Learners will gain sufficient knowledge and understanding of the medical scheme industry to render financial services in respect of Health Service Benefits adequately.

The course will provide learners with enough knowledge to have an understanding of the construction of medical schemes and the complex environment in which the various role players in the medical scheme market, operates.  

The following topics are covered:

1 INTRODUCTION

Introduction to the Medical Schemes Act

 2 REGULATORS

2.1       Council of Medical Schemes (CMS)

2.1.1    Role of the CMS

2.1.2    The general functions of the CMS and interaction with medical schemes and related services

2.1.3    Other CMS functions

2.1.4    Medical schemes and related service providers regulated by the CMS

2.2       FSCA

3 CMS Healthcare Benefits Regulations

3.1       Prescribed Minimum Benefits (PMB)
 
3.2       Emergency conditions

3.3       Medical conditions (Diagnosis, Treatment Pairs or DTPs)

3.4       Chronic Disease List

3.5       Designated Service Provider (DSP)

3.6       ICD Code protocol (Procedure ID)

3.7       Medical schemes' responsibilities in relation to PMBs

3.8       Medical schemes solvency requirements

 
4 HEALTHCARE PRODUCT   

 4          Healthcare Plan variations

4.1       Limitation variations (service limitations)

4.2       The cost or contributions variations (monthly contributions)

4.3       Different products and fees structures

4.3.1    Basic product range

4.3.2    Additional benefits

4.3.3    Other products

4.3.4    Benefit details and limitations

4.3.5    Medical Scheme: Improved benefit and cost reductions strategies

4.3.6    General membership limits

 
5 KNOW YOUR CLIENT “KYC”

5.1       Determine client needs: (consider all options for client) all variables list

5.2       Inform

5.3       Rating of medical schemes

5.4       Suitability       

6 RISK RELATED TO HEALTHCARE

6.1       Risks related to cover

6.2       Risks related to medical schemes

6.3       Measure of risk and ability of medical schemes

 7 NATIONAL HEALTH INSURANCE  

 National Health Insurance (NHI) background