Focus on mental health

Below is information about Focus on mental health Focus on mental health Benefits

Mental health disorders encompass a wide array of diagnoses, each presenting its own unique set of symptoms. Despite this diversity, these disorders typically share common characteristics, which often include abnormal thoughts, emotions, behaviors, and difficulties in relationships with others. Some notable examples of mental disorders include schizophrenia, depression, intellectual disabilities, and substance abuse disorders. Fortunately, many of these conditions can be effectively managed and treated with appropriate interventions.

Both bipolar affective disorder and schizophrenia are classified as mental health conditions that fall under the 26 Chronic Disease List, which is part of the Prescribed Minimum Benefit (PMB) conditions. This classification ensures that these disorders are covered in accordance with the chronic provider you have chosen. Additionally, medication for these conditions is included in the coverage provided for the 26 Chronic Disease List conditions.

On the other hand, conditions such as depression, substance abuse rehabilitation, and acute stress disorder—especially when triggered by significant recent trauma—are classified under the 271 Prescribed Minimum Benefit conditions. However, it is important to note that medication for these specific conditions is not covered under this plan. Instead, benefits for treatment of these conditions include either 21 days of inpatient care or 15 outpatient consultations. Coverage for these treatments is available at network providers, in accordance with your selected hospital provider, and is subject to any applicable annual limits. For outpatient benefits, members are strongly encouraged to utilize Associated specialists to avoid incurring additional costs when opting for non-Associated specialists, who may charge fees exceeding the Momentum Medical Scheme Rate.

For further details regarding your chronic benefits and guidance on where to obtain chronic medication and treatment,

(please see more here: - https://content.momentum.co.za/mmsa/complete_health/pdfs/Sales%20Tools/Focus%20Pages/2024/Benefits/Focus%20on%20the%20Chronic%20Benefit%202024.pdf)

General rules regarding the mental health benefit

• Benefits are accessible through Designated Service Providers, in alignment with your benefit option.

• Pre-authorisation is a prerequisite for both inpatient and outpatient benefits.

• A treatment plan from your treating physician will be necessary.

• Services such as educational assessments, disability evaluations, forensic investigations, and marriage counseling are not included within the mental health benefit framework.

Bipolar affective disorder: Forms part of the 26 Chronic Disease List Prescribed Minimum Benefit (PMB) conditions

Ingwe

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Limited to PMBs at State facilities.

Evolve

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Limited to PMBs.

Custom

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Subject to the treatment plan.

Incentive

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Subject to the treatment plan.

Extender

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Subject to the treatment plan.

Summit

Medication - Benefits are available from any provider.

Doctors, pathology, and radiology - Subject to the treatment plan.

Schizophrenia: Forms part of the 26 Chronic Disease List Prescribed Minimum Benefit (PMB) conditions

Ingwe

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Limited to PMBs at State facilities.

Evolve

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Limited to PMBs.

Custom

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Subject to the treatment plan.

Incentive

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Subject to the treatment plan.

Extender

Medication - Benefits are available through applicable chronic network providers.

Doctors, pathology, and radiology - Subject to the treatment plan.

Summit

Medication - Benefits are available from any provider.

Doctors, pathology, and radiology - Subject to the treatment plan.

Summary of benefits per condition, per option

Depression, acute stress disorder accompanied by recent significant trauma, alcohol and drug rehabilitation: Form part of the 271 Prescribed Minimum Benefits (PMBs)

Ingwe

Medication - No Benefits.

In-hospital - Limited to PMBs at State facilities.

Out-of-hospital - Limited to PMBs at State facilities.

Evolve

Medication - No Benefits.

In-hospital - Limited to PMBs at Evolve Network hospitals.

Out-of-hospital - Limited to PMBs.

Custom

Medication - Subject to HealthSaver+ if available.

In-hospital - 21 days at a private facility Designated Service Provider (DSP), subject to a mental health limit of R43,000 per beneficiary. Alcohol and drug rehabilitation is included within this 21-day limit (it is required to complete the full 21 days at a SANCA facility). Alternatively,

Out-of-hospital - 15 outpatient psychotherapy consultations (this is not in addition to the in-hospital benefit and limit).

Incentive

Medication - Subject to available Savings and/or HealthSaver+.

In-hospital - 21 days at a private facility DSP, subject to a mental health limit of R46,000 per beneficiary. Alcohol and drug rehabilitation is included within this 21-day limit (it is required to complete the full 21 days at a SANCA facility). Alternatively,

Out-of-hospital - 15 outpatient psychotherapy consultations (this is not in addition to the in-hospital benefit and limit).

