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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD THAT HAS PASSED THE END DATE: 

Demonstrate knowledge and understanding of different products marketed by Healthcare Benefits Administrators 
SAQA US ID UNIT STANDARD TITLE
12323  Demonstrate knowledge and understanding of different products marketed by Healthcare Benefits Administrators 
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  4 
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
117141  Describe healthcare cover in South Africa  Level 3  NQF Level 03  2   

PURPOSE OF THE UNIT STANDARD 
This unit standard requires detailed knowledge of the main products offered by Healthcare Benefits Administrators.

The qualifying learner is capable of:
  • Explaining the difference between medical insurance and a medical scheme.
  • Analysing and generalising the characteristics of traditional and new generation medical schemes.
  • Explaining the benefits covered by medical schemes.
  • Using terminology used in the industry in the correct context. 
    		•

    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. Medical schemes and medical insurance as marketed by Healthcare Benefits Administrators in South Africa.
    2. General characteristic of medical scheme products include general pooling of funds; a cross spectrum of benefits; defined benefits; fixed contributions; fee for service.
    3. General characteristics of new generation scheme products include pooling of funds across certain benefits; options; savings; threshold benefits and gap cover.
    4. Limits on benefits include pathology; optical; dental; psychological; occupational therapy; alternate medicine; auxiliary services.
    5. Restrictions include waiting periods; limit of benefits to specific time periods; severity of ailment; pre-notification; notification to medical advisory committee and enrollment on lifestyle management programmes.
    6. Legislation means the Medical Schemes Act and Accompanying Regulations. 

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Explain the difference between a medical scheme and medical insurance. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    1. The concept of a medical scheme is explained with reference to the role of the Administrator in the structure, the co-role of trustees and the role of the member in the scheme. 

    ASSESSMENT CRITERION 2 
    2. Medical insurance is explained with reference to the role of the insurance company and the board of directors. 

    ASSESSMENT CRITERION 3 
    3. The kinds of events covered by a medical scheme and the events covered by a medical insurance product are compared in a table. 

    ASSESSMENT CRITERION 4 
    4. The payment of claims against a medical scheme is compared to claims against an insurance product. 

    ASSESSMENT CRITERION 5 
    5. Legislation governing medical schemes and insurance products is named and an indication is given of the limitations that legislation places on the structure of the different products. 

    SPECIFIC OUTCOME 2 
    Compare traditional and new generation medical schemes. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    1. The broad spectrum of packages that make up three traditional medical scheme products are analysed in terms of benefits and limits. 

    ASSESSMENT CRITERION 2 
    2. The information obtained in the research is used to generalise the characteristics of conventional medical scheme products. 

    ASSESSMENT CRITERION 3 
    3. Three new generation products are researched in terms of guaranteed benefits and discretionary benefits. 

    ASSESSMENT CRITERION 4 
    4. Information from the research is used to generalise the characteristics of new generation products. 

    ASSESSMENT CRITERION 5 
    5. Reasons why the industry is moving away from traditional to new generation products are researched with reference to financial implications for the scheme, claiming patterns, increasing costs of healthcare, needs and priorities of members in terms of medical care and costs to the member. 

    SPECIFIC OUTCOME 3 
    Explain the benefits that are covered by medical schemes. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    1. Benefits across three different medical scheme products are compared in terms of what is standard, what has limits and how they are covered. 

    ASSESSMENT CRITERION 2 
    2. Common exclusions from benefits and exceptions to the exclusions are named with reasons why these are generally classified as exclusions. 

    ASSESSMENT CRITERION 3 
    3. Benefits that have restricted access are named and reasons are given to explain the restriction. 

    SPECIFIC OUTCOME 4 
    Understand, and use in the correct context, terminology used in the industry. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    1. The concept of ex gratia payments is explained with reference to case studies. 

    ASSESSMENT CRITERION 2 
    2. Pro-ration of benefits is explained with reference to case studies. 

    ASSESSMENT CRITERION 3 
    3. The terms date of inception; date of termination and suspension are explained with reference to the effect that these have on access to benefits. 

    ASSESSMENT CRITERION 4 
    4. The concept of a pre-existing condition is explained with reference to the effect on a benefit and the implications of non disclosure. 

    ASSESSMENT CRITERION 5 
    5. The difference between the Board of Healthcare Funders (BHF) and South African Medical Association (SAMA) rates is explained with reference to the government gazette. 

    ASSESSMENT CRITERION 6 
    6. Prescribed minimum benefits are explained with examples. 

    ASSESSMENT CRITERION 7 
    7. Late joining penalties are explained and calculated for five different case studies. 

    SPECIFIC OUTCOME 5 
    Select a product according to a client profile. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    1. Healthcare needs are identified for a single person, a couple and a family of four. 

    ASSESSMENT CRITERION 2 
    2. The risk profile of the three cases is established based on age and pre-existing conditions. 

    ASSESSMENT CRITERION 3 
    3. Suggestions are made as to what kind of healthcare products would be most suitable in each case. 


    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 
    Learners are able to identify and solve problems in making suggestions as to the healthcare product most suitable for three different situations. 

    UNIT STANDARD CCFO ORGANISING 
    Learners are able to organise and manage themselves effectively by becoming responsible citizens in conducting research into medical scheme and medical insurance products. 

    UNIT STANDARD CCFO COMMUNICATING 
    Learners are able to communicate effectively using visual, mathematics and language skills to analyse, compare and present their conclusions in the activities required by the unit standard, calculating late joining penalties and explaining terminology commonly used in the industry. 

    UNIT STANDARD CCFO DEMONSTRATING 
    Learners are able to demonstrate an understanding of the world as a set of related systems when explaining the implications of non-disclosure, indicating ways in which legislation places limitations on the structure of different products and researching reasons why the industry is moving away from traditional schemes to new generation products. 

    UNIT STANDARD CCFO CONTRIBUTING 
    Learners are able to act as responsible citizens in the organisation and local community when selecting a product according to a client profile. 

    UNIT STANDARD NOTES 
    This unit standard has been replaced by 117141, which is 'Describe healthcare cover in South Africa', Level 3, 2 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  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  20774   National Certificate: Insurance: Long Term: Risk Assessment  Level 4  NQF Level 04  Passed the End Date -
    Status was "Registered"     		 2004-12-05  Was INSETA until Last Date for Achievement 
    Elective  20773   National Certificate: Long Term Insurance  Level 4  NQF Level 04  Passed the End Date -
    Status was "Registered"     		 2004-12-05  INSETA 
    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 


    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. Faisit (Pty) Ltd 
    2. The Graduate Institute of Financial Sciences (Pty) Ltd 


    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.