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How do medical schemes treat substance abuse?

Substance abuse is on the increase in South Africa and at least 15% of South Africans are said to have a substance abuse problem according to 2016 statistics. Alcohol, marijuana (dagga), cocaine, tik and heroin are some of the most frequently used substances in this country, according to the South African Depression and Anxiety Group (SADAG). How do medical schemes treat substance abuse and what is covered under PMB regulations?

According to a recent Council of Medical Schemes (CMS) post, the PMB include the diagnosis, treatment and care of the conditions whilst an individual is in hospital. In-hospital management may include medicines (e.g. withdrawal support), and consultations with other health professionals e.g. a psychologist.

The PMB regulations however do not include the out-patient treatment for substance abuse.

Although the condition is a PMB condition, it is important to remember that medical schemes can use designated service providers (DSPs). A designated service provider (DSP) is a healthcare provider (e.g. doctor, pharmacist, hospital) that is appointed by the medical scheme for the treatment or care of PMB conditions. An individual may use a non-DSP voluntarily but should be aware that when one chooses to use a non-DSP, one may have to pay a portion of the bill as a co-payment. This should be discussed and clarified with the Medical Scheme in writing, if possible, to avoid any misunderstandings.

Click here to download CMScript 2 of 2021 to read more about substance abuse as well as to Diagnostic Treatment Pairs (DTP) as per the PMB regulations.

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