Extender

Medication - Covered from the chronic benefit up to R12,400 per family per year (this is a combined limit for the 36 additional conditions).

In-hospital - 21 days at a private facility DSP, subject to a mental health limit of R46,000 per beneficiary. Alcohol and drug rehabilitation is included within this 21-day limit (it is required to complete the full 21 days at a SANCA facility). Alternatively,

Out-of-hospital - 15 outpatient psychotherapy consultations (this is not in addition to the in-hospital benefit and limit).

Summit

Medication - Covered from the chronic benefit (which accumulates to an overall day-to-day limit of R31,300 per beneficiary per year).

In-hospital - 21 days at a private facility DSP, subject to a mental health limit of R46,000 per beneficiary. Alcohol and drug rehabilitation is included within this 21-day limit (it is required to complete the full 21 days at a SANCA facility). Alternatively,

Out-of-hospital - 15 outpatient psychotherapy consultations (this is not in addition to the in-hospital benefit and limit).

Who is eligible for mental health benefits?

Individuals who have received a diagnosis of a mental health condition from their family doctor, specialist psychiatrist, or psychologist are eligible to access mental health benefits.

How to register

1. First, obtain a treatment plan from your treating physician and/or facility.

2. If hospitalization is necessary, you must request pre-authorisation. This can be done by emailing us at [e-mail], sending us a WhatsApp message, or calling us at 0860 11 78 59. When making this request, please include the following details in a letter of motivation from your treating physician:

• The diagnosis along with the 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, which should detail the duration of treatment and tariff codes for all healthcare providers involved, such as psychologists and psychiatrists. For children under the age of 14, a referral letter from the child’s general practitioner, pediatrician, or psychiatrist is required.

3. Submit a letter of motivation or completed DSM form from your treating physician for in-hospital benefits related to depression, substance abuse rehabilitation, and acute stress disorder to us via email at [e-mail] for evaluation.

4. For outpatient psychotherapy sessions (for Prescribed Minimum Benefit conditions) instead of hospitalization, you should submit a letter of motivation or treatment plan from the treating psychiatrist or psychologist to us via email at [e-mail].

5. Registration for mental health chronic benefits (specifically for bipolar affective disorder and schizophrenia) must be initiated by the treating psychiatrist through the chronic registration process. For chronic medication registration, please contact 0860 11 78 59. Once your registration is authorized, ensure that you obtain your chronic medication on a monthly basis and adhere strictly to the prescribed dosage and quantity. It is crucial not to miss any doses, as non-compliance can have serious repercussions for your health and overall well-being.

Glossary of terms used in this document

Chronic Disease List (CDL) - This refers to a list of 26 chronic conditions that all medical schemes in South Africa are mandated to cover, as stipulated by the Medical Schemes Act No 131 of 1998.

Designated service provider (DSP) - Momentum Medical Scheme utilizes a network of designated service providers, which includes Associated General Practitioners (GPs) and specialists, as well as State facilities, to diagnose and treat members for the Prescribed Minimum Benefits. For additional information, please refer to the definition of Prescribed Minimum Benefits below.

DSM form - The DSM form serves as a diagnostic assessment and treatment plan report that is standardized according to the Diagnostic Statistical Manual.

ICD-10 code - This coding system documents various medical records, including diseases, symptoms, abnormal findings, and external causes of injury. It serves as your diagnosis code.

Prescribed Minimum Benefits (PMBs) - PMBs represent a list of benefits that all medical schemes in South Africa are required to cover under the Medical Schemes Act No 131 of 1998. These benefits include life-threatening emergency medical conditions, a specific set of 271 diagnoses, and 26 chronic conditions. Benefits are fully covered when utilizing the Scheme’s Designated Service Providers (DSPs). If you choose to use non-designated service providers voluntarily, the Scheme will reimburse up to the Momentum Medical Scheme Rate, and relevant co-payments will apply. In cases of life-threatening emergencies involving non-designated service providers, the situation is considered involuntary, and co-payments are waived.

Tariff codes - These codes are used by healthcare providers to bill for the services rendered.

HealthSaver+ - HealthSaver+ is a voluntary supplementary product offered by Momentum. You may opt to utilize additional products available from Momentum Metropolitan Holdings Limited (Momentum) to seamlessly enhance your medical aid coverage. It is important to note that Momentum is not a medical scheme and operates as a separate entity from Momentum Medical Scheme.