Can Medical Aid Cover Rehab in KwaZulu-Natal? A 2025 Roadmap

The Recovery Blueprint: Part 1 - Medical Aid. Finding affordable addiction treatment in South Africa, even when it feels out of reach.

What will my medical aid cover? understanding addiction treatment, prescribed minimum benefits, and extended medical aid stays

If you or someone close to you in KwaZulu-Natal is struggling with drug or alcohol addiction, the question often comes up: Will medical aid cover the cost of rehab?

This practical guide, part of The Recovery Blueprint Series, outlines how to access treatment through your medical aid provider in 2025. Whether you are in Durban, Hillcrest, the North Coast, inland KZN, or anywhere else in South Africa this resource will help you take the next step with confidence.

1. Understand addiction as a treatable health condition

Addiction is no longer viewed as a moral failure. It is now recognised as a chronic brain disorder that requires professional treatment. Substance use disorder (SUD) and alcohol use disorder (AUD) are medical conditions, not personal shortcomings.

Getting assessed by a qualified mental health professional or addiction specialist is the first step towards receiving the right kind of help.

2. Check your medical aid cover for rehab in detail

South African medical aid schemes are legally required to fund treatment for substance and alcohol addiction under the Prescribed Minimum Benefits (PMBs). However, coverage differs by provider and plan:

• Discovery Health usually pays for 24 days per year, including 3 days of medically supervised detox

• Most other schemes cover 21 days of inpatient treatment, but with a required co-payment

• Medical aid does not pay for treatment at centres that are not registered with the Department of Social Development and the Department of Health.

• Rehabilitation centres must have a BHF practice number to process medical aid claims.

  
  

It is important to confirm whether the rehab centre you choose in Durban, Hillcrest, Salt Rock, Ballito, or anywhere else in KZN meets these requirements.

3. Secure pre-authorisation before starting

Before you can be admitted to treatment, your medical aid provider must approve the stay. This step involves providing your membership information, ID number and the correct diagnostic codes, which relate to substance or alcohol use disorder.

Most accredited rehab centres in KwaZulu-Natal can assist with this step and contact the medical aid scheme on your behalf. This process usually takes only a short time and will confirm whether any additional payment is required.

4. Choose a qualified and registered rehab centre in KZN

Not all treatment centres are created equal. Look for one that is fully licensed and offers a team of qualified professionals.

A good centre will also offer extended care such as secondary treatment, outpatient programmes and aftercare groups. Always ensure centres are properly registered and capable of dealing with co-occurring disorders like depression or anxiety.

5. Begin the inpatient treatment process

Once authorisation is approved, treatment can begin. A standard inpatient stay typically lasts around 21 days. Exiting treatment early by signing a refusal hospital treatment (RHT) without medical clearance could lead to your scheme cancelling cover and holding you responsible for the full cost.

Programmes often include individual therapy, group sessions, family counselling and structured daily routines. These form the core of effective addiction recovery.

6. Make a plan for aftercare

Recovery continues long after you leave the rehab centre. Ongoing support such as outpatient therapy, counselling and relapse prevention planning is essential for long-term success.

Some medical aid schemes offer limited cover for these services. Check what is included in your plan and discuss options with your treatment provider before discharge.

Extended stay options for addiction treatment

While 21 days of treatment may be enough for some, others may require additional time in a structured rehabilitation environment to ensure lasting recovery. In such cases, medical aid coverage can vary, and accessing extended stays may require special arrangements or additional authorisation.

Why more than 21 days may be necessary:

1. Severe addiction: Those with long-term substance abuse issues may need more than 21 days of treatment to detox properly, undergo intensive therapy, and begin to rebuild their lives.

2. Co-occurring mental health disorders: Individuals who suffer from both addiction and mental health issues (e.g., depression, anxiety, or trauma) may require longer stays to address both aspects of their recovery. Treating both addiction and mental health together is crucial for long-term success. For more information on co-occuring mental health disorders please read our article on bipolar disorder and addiction.

3. Relapse prevention: Extended treatment stays provide more opportunities for recovery skills to be learned and reinforced, which is essential for relapse prevention. The risk of returning to addictive behaviours is significantly reduced with longer treatment periods. Rehabilitation programmes that last more than 90 days tend to be significantly more successful than shorter ones. This is supported by research in addiction treatment and behavioural health. The science behind this points to the need for sufficient time to support biological recovery, psychological development, and meaningful lifestyle changes

4. Aftercare and Reintegration: After the initial treatment period, many individuals need continued care, including counselling and life skills training, to reintegrate successfully into society. This aftercare often requires an extended stay in a supportive, residential environment.

Medical Aid and Extended Stays

For individuals who require more than 21 days of rehab, medical aid coverage can vary. Some schemes may cover longer stays in rehabilitation centres if medically necessary, while others may only provide coverage for the initial 21 days.

Here's what you need to consider:

• Pre-approval and authorisation: Extended stays beyond 21 days often require prior approval from your medical aid provider. You may need a detailed assessment or recommendation from a specialist to justify the need for additional time in rehab.

• Medical aid limits: Depending on your medical aid plan, the number of days covered for inpatient rehabilitation may be capped, with extra days requiring additional authorisation or co-payments.

• Extended care programs: Some medical aids may offer coverage for extended care programmes or aftercare treatment once the primary rehabilitation period is over. These services are crucial for ongoing recovery and relapse prevention.

• Co-payments: Even if your medical aid covers a portion of the treatment, you may still be responsible for co-payments or other out-of-pocket expenses, particularly for extended stays.

How to access extended rehab stays

A man and woman speaking with their medical aid provider online to confirm whether extended addiction rehab stays beyond 21 days are covered.

1. Speak to your medical aid provider: Contact your provider directly to discuss your need for an extended stay. Ask about coverage options beyond the initial 21 days and what documentation is required for pre-authorisation.

2. Referral from a specialist: Your GP or an addiction specialist can help facilitate the process by providing the necessary medical documentation to support your case for an extended stay.

3. Choose the right treatment centre: Select a rehabilitation centre that offers the extended care you need and is within the network of your medical aid plan. Ensure the facility has a good track record of helping individuals with long-term recovery.

4. Negotiate payment plans: If your medical aid does not fully cover the extended treatment period, consider discussing payment plans with the treatment centre to make the remaining costs more manageable. For more information, please see our articles in part 2 of the recovery blueprint series.

   
   

If you or your loved one require more than 21 days of addiction treatment, it’s crucial to explore your medical aid options and the extended stay services available. Longer stays may be essential for full recovery, especially for individuals with severe addictions or co-occurring mental health issues. By working closely with your medical aid provider and treatment facility, you can access the support you need to ensure lasting recovery.

Find out more

---

Read our new 2025 4-Part Guide to Finding Affordable Addiction Treatment in South Africa, Even When It Feels Impossible.

• Exploring every avenue for affordable addiction rehabilitation

• Part 1: Medical aid cover, understanding prescribed minimum benefits (PMB's), and extended medical aid rehab stays.