SAQA

All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.

SOUTH AFRICAN QUALIFICATIONS AUTHORITY

REGISTERED UNIT STANDARD THAT HAS PASSED THE END DATE:

Demonstrate knowledge and insight into the Medical Schemes Act (131 of 1998) and the accompanying regulations

SAQA US ID	UNIT STANDARD TITLE
12335	Demonstrate knowledge and insight into the Medical Schemes Act (131 of 1998) and the accompanying regulations
ORIGINATOR
SGB Financial Services
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-
FIELD			SUBFIELD
Field 03 - Business, Commerce and Management Studies			Finance, Economics and Accounting
ABET BAND	UNIT STANDARD TYPE	PRE-2009 NQF LEVEL	NQF LEVEL	CREDITS
Undefined	Regular	Level 4	NQF Level 04	3
REGISTRATION STATUS		REGISTRATION START DATE	REGISTRATION END DATE	SAQA DECISION NUMBER
Passed the End Date - Status was "Registered"		2001-12-05	2004-12-02	SAQA 0639/01
LAST DATE FOR ENROLMENT		LAST DATE FOR ACHIEVEMENT
2005-12-02		2008-12-02

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.

This unit standard is replaced by:

US ID	Unit Standard Title	Pre-2009 NQF Level	NQF Level	Credits	Replacement Status
117118	Apply knowledge of the current Medical Schemes Act and the accompanying regulations	Level 4	NQF Level 04	3

PURPOSE OF THE UNIT STANDARD

This unit standard requires basic knowledge of the legislation governing Medical Schemes. It is intended for learners who work in Healthcare Benefits Administration and who give financial advice.

The qualifying learner is capable of:

Explaining the rationale for the introduction of the Medical Schemes Act of 1998.

Explaining the regulations to the Act as they apply to members.

Investigating the practical implications for financial risk to the scheme as a result of the regulations.

Explaining the administrative requirements of the Act.

Describing the role of intermediaries in Healthcare Benefits Administration.

LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING

There is open access to this unit standard. Learners should be competent in Communication and Mathematical Literacy at Level 3.

UNIT STANDARD RANGE

The typical scope of this unit standard is:

1. Stakeholders governed by the Act include intermediaries, administrators, schemes, trustees, managed care organisations and providers.
2. Conditions of enrollment are pre existing conditions, late joiner penalties and conditions for continued membership.
3. Products to reduce risk include savings plans, capitation plans, co-payment plans and limited benefit plans.

Specific Outcomes and Assessment Criteria:

SPECIFIC OUTCOME 1

Explain the rationale for introduction of the Medical Schemes Act.

OUTCOME NOTES

Explain the rationale for the introduction of the Medical Schemes Act and the concepts that are implicit in the Act.

ASSESSMENT CRITERIA

ASSESSMENT CRITERION 1

1. Reasons for the introduction of the Medical Schemes Act are explored with reference to the historical situation in the industry and the need for pooling of health risk.

ASSESSMENT CRITERION 2

2. The concept of community rating is explained with reference to how it contributes to spreading the risk.

ASSESSMENT CRITERION 3

3. The concept of risk rating is explained with reference to the negative effect that it has on the concept of community rating.

ASSESSMENT CRITERION 4

4. The concept of dependence is explained as it is applied in the Act.

ASSESSMENT CRITERION 5

5. The concept of a late joiner penalty is explained in relation to community rating.

ASSESSMENT CRITERION 6

6. The concept of guaranteed acceptance is explained in relation to community rating and non-discrimination.

ASSESSMENT CRITERION 7

7. The effect of the Act on scheme rules is explained and examples are given of instances where a scheme may exercise own discretion to the benefit of members.

ASSESSMENT CRITERION 8

8. The stakeholders governed by the Act are named in terms of the administration and marketing of a scheme.

SPECIFIC OUTCOME 2

Explain how the regulations apply to members of medical schemes.

ASSESSMENT CRITERIA

ASSESSMENT CRITERION 1

1. The concept of prescribed minimum benefits is explained in terms of unconditional payment irrespective of the benefit option.

ASSESSMENT CRITERION 2

2. The conditions of enrollment prescribed by the regulations are explained in terms of pre-existing conditions, late joiner penalties and conditions for continued membership.

ASSESSMENT CRITERION 3

3. The concept of Personal Medical Saving accounts is explained in terms of the regulations.

SPECIFIC OUTCOME 3

Investigate the practical implications of the regulations & the resultant financial risk.

OUTCOME NOTES

Investigate the practical implications of the regulations and the resultant financial risk to the scheme.

ASSESSMENT CRITERIA

ASSESSMENT CRITERION 1

1. The reasons why the prescribed minimum benefits pose a financial risk to a scheme are explained using examples.

ASSESSMENT CRITERION 2

2. The financial implications of each condition for enrolment are explained from the perspective of both the scheme and the member.

ASSESSMENT CRITERION 3

3. Different interpretations of the waiting period are investigated as applied in three different schemes.

ASSESSMENT CRITERION 4

4. The basis on which membership fees are determined is explained and an indication is given of the effect on the member and the scheme.

ASSESSMENT CRITERION 5

5. Products to meet the required regulations and reduce risk to the scheme are investigated and an indication is given of the implications of each product for the scheme, the provider and the member.

