered by Momentum.