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: 

Objectively evaluate the criteria that materially affect the performance of a medical scheme and its administration 
SAQA US ID UNIT STANDARD TITLE
242616  Objectively evaluate the criteria that materially affect the performance of a medical scheme and its administration 
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 5  Level TBA: Pre-2009 was L5  10 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Passed the End Date -
Status was "Reregistered" 		 2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2026-06-30   2029-06-30  

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 does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
This Unit Standard is intended for learners who work at a senior or strategic level in healthcare benefits administration and/or advise on medical schemes and products. It should enable learners to evaluate the performance of a medical scheme and its administrator and to proactively manage a medical scheme to identify and rectify problem areas. It will be useful for Trustees, Consultants, Intermediaries, Fund Managers, Principal Officers, Clinicians, Underwriters and learners in administration.

The qualifying learner is capable of:
  • Analysing Government Health Policy in terms of how this affects the performance of a medical scheme.
  • Analysing the impact of decisions of the various stakeholders on a selected medical scheme.
  • Evaluating the performance of a medical scheme.
  • Evaluating the resources of a medical scheme and their effect on performance. 
    		•

    LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    It is assumed that learners are competent in Communication and Mathematical Literacy at NQF Level 4. 

    UNIT STANDARD RANGE 
    The typical scope of this Unit Standard is:
  • Performance of a medical scheme includes, but is not limited to, financial management, pricing, members' perceptions of a scheme, and outcomes measurement or quality.
  • Impact of legislation includes, but is not limited to, cost drivers.
  • Cost drivers include, but are not limited to, demographics, fraud, cost of compliance, benefit design and pricing.
  • Risk management includes, but is not limited to risk assessment, evaluation and control.
  • Decisions relating to management of risk include, but are not limited to demographics, benefit design, fraud, abuse, peer review, protocols and formularies.
  • Data and information include, but are not limited to, current rules of a medical scheme, financial statements, global credit rating, information from health risk management programmes relating to the spend of a scheme, service level agreements and contracts.
  • Evaluations should include at least administration skills, actuarial evaluations, financial management, sales and marketing, ex gratia policies, underwriting criteria, external and internal audits, control of fraud and abuse, return on investment (ROI) in the context of a medical scheme.
  • Efficiency of IT infrastructure includes, but is not limited to, data management, flexibility, adaptability, potential for integration, work processes, work flows, call centres, integration of information, electronic systems and software applications.
  • Legislation includes, but is not limited to, National Health Act, Medical Schemes Act, Pharmacies Act, Medicine and Controlled Substances Act, Compensation for Occupational Injuries and Diseases Act (COIDA), Road Accident Fund (RAF), Financial Advisory and Intermediary Services Act (FAIS).
  • Impact of National Health Policy includes, but is not limited to, Low Income Medical Schemes (LIMS), Government Employees Medical Schemes (GEMS), Prescribed Minimum Benefits (PMBs) and Risk Equalisation Fund.
  • Health risk management includes, but is not limited to, disease and condition management, managed healthcare programmes, HIV/AIDS and Asthma programmes.
  • Demographic information includes, but is not limited to, health status, income, family size and age, geographic distribution, membership of other medical schemes, occupation and level of education.
  • Limitations on benefit design include, but are not limited to, risk equalisation LIMS, PMBs and primary healthcare.
  • Governance includes, but is not, limited to, financial matters, communication, contracts, management of risk and service level agreements.
  • Analysis of financials includes, but is not limited to, cost drivers, income, expenses, calculation of income, contributions, solvency requirements, underwriting profits and losses, demographics, utilisation, and claims rating. 
    		•

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Analyse Government Health Policy in terms of how it affects the performance of a Medical Scheme. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Current health policy and government healthcare initiatives are analysed to determine their current and potential impact on the performance of a selected medical scheme. 

    ASSESSMENT CRITERION 2 
    The implications of relevant legislation on the performance of a medical scheme are analysed in terms of their impact on a selected scheme. 

    ASSESSMENT CRITERION 3 
    Issues of governance arising out of legislation that impacts on the performance of a medical scheme are analysed with reference to the role and functions of the stakeholders. 

    ASSESSMENT CRITERION 4 
    Selected products are analysed to identify the principles of health risk management. 

    ASSESSMENT CRITERION 5 
    The income statement and balance sheet of a medical scheme are analysed to identify financial limitations on decisions about product design. 

    SPECIFIC OUTCOME 2 
    Analyse the impact of decisions of the various stakeholders on a selected medical scheme. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Decisions relating to benefit design of a selected medical scheme are analysed to determine the impact on performance. 

    ASSESSMENT CRITERION 2 
    Decisions relating to management of risk are evaluated in terms of factors impacting on price and utilisation. 

    ASSESSMENT CRITERION 3 
    The marketing plan of a medical scheme is analysed in terms of its impact on membership growth and the risk profile of existing and potential members. 

    ASSESSMENT CRITERION 4 
    The decisions of different stakeholders of a medical scheme are evaluated and a recommendation is made to improve the performance of a medical scheme. 

    SPECIFIC OUTCOME 3 
    Evaluate the performance of a medical scheme. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    The data and information required to evaluate the performance of a medical scheme are identified and accessed for a specific scheme administrator. 

    ASSESSMENT CRITERION 2 
    Criteria that affect the performance of a medical scheme are researched and applied to evaluate the performance of a selected medical scheme. 

    SPECIFIC OUTCOME 4 
    Evaluate the resources of a medical scheme and their effect on performance 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Information Technology (IT) infrastructure of a selected medical scheme is evaluated in terms of efficiency. 

    ASSESSMENT CRITERION 2 
    Non-healthcare and risk management spend of a medical scheme is evaluated and justified in terms of effectiveness, outcomes measurement, value add and Return on Investment (ROI). 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
  • Anyone assessing a candidate against this Unit Standard must be registered as an assessor with the relevant ETQA or ETQA where a Memorandum of Understanding (MOU) exists with the relevant ETQA.
  • Any institution offering learning that will enable achievement of this Unit Standard must be accredited as a provider through the relevant ETQA or ETQA where a Memorandum of Understanding (MOU) exists with the relevant ETQA.
  • Moderation of assessment will be overseen by the relevant ETQA according to the moderation guidelines and the agreed ETQA procedures. 
    		•

    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 using critical and creative thinking have been made in analysing the potential impact of proposed changes on a medical scheme. 

    UNIT STANDARD CCFO COLLECTING 
    The learner is able to collect, organise and critically evaluate information in evaluating the performance of a medical scheme and justifying non-healthcare spend. 

    UNIT STANDARD CCFO COMMUNICATING 
    The learner is able to communicate effectively in recommending changes to a medical scheme. 

    UNIT STANDARD CCFO SCIENCE 
    The learner is able to use science and technology effectively and critically in evaluating the IT infrastructure of a selected medical scheme. 

    UNIT STANDARD CCFO DEMONSTRATING 
    The learner is able to demonstrate an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation by analysing Government Health Policy and the impact of decisions in terms of how they affect the performance of a medical scheme and the various stakeholders on a selected medical scheme. 

    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 
    Search words: Healthcare Benefits Administration; medical schemes, performance medical scheme. 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Elective  66611   National Certificate: Wealth Management  Level 5  NQF Level 05  Passed the End Date -
    Status was "Reregistered"     		 2023-06-30  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.
     
    NONE 


    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.