ASSESSMENT CRITERION 6

6. The risk to the scheme and the member of the regulated waiting period for pre existing conditions is explained as upside and downside risk.

ASSESSMENT CRITERION 7

7. The regulations regarding penalties applied to members for late joining are indicated and the amount of the penalty is calculated for five case studies.

ASSESSMENT CRITERION 8

8. The rules governing the reserves of funds are explained in terms of the liquidity of the fund.

ASSESSMENT CRITERION 9

9. The regulations regarding pre-existing illness conditions applied to members.

SPECIFIC OUTCOME 4

Explain the administration requirements of the Act.

ASSESSMENT CRITERIA

ASSESSMENT CRITERION 1

1. The regulations that apply to administrators and schemes are explained with reference to the Act.

ASSESSMENT CRITERION 2

2. The responsibility of the scheme and the member regarding proof of continuation membership is described with reference to who should initiate the certificate.

ASSESSMENT CRITERION 3

3. The relationship between medical schemes, products and options within the product is explained with examples.

ASSESSMENT CRITERION 4

4. The requirements regarding proof of membership are explained in terms of the responsibility of the scheme.

ASSESSMENT CRITERION 5

5. Rules regarding the timing of payments are indicated with reference to the regulations and the rules of the scheme.

ASSESSMENT CRITERION 6

6. The implications of making payments late are explained with reference to suspension of membership.

ASSESSMENT CRITERION 7

7. The responsibility of the scheme to pay claims that are submitted late is explained in cases where membership has been terminated.

ASSESSMENT CRITERION 8

8. The responsibility of the scheme to pay claims submitted in connection with exclusions and waiting periods in terms of prescribed minimum benefits are explained.

ASSESSMENT CRITERION 9

9. Rules regarding the conditions for providing managed health care are explained.

SPECIFIC OUTCOME 5

Describe how the Act governs the relationship between Intermediaries & Healthcare Benefits Admin.

OUTCOME NOTES

Describe how the Act governs the relationship between intermediaries and Healthcare Benefits Administrators.

ASSESSMENT CRITERIA

ASSESSMENT CRITERION 1

1. The code of behaviour that applies to brokers who market the products of Healthcare Benefits Administrators is described with reference to the Medical Schemes Act.

ASSESSMENT CRITERION 2

2. The limits on payment of commission to brokers are explained and an indication is given of the implications of exceeding the limits.

ASSESSMENT CRITERION 3

3. Conditions under which a broker may be disqualified are identified using case studies.

ASSESSMENT CRITERION 4

4. The accreditation process for brokers who market products of Healthcare Benefits Administrators is illustrated graphically.

UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS

This unit standard will be internally assessed by the provider and moderated by a moderator registered by INSQA or a relevant accredited ETQA. The mechanisms and requirements for moderation are contained in the document obtainable from INSQA, - INSQA framework for assessment and moderation.

Critical Cross-field Outcomes (CCFO):

UNIT STANDARD CCFO IDENTIFYING

The learner is able to identify and solve problems in which responses show that responsible decisions have been made in applying the regulations and the Act.

UNIT STANDARD CCFO COLLECTING

The learner is able to collect, organise and critically evaluate information relating to the Act and regulations.

UNIT STANDARD CCFO COMMUNICATING

The learner is able to communicate effectively using visual, mathematics and language skills in the modes of oral and/or written presentations in explaining the concepts in the regulations.

UNIT STANDARD CCFO DEMONSTRATING

The learner is able to demonstrate an understanding of the world as a set of related systems by recognising the financial and other implications of the regulations and risk to the scheme, and the relationship between medical schemes, products and options.

UNIT STANDARD NOTES

This unit standard has been replaced by 117118, which is 'Apply knowledge of the current Medical Schemes Act and the accompanying regulations', Level 4, 3 Credits.

QUALIFICATIONS UTILISING THIS UNIT STANDARD:

	ID	QUALIFICATION TITLE	PRE-2009 NQF LEVEL	NQF LEVEL	STATUS	END DATE	PRIMARY OR DELEGATED QA FUNCTIONARY
Core	20639	National Certificate: Healthcare Benefits Administration: Claims Assessing	Level 4	NQF Level 04	Passed the End Date - Status was "Registered"	2004-12-05	INSETA
Elective	48494	National Certificate: Financial Services Management	Level 3	NQF Level 03	Passed the End Date - Status was "Reregistered"	2012-06-30	INSETA
Elective	48640	National Certificate: Financial Services Management	Level 4	Level TBA: Pre-2009 was L4	Passed the End Date - Status was "Reregistered"	2023-06-30	INSETA
Elective	48493	National Certificate: Financial Services: Wealth Management	Level 4	NQF Level 04	Passed the End Date - Status was "Registered"	2007-02-11	Was INSETA until Last Date for Achievement
Elective	24396	National Certificate: Risk Management	Level 4	NQF Level 04	Passed the End Date - Status was "Registered"	2006-10-08	Was INSETA until Last Date for Achievement
Elective	21796	National Certificate: Short Term Insurance	Level 4	NQF Level 04	Passed the End Date - Status was "Registered"	2005-06-12	Was INSETA until Last Date for Achievement
Elective	23973	National Certificate: Financial Services: Wealth Management	Level 5	Level TBA: Pre-2009 was L5	Passed the End Date - Status was "Registered"	2006-08-13	Was INSETA until Last Date for Achievement

PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD:

This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.

NONE