Therapy & Medical Aid in South Africa: What You Need to Know

If you are considering counselling or therapy in South Africa, you may be wondering: Will my medical aid pay for it? What is the difference between a counsellor, psychologist and psychiatrist? And how do I know which professional I should see?

This article will walk you step by step through making a choice in an environment that is not always straightforward, so that you can better understand your options, your medical aid benefits and which type of mental-health professional might be right for you.

1. Do medical aids pay for counselling or therapy in South Africa?

Yes, they can.

Many South African medical aid plans provide some form of cover for psychological or counselling services. However, this does not mean that every medical aid or every plan will automatically pay for every counselling session.

Your cover can depend on your medical scheme, your specific plan, the type and registration of the healthcare professional, the reason you are seeking support, the benefits you have available, and whether particular authorisation or network requirements apply.

It is therefore always worth checking directly with your medical aid before beginning counselling if reimbursement is important to you.

2. What kind of psychological support can medical aid cover?

Medical aid schemes may recognise different registered mental-health and allied healthcare professionals, depending on their rules and your particular plan.

These can include psychologists, Registered Counsellors, Clinical Social Workers and other recognised mental-health professionals.

The important distinction is that the professional usually needs to have the appropriate professional registration and billing details for the service to be considered by your medical aid.

However, simply knowing that your medical aid covers a particular professional is not enough.

You should also ask your medical aid how much they will reimburse for a session and compare this with the fee charged by the mental-health professional you would like to see.

For example, your practitioner might charge a higher professional fee than the amount your medical aid reimburses. In this case, you may have to pay the difference yourself.

Your medical aid may also limit the number of counselling or psychological sessions available per year, depending on your plan and benefits.

It is therefore helpful to think beyond the first few sessions. If your benefits run out, would you be able to continue seeing this professional privately?

When choosing a practitioner, consider both whether you feel comfortable working with them and whether their fees are financially sustainable for you if you eventually need to cover the sessions yourself.

3. What is the difference between a psychologist and a Registered Counsellor in South Africa?

Both psychologists and Registered Counsellors are recognised professional categories within South Africa’s psychological healthcare environment, but their training and scopes of practice are different.

Registered Counsellors generally work in areas such as prevention, early intervention and counselling for psychological and psychosocial difficulties. They can support people through challenging periods in their personal lives, relationships, families and careers.

This is also where my own work fits in. I am Juliane Hoss, a Registered Counsellor in South Africa, and I hold a Master’s degree in Psychology from a German university. I support individuals and couples who are generally functioning in their everyday lives but may be going through difficult periods, experiencing stress, relationship or marital difficulties, grief and loss, family challenges, conflict at work, career questions or major life changes. I also work with people who want to understand themselves and their patterns better, improve their relationships, develop personally or work towards new goals.

I do not diagnose psychiatric or mental-health disorders and do not prescribe medication. Where someone requires specialised diagnosis, psychiatric medication, treatment for a severe or complex mental-health condition, or a higher level of mental-health care, I recommend involving an appropriately qualified psychologist, psychiatrist, medical doctor or other relevant healthcare professional.

My professional registration details are:

Juliane Hoss – Registered Counsellor
Council number: PRC0041637
Practice number: 1271865
Registration number: 2020/528224/07

4. What is the difference between a psychologist and a psychiatrist?

One of the easiest distinctions to remember is that psychiatrists are medical doctors specialising in psychiatry.

They can medically assess psychiatric conditions and prescribe medication when appropriate.

Psychologists are psychological professionals rather than medical doctors. Their work can include psychological assessment, diagnosis and psychological treatment, depending on their professional category and scope of practice.

If you are experiencing symptoms that may require psychiatric diagnosis, medication or medical management, a psychiatrist may therefore need to be involved.

This does not mean that you necessarily have to choose between professionals. Depending on someone’s needs, different professionals can work together.

5. What is the difference between a Registered Counsellor and a coach or someone calling themselves a “therapist”?

This is an important question because the terminology can be confusing.

Registered Counsellor is a regulated professional registration category in South Africa.

Terms such as coach can describe valuable services, but coaching itself is not the same professional registration category as Registered Counselling. Similarly, the word therapist on its own does not tell you what statutory healthcare registration a person holds.

That is why I recommend looking beyond someone’s title and asking:

“What professional body are you registered with, and what is your professional registration category?”

This is also relevant to medical aid. A medical aid scheme generally requires recognised healthcare-provider and billing information before it can process a healthcare claim.

A general coach or practitioner without the relevant recognised healthcare registration would therefore usually not be claimable in the same way as an appropriately registered healthcare professional.

6. How does medical aid in South Africa pay for psychological services?

There are different ways psychological and counselling services may be funded, and understanding the difference is important.

Firstly, your sessions may be funded through your ordinary day-to-day benefits or Medical Savings Account, depending on your medical aid and plan.

Routine outpatient counselling or psychological services may be paid from these available benefits. Your medical aid may reimburse according to its own rate rather than the practitioner’s full private fee.

