ANS updates rules for changing hospitals in health plans

Health insurance

Standard expands portability of shortages

The National Supplementary Health Agency (ANS) approved new rules for changing the hospital network of health plan operators. The changes are related to Public Consultation nº 82/2021, which received contributions on what should be the criteria for changing the assistance network of operators.

New rules come into force 180 days after publication in the Official Gazette of the Union. The changes apply both to the withdrawal of a hospital from the network and to the exchange of one hospital for another. The objective is to provide greater transparency and security to beneficiaries.

portability

In cases where beneficiaries are dissatisfied with the exclusion of a hospital or emergency and emergency service from the hospital provider’s network, which occurred in the beneficiary’s municipality of residence or in the municipality where the plan was contracted, the beneficiary becomes entitled portability with no period of permanence in the plan. With this, you will not need to comply with the minimum periods of permanence in the plan (1 to 3 years).

It will also not be required that the origin and destination plan be in the same price range, as is currently the case in other cases of grace portability.

Communication

Under the new rules, operators will also be required to communicate to consumers, individually, about exclusions or changes in hospitals and urgent and emergency services in the accredited network in the beneficiary’s municipality of residence. Individual communication must be made 30 days in advance, counting from the end of the service provision.

The director-president of ANS, Paulo Rebello, emphasizes the benefits to the consumer of the health plan.

“In addition to being officially informed about any change in their operator’s hospital network, the consumer will have greater mobility, as it will be easier to carry out the portability of shortages if the hospital of their choice leaves their operator’s network”.

network reduction

Regarding the reduction of the hospital network, one of the main changes is related to the analysis of the impact of the withdrawal of the hospital on the consumers served by the operator.

Thus, if the unit to be excluded is responsible for up to 80% of hospitalizations in its service region, ANS determines that the operator will not only be able to remove the hospital from the network, but must replace it with a new one.

replacement of hospitals

The evaluation of the equivalence of hospitals for replacement should also be carried out based on the use of hospital services and urgent and emergency care in the last 12 months. Thus, if, during the analyzed period, the services were used at the excluded provider, they will need to be offered at the substitute provider.

And if the hospital to be withdrawn belongs to the group of hospitals that concentrate up to 80% of the plan’s admissions, partial exclusion of hospital services will not be allowed.

The approved norm also obliges the substitute hospital to be located in the same municipality as the excluded one, except when there is no provider available. In this case, a hospital in another nearby municipality may be indicated.

The director of Standards and Product Operations at ANS, Alexandre Fioranelli, highlighted that the focus of ANS, with the adoption of the new criteria, is on the safety of consumers with a health plan.

“The proposal is that the beneficiary is less affected due to the broken relationship between the operator and the provider. This normative proposal is the result of careful elaboration work, which had intense social participation and broad debate”,

said the director.

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