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: 

Apply knowledge of the current Medical Schemes Act and the accompanying regulations 
SAQA US ID UNIT STANDARD TITLE
117118  Apply knowledge of the current Medical Schemes Act and the accompanying regulations 
ORIGINATOR
SGB Insurance and Investment 
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 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Reregistered  2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2024-06-30   2027-06-30  

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 replaces: 
US ID Unit Standard Title Pre-2009 NQF Level NQF Level Credits Replacement Status
12335  Demonstrate knowledge and insight into the Medical Schemes Act (131 of 1998) and the accompanying regulations  Level 4  NQF Level 04  Complete 

PURPOSE OF THE UNIT STANDARD 
This unit standard requires basic knowledge of legislation governing Medical Schemes. It is intended for learners who work in Healthcare Benefits Administration, financial service providers and their intermediaries and Trustees of Medical Schemes.

The qualifying learner is capable of:
  • Explaining the rationale for the introduction of the current Medical Schemes Act as amended and the concepts that are implicit in the Act.
  • Explaining how the regulations apply to members of medical schemes.
  • Investigating the practical implications of the regulations and the financial risk to the scheme.
  • Explaining the administrative requirements of the Act.
  • Describing how the legislation governs the relationship between intermediaries and medical schemes. 

  • 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
  • Stakeholders governed by the Act include intermediaries, administrators, schemes, trustees, managed care organisations and providers.
  • Conditions of enrollment are pre existing conditions, late joiner penalties, waiting periods and conditions for continued membership.
  • Treatment for prescribed minimum benefits includes formularies and designated service providers.
  • Products to reduce risk include savings plans, capitation plans, formularies, designated service providers, co-payment plans and limited benefit plans.
  • Regulations that apply to administrators include transfer of personal medical savings. 

  • Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Explain the rationale for the introduction of the current Medical Schemes Act, as amended, and the concepts that are implicit in the Act. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Reasons for the introduction of the current 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 
    The concept of community rating is explained with reference to how it contributes to spreading the risk. 

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

    ASSESSMENT CRITERION 5 
    The concept of dependants is explained as it is applied in the Act. 

    ASSESSMENT CRITERION 6 
    The concept of a late joiner penalty is explained in relation to community rating. 

    ASSESSMENT CRITERION 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 
    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 
    The concept of prescribed minimum benefits is explained in terms treatment and payment irrespective of the benefit option as applied by a selected medical scheme. 

    ASSESSMENT CRITERION 2 
    The concept of Personal Medical Saving accounts is explained in terms of the regulations. 

    ASSESSMENT CRITERION 3 
    The conditions of enrollment prescribed by the regulations are explained in terms of pre-existing conditions, waiting periods, late joiner penalties and conditions for continued membership. 

    SPECIFIC OUTCOME 3 
    Investigate the practical implications of the regulations and the financial risk to the scheme. 

    ASSESSMENT CRITERIA
     

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

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

    ASSESSMENT CRITERION 3 
    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 4 
    Two products to meet the required regulations and reduce risk to the scheme are compared and an indication is given of the implications of each product for the scheme, the provider and the member. 

    ASSESSMENT CRITERION 5 
    The risk to the scheme and the member of the regulated waiting period for pre-existing conditions is explained as upside and downside risk and the responsibility of the scheme. 

    ASSESSMENT CRITERION 6 
    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 7 
    The rules governing the reserves of funds are explained in terms of the liquidity of the fund. 

    SPECIFIC OUTCOME 4 
    Explain the administration requirements of the Act. 

    ASSESSMENT CRITERIA
     

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

    ASSESSMENT CRITERION 2 
    The relationship between medical schemes and options within a product is explained in terms of payment of claims. 

    ASSESSMENT CRITERION 3 
    The requirements regarding proof of membership are explained in terms of the responsibility of the scheme/administrator and the member. 

    ASSESSMENT CRITERION 4 
    Rules and implications regarding the timing of payments are indicated with reference to the regulations and the rules of the scheme. 

    ASSESSMENT CRITERION 5 
    The responsibility of the scheme to pay claims where membership has been terminated or claims are submitted late is explained with examples. 

    ASSESSMENT CRITERION 6 
    The responsibility of the scheme to pay claims submitted in connection with exclusions and waiting periods in terms of prescribed minimum benefits are explained with examples. 

    ASSESSMENT CRITERION 7 
    Rules regarding the conditions for providing managed health care are explained with examples. 

    SPECIFIC OUTCOME 5 
    Describe how legislation governs the relationship between intermediaries and medical schemes. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The code of conduct that applies to intermediaries who market the products of medical schemes is described with reference to FAIS and the Medical Schemes Act. 

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

    ASSESSMENT CRITERION 3 
    Conditions under which an intermediary may be disqualified are identified using case studies. 

    ASSESSMENT CRITERION 4 
    The accreditation process for intermediaries who market products of Medical Schemes is explained with examples. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    This Unit Standard will be internally assessed by the provider and moderated by a moderator registered by a relevant accredited ETQA or an ETQA that has a Memorandum of Understanding with the relevant accredited ETQA. 

    UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    N/A 

    UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    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 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 ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    This unit standard has replaced 12335 which was "Demonstrate knowledge and insight into the Medical Schemes Act (131 of 1998) and the accompanying regulations", Level 4 with 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  49356   Further Education and Training Certificate: Medical Claims Assessing  Level 4  NQF Level 04  Reregistered  2023-06-30  INSETA 
    Elective  49089   National Certificate: Financial Services  Level 3  NQF Level 03  Reregistered  2023-06-30  INSETA 
    Elective  49649   Further Education and Training Certificate: Long-term Insurance  Level 4  NQF Level 04  Reregistered  2023-06-30  INSETA 
    Elective  57613   Further Education and Training Certificate: Short-Term Risk Management  Level 4  NQF Level 04  Passed the End Date -
    Status was "Reregistered" 
    2012-06-30  INSETA 
    Elective  66613   Further Education and Training Certificate: Wealth Management  Level 4  NQF Level 04  Reregistered  2021-06-30  As per Learning Programmes recorded against this Qual 


    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.
     
    1. African Resources & Financial Training (Pty) Ltd 
    2. ALCARI 233 CC T/A ALCARI (Eversdal)(TP) 
    3. CKP Development Agency (Pty) Ltd. 
    4. De Vries Management & Training Services cc 
    5. DSBI (Pty) Ltd 
    6. Duxah (Pty) Ltd 
    7. Faisit (Pty) Ltd 
    8. Intec College 
    9. Invuya Institute of Learning (Pty) Ltd 
    10. Masifunde Training Centre (Pty) Ltd 
    11. Old Mutual Life Assurance Company South Africa 
    12. Ray Strodl Consulting (Pty) Ltd 
    13. Sanlam Life Insurance Ltd 
    14. Sanlam Life Insurance Ltd. 
    15. The Institute of Health Risk Managers (Pty) Ltd 
    16. Umfolozi FET College - Central Office 



    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.