This means that even if your medical aid accepts your counselling claim, you may not necessarily receive the full session fee back.

Your particular plan may also provide only a certain amount of funding or a limited number of sessions. Once these benefits are exhausted, you may need to fund further sessions yourself.

Secondly, certain mental-health conditions may qualify for Prescribed Minimum Benefits (PMBs).

Prescribed Minimum Benefits are benefits that South African medical schemes are legally required to provide for specified conditions and treatments. These include certain mental-health conditions.

However, having a mental-health concern or an ICD-10 code does not automatically mean that your counselling qualifies as a PMB. The condition needs to meet the applicable PMB criteria and specified level of care.

Medical aid schemes may also have requirements concerning diagnosis, treatment protocols, pre-authorisation, applications, treatment plans and Designated Service Providers (DSPs).

If you think you may have a condition that qualifies for PMB treatment, ask your medical aid specifically about its PMB application process, mental-health benefits and which healthcare professionals may provide the covered treatment.

7. Who submits the medical aid claim?

There are generally two approaches.

Some healthcare practices submit claims directly to the medical aid scheme. Depending on the arrangement, the medical aid may then pay the practitioner or the member.

Other practices operate on a private-pay basis: you pay the practitioner and then submit the invoice or statement to your medical aid yourself for possible reimbursement.

This is how it works in my practice.

All sessions with me are privately payable. You are welcome to submit the invoice provided by my practice to your medical aid for reimbursement.

Please keep in mind that I charge my standard professional rate. Your medical aid determines whether the session is covered and how much it will reimburse. Some medical aids may reimburse only part of the amount charged for a Registered Counsellor.

You may therefore receive the full amount, a portion of it, or no reimbursement, depending on your medical aid and plan.

For this reason, I recommend checking your benefits directly with your medical aid if reimbursement will influence your decision to start counselling.

8. What should I ask my medical aid before starting counselling?

Instead of simply asking:

“Does my medical aid pay for therapy?”

I recommend being much more specific.

You can ask:

“Does my particular plan cover outpatient consultations with an HPCSA Registered Counsellor or psychologist? From which benefit will the claim be paid? How much will you reimburse per session, and how many sessions or how much funding do I have available per year? Are there any authorisation, network, tariff or ICD-10 requirements?”

If you have been diagnosed with a mental-health condition, you can additionally ask:

“Could my condition qualify for Prescribed Minimum Benefits, and if so, what is the application process and which healthcare professionals or Designated Service Providers may provide the covered treatment?”

These questions will give you much more useful information than simply asking whether “therapy” is covered.

9. What types of concerns can a Registered Counsellor help with?

Registered Counsellors primarily work with prevention, early intervention, counselling and psychological support within their professional scope.

In practical terms, people may seek Registered Counselling for concerns such as:

• Relationship difficulties: relationship or marital challenges, separation, family conflict or difficulties with significant people.
• Work-related concerns: work stress, workplace conflict, unemployment, job dissatisfaction and career challenges.
• Stress and feeling overwhelmed: difficulties coping with everyday demands, exhaustion and stress-related concerns.
• Life transitions: adjusting to changes in relationships, work, family circumstances or other major changes.
• Grief and loss: counselling following bereavement or other significant losses.
• Family and parenting concerns: difficulties within the family or challenges associated with parenting and family circumstances.
• General emotional difficulties: feeling overwhelmed, uncertain or stuck and wanting professional support.
• Personal development: improving emotional awareness, communication, boundaries, resilience, relationships and self-understanding.

Depending on the circumstances, appropriate ICD-10 codes may be used for medical-aid billing. However, an ICD-10 code should reflect the actual reason for the healthcare encounter and should not simply be selected because it is more likely to be reimbursed by a medical aid.

Where a person’s needs fall outside the scope of Registered Counselling, referral to another appropriate healthcare professional may be necessary.

10. How do I choose the right mental-health professional?

Start by asking yourself:

What kind of help do I actually need?

Do I need a diagnosis? Do I potentially need medication or a specialised treatment plan? Am I struggling with a severe or complex mental-health condition that may require more intensive or even inpatient treatment?

If so, it is important to find a professional with the appropriate clinical or medical scope.

Or am I generally coping with everyday life but going through a difficult period? Perhaps I am struggling with stress, grief, my relationship, my family, work, a major transition or patterns in my life that I would like to understand and change. Perhaps I simply want professional support to reflect, grow and move forward.

In these circumstances, counselling may be an appropriate place to start.

However, qualifications and professional registration are only part of choosing the right person.

One of the most important factors is that you feel comfortable with the professional you choose.

Counselling and therapy are personal. You should feel that you can speak openly, that the professional listens to you and that their way of working makes sense to you.

It can therefore be worth checking twice before deciding who you want to work with rather than simply booking the first professional you find.

Many mental-health professionals offer introductory calls so that you can get an initial sense of the person and their approach before committing to a full session.

I offer a free 15-minute introductory call for exactly this reason. It gives us an opportunity to briefly discuss what brings you to counselling, how I work and whether working together could be a good fit.