Schizophrenia

Schizophrenia appears on the Chronic Disease List (CDL) under South Africa’s Prescribed Minimum Benefit regulations, issued under the Medical Schemes Act 131 of 1998. Every registered medical scheme must fund diagnosis, treatment and ongoing care for CDL conditions at the prescribed level of care, whatever option a member is on.

Practically, that means a scheme cannot stop paying for care related to this condition simply because an annual limit, sub-limit or medical savings account has been exhausted. Schemes may apply protocols, formularies and designated service providers to manage the benefit — but not to remove it.

Long-acting injectable antipsychotics are declined as outside the formulary where the oral equivalent is listed. Admissions are also rejected once an annual mental health day limit is reached, without the PMB care pathway being considered.

In both scenarios the underlying entitlement usually still exists. What failed was the administrative pathway — a registration that was never completed, a code that did not match the clinical record, or a limit applied to treatment that should have been funded as a Prescribed Minimum Benefit.

• The claims statement or rejection letter showing the scheme’s reason code.
• The itemised provider account with the ICD-10 and procedure codes.
• Clinical notes, discharge summary or the prescription confirming the diagnosis.
• Proof of chronic registration, or the application if one was submitted.
• A clinical motivation from the treating practitioner where a protocol or formulary was applied.