Health plan: customer can have double readjustment; understand – 06/12/2023 – Market

Customers of individual and family health plans can have two readjustments in 2023, if it is the year in which the medical insurance is authorized to apply the increase by age group. This Monday (12), the ANS (National Agency for Supplementary Health) set up to 9.63% the percentage of annual readjustment allowed for these agreements.

The annual readjustment is valid between May this year and April 2024 for individual and family plans contracted from January 1999 or adapted to Law No. 9656/98. The increase, which should only be applied in the birthday month, should reach 8 million contracts. The index is not valid for collective corporate plans or membership plans (contracted through unions or associations).

According to Leonardo Camiza Machado, partner at Silveiro Advogados and member of the special commission on the right to health at the OAB/RS (Brazilian Bar Association of Rio Grande do Sul), the increase in the agreement due to age group changes depends on the type of contract and when it was signed.

For those who have a health plan with a contract signed before January 1999, the age range depends on what is in the contract. For those signed up to December 2003, there are seven age groups, ranging from zero to 17 years old, 18 to 30 years old, 30 to 39 years old, 40 to 49 years old, 50 to 59 years old, 60 to 69 years old and, finally, 70 years old or more .

Contracts signed from 2004 follow the current rules of the ANS, which consider ten age groups in which it is possible to apply readjustment by age, the last one being 59 years old.

See which are the age groups in which there may be readjustment of the plan:

Range	Age
1	zero to 18 years
two	19 to 23 years old
3	24 to 28 years old
4	29 to 33 years old
5	34 to 38 years old
6	39 to 43 years old
7	44 to 48 years old
8	49 and 53 years old
9	54 to 58 years old
10	59 years or older

Giselle Tapai, specialist in consumer law with a focus on health and partner at Tapai Advogados, says that, in the year in which there is the possibility of readjustment by age group, the consumer can, yes, have two increases, but there are limitations, according to norms of ANS.

“The ANS does not interfere in the readjustment index that the health plan operator wants to apply, as long as two rules are respected. The first is that there cannot be a variation greater than six times between the first and last age group”, he says. .

The second rule to be followed by health plans is that the accumulated increase between the seventh range, from 44 to 48 years old, and the last (59 years old), cannot be greater than the readjustment that was given between the first and seventh range .

“The purpose of this rule is to prevent the health operator from concentrating the highest readjustment rates for the last age groups, a very common practice and which aims to make the monthly fee unfeasible for the elderly, as this represents a much greater risk for private health plan companies”, explains Giselle.

Lawyer Sandra Franco, specialist in medical and health law, says that, in addition to the norms determined by the ANS in the readjustment by age group, there is no other form of consumer protection from the impact that the double readjustment will have on the family budget.

However, she recommends that, if the customer believes that his readjustment is abusive, even in the year in which it is allowed to apply the double increase, he should look for the operator before filing any lawsuit. “It is always possible to go to the Judiciary, but I recommend first seeking explanations with the operator itself”, she says.

According to ANS, if the operator does not clarify the issue, it is possible to file a complaint at the agency itself, through the website (click here to register your complaint), and by telephone, at Dial ANS (0800-7019656) or 0800-0212105, for the hearing impaired, from Monday to Friday, from 8 am to 8 pm, with the exception of holidays.

It is also possible to activate the existing ANS centers in 12 cities in the country, from Monday to Friday, from 8:30 am to 4:30 pm, except on holidays. Click here to see the addresses. Anyone who is going to make the complaint over the internet will have to inform the CPF and create an access password.

How does the readjustment of individual and family health plans work?

The annual readjustment percentage for individual and family health plans contracted as of January 1999 or adapted to Law No. 9656/98 is defined by the ANS generally between the months of May and June.

The health plan may apply the readjustment after publication in the Official Gazette, limiting it to the percentage defined by the agency, but only on the anniversary date of the medical insurance contract.

How is the readjustment calculated?

Since 2019, the ANS has used a calculation methodology that combines the variation in assistance expenses with the inflation measured by the IPCA (National Index of Broad Consumer Prices), which is the country’s official inflation measured by the IBGE (Brazilian Institute of Geography and Statistics) . To arrive at the final calculation, there is still the sub-item health plan discount within the inflation index.

The calculation is based on the difference between the assistance expenses per client of this type of plan between one year and another. Thus, the 2023 index is the result of plan spending in 2022 compared to 2021.

In 2022, the readjustment was 15.5%. This year, it was 9.63%. In the agency’s assessment, the lower percentage indicates that “the sector’s situation is returning to normal levels of use”, hampered by the coronavirus pandemic.

Can there be retroactive billing?

Yes. The readjustment defined in June is valid from May 2023 to April 2024. As this year the readjustment was defined this month for contracts with an anniversary between May and July, the collection should start, at most, until August, retroacting until the month in which the contract was signed.

For the others, operators must start billing within a maximum of two months after the anniversary of the contract, retroacting until the anniversary month.

How do I know if the amount charged on my invoice is correct?

According to the ANS, the payment slip sent by the operator must inform the rate authorized by the regulatory agency; the name, code and registration number of the plan; the month expected for the next readjustment, and the number of the ANS authorization letter. In addition, the values ​​need to be clear and itemized.

See an example:

• Health plan that costs R$ 100, with a birthday in May. Readjustment authorized by ANS is 9.63%
• May/23 monthly fee BRL 100: without readjustment
• June/23 monthly fee: BRL 100: without readjustment
• Monthly fee for July/23: R$ 109.63 (adjusted monthly fee) + R$ 9.63 (difference from the May readjustment). Total amount to be paid in July/23: BRL 119.26
• Monthly fee for August/23: R$ 109.63 (adjusted monthly fee) + R$ 9.63 (difference from the June adjustment). Total amount to be paid in August/23: BRL 119.63
• September/23 monthly fee: BRL 109.63

Can the operator apply a higher readjustment?

No, the annual increase is limited to the percentage defined by ANS for this type of contract. There is, however, the possibility of charging for changing age groups, which is another increase to be applied by the plan through its own accounting. In this case, in addition to respecting the age group, it is necessary to follow other rules defined by the ANS that limit abusive charges.

If the health plan wants to apply a smaller readjustment, is it possible?

Yes, it is possible to apply a smaller readjustment, but operators do not usually apply this practice. The index of 9.63% was lower than expected by the sector. Abramge (Brazilian Association of Health Plans) projected that the readjustment would be between 10% and 12%.