MHM Magazine

8 | MENTAL HEALTH MATTERS | 2025 | Issue 5 MHM family therapy sessions conducted over 12 weeks to 1 year. These sessions can be delivered as single- family or multi-family group interventions. • Social work interventions that include family psychoeducation and support, family aided acceptance and commitment therapy (ACT) and case management. • Physiotherapy that encourages a healthier lifestyle choices and physical activity, assesses movement disorders and develops a physical therapy care plan as part of the multidisciplinary team (MDT). The benefit available should follow the equivalent number of sessions that is available to patients in the public sector. • A mental health nurse to assist with the treatment of patients in and out of hospital. • Assessment by dieticians regarding nutritional status and recommend appropriate diets to improve physical health and assist with metabolic problems patients often face. The benefit available should follow the equivalent number of sessions that is available to patients in the public sector. • Coverage for 15 ECT treatments per year and medications now listed in the PMB definition guidelines, classified as PMBs are: - Oral medication: Lithium, Valproate, Risperidone, Quetiapine, Olanzapine, Aripiprazole, Haloperidol, Carbamazepine, Fluoxetine, and Clozapine These PMB definitions are designed to ensure comprehensive, continuous, and person-centred care that integrates pharmacological, psychosocial, and rehabilitative interventions. Difficulties in Adopting and Implementing the CMS Guidelines Despite the clear intent and clinical value of these guidelines, patients, healthcare providers, and medical schemes face several challenges in their implementation: • Limited Awareness and Understanding - Many medical schemes, patients and even some healthcare providers remain unaware of the expanded PMB entitlements. As a result, patients often don’t claim or insist on services that are rightfully covered under the PMB framework. This lack of awareness contributes to underutilisation of available benefits and patients not fully treated. • Administrative and Funding Constraints within Medical Schemes - Medical schemes have been slow to adopt the new PMB guidelines, citing budgetary limitations, administrative complexities, and interpretive ambiguities. Since PMBs are legally required but not always explicitly detailed in medical scheme benefit designs, disputes often arise about which services are “essential” or “evidence based.” This leads to frequent claim rejections or delays in reimbursement. • Insufficient Multidisciplinary Infrastructure - The guidelines call for coordinated care from psychiatrists, psychologists, occupational therapists, social workers, physiotherapists, dieticians, and mental health nurses. However, access to such multidisciplinary teams remains limited, particularly in the rural areas, where mental health specialists are scarce. As a result, even when benefits are theoretically available, patients struggle to find providers who can deliver the full range of services. • Inconsistent Interpretation of PMB regulations - Because each medical scheme interprets PMB compliance differently, there is inconsistent application of the guidelines across schemes. Some cover only hospital-based care, while others dispute the inclusion of certain therapies or outpatient benefits. This inconsistency places patients and providers in difficult positions, often requiring legal appeals or intervention by the CMS. • Stigma and Prioritization Challenges - Mental health conditions still face social stigma, and this extends into the healthcare system. Medical schemes often prioritize physical health conditions over psychiatric disorders when allocating funds or designing benefit packages, further delaying equitable implementation of mental health PMBs. Conclusion The CMS’s Prescribed Minimum Benefit Definition Guidelines for Schizophrenia and Bipolar Disorder represent a major step forward in ensuring equitable, holistic mental healthcare in South Africa. By setting clear minimum standards, the CMS aims to close the gap between mental and physical healthcare coverage. However, true implementation remains a challenge. Greater education, advocacy, and collaboration among stakeholders - including medical schemes, healthcare providers, patients, and the CMS itself are essential to turn these guidelines from policy into practice. Only through consistent adoption and enforcement can South Africa ensure that individuals living with schizophrenia and bipolar disorder receive the continuous, dignified, and comprehensive care they are legally entitled to. References available on request. MHM | 2025 | Volume 12 | Issue 5 | Challeng s in Implementing the Council for Medical Schemes PMB Definition Guidelines for Schizo- phrenia and Bipolar Disorder in South Africa H