Individual health plans may have extraordinary adjustments

A new pricing policy for health plans will be discussed at a public hearing of the National Health Agency (ANS) next Monday (7). On that occasion, a text classified as “combo” will be analyzed to avoid distortions with “isolated measures” that provide for the possibility of exceptional readjustments for individual and family health plans.

According to the ANS, requirements would be established so that operators in economic-financial imbalance could have “exceptional” adjustments — that is, above the ceiling established by the ANS for the type of contract. This imbalance, however, would have to be characterized by pre-defined indicators.

A new adjustment through technical review was already foreseen by the ANS, but its regulation was suspended after an injunction from the Federal Supreme Court (STF) suspended the effectiveness of this standard.

The ANS proposal also includes new rules for collective plans, limits for reimbursement and co-participation and the regulation of programs known as benefit cards. The proposed changes were approved at a meeting of the ANS collegiate board last Friday and will therefore be analyzed at a public hearing.

About collective plans. ANS intends to define a standard readjustment clause for collective plans, which, according to the agency, would give consumers more transparency about the calculation carried out to define the percentage. Currently, increases are defined between the operator and the contracting company (or the administrator, in the case of adhesion contracts).

Other health plan policy rules

Among the new rules, ANS also proposes expanding the size of plans for Small and Medium-sized Companies (SMEs), currently with a maximum of 29 users. The idea, according to ANS, would be to have greater “dilution of risk” and more balanced adjustments.

In relation to health plan co-participations and deductibles, a maximum percentage of charges per procedure will be determined, with monthly and annual financial limits. And, also, the list of procedures for which there could be no charge.

Another point that will be debated at the public hearing are the rules for marketing exclusively outpatient plans, the so-called discount cards, which only cover exams and consultations, but not hospital admission.

At the hearing, the criteria for the online sale of plans will also be defined, including the requirement that contracts be sold via the internet “in order to facilitate consumers’ access to different product options, quickly”.