Project proposes to limit readjustment of collective health plan – 06/17/2023 – Health

After 17 years in progress in the Chamber of Deputies, a project that changes the law on health plans has advanced after the appointment last month of a new rapporteur who has a speech in defense of consumer rights. The situation has left the supplementary health sector in an uproar.

Among the proposed changes is the prediction of limits for readjustments in the monthly fees of collective plans. Today, only individual plans have a readjustment base defined by the ANS (National Supplementary Health Agency).

There is also a ban on the unilateral termination of contracts by the operator. Today, the collective plan can be suspended for no reason, such as fraud or default, provided that the contract is in force for 12 months and that the operator notifies the user at least 70 days in advance.

The proposal to change the law has been discussed in public hearings across the country. Last week, at a meeting in Brasilia, the project’s rapporteur, federal deputy Duarte Jr. (PSB-MA), said that these and other points have already been agreed upon and that they should be included in the report that he will present by the end of this month. There are more than 270 proposals appended to PL 7419/06.

“[A proposta é] Prohibit unilateral termination, limit readjustments of collective plans. It doesn’t have to be a land without rules, without any kind of transparency. Consumers need to know why and how much [o seu plano] is being readjusted,” he said.

There is unanimity in the sector that it is necessary to revise the law of plans, which completed 25 years, however, the rapporteur’s proposals go against the grain of what health operators defend. In recent years, they have sought to make the current rules of individual contracts more flexible and release the sale of plans with less coverage, for example.

The hearing in Brasilia was attended by representatives of the Ministry of Health, Public Ministry, ANS (National Supplementary Health Agency), consumer protection entities, among others. According to Duarte Jr., the operators were invited, but did not send representatives.

In a note, Fenasaúde says it was not invited to any debate organized by the deputy. She claims that the Commission for Consumer Protection of the Chamber approved two requests for the entity to be called, but that the invitation was never formalized. Already the Abramge (Brazilian Association of Health Plans) preferred not to comment.

Duarte Jr., who has chaired Procon Maranhão and Procon Nordeste, has been advocating that changes in the law in favor of the consumer are necessary to curb abusive practices by health plans.

He says that he will not include in his report proposals that aim to make the current rules more flexible, to the benefit of operators, as previous opinions have proposed. The Chamber has already had two commissions to analyze changes in the Law of Plans (in 2017 and in 2021).

But the scenario regarding the project in the Chamber, which is being processed on an urgent basis, is still uncertain because part of the deputies defends more discussions on the subject.

Another alteration that will appear in the report, according to Duarte Jr., will be the authorization for other health professionals, such as nutritionists, physiotherapists and speech therapists, to request tests from the plans.

Currently, only the physician has this prerogative. He also defends that the ANS starts to inspect service providers, such as hospitals and clinics. Today the agency only regulates the plans.

During the hearing, the participants argued that the changes in the law do not bring setbacks to the consumer and that they expand access to supplementary health, but that they also look at the sustainability of the sector.

Lawyer Ana Carolina Navarrete, from Idec (Brazilian Institute of Consumer Defense), said that the regulation of collective plans is necessary to solve the current shortage of individual plans in the market.

“If you let [os coletivos, que são] most of the market without regulation or with very little regulation, compared to the individual plan, which is more and better regulated, it is clear that the market escapes to where it is less regulated, and then we have a reduction in the offer of plans individual.”

Economist Rudi Rocha, professor at FGV and director of research at Ieps (Institute of Studies for Health Policies), says that regulatory changes can have an impact on both the private and public sectors. “We have to be very careful, we have to think about all fronts and what the result will be.”

According to him, the Brazilian population is aging, there will be more chronic diseases, there will be offers of new technologies and the health bill will become increasingly expensive. “Who is going to pay this bill? It is essential that the debate remains active in all segments of society.”

Paulo Roberto Rebello Filho, CEO of ANS, said that the agency should soon complete a study on the regulation of collective plans, which provides for a change in the calculation of readjustments and more transparency and clarity for the beneficiary. “The ANS has been doing its work, it is not stagnant.”

He stated that health is facing several challenges, such as the demographic transition, technological incorporations and rising costs, which impact the entire health system. “It is important that we have a vision of the forest [quando se pensa em regulação] because, without looking at the whole, the sustainability of the sector could be jeopardized.”

Rebello Filho affirms that it is necessary to understand that there are health insurance companies of different sizes and that today there is a great concern with minors. He mentioned the impact caused by the inclusion of Zolgensma, a medication against spinal muscular atrophy (AME) type 1 in the ANS list, in February this year.

The medication costs BRL 7.2 million per person to the plans. “20% of small operators do not invoice for a year the cost of a medicine like this.”

The president of the ANS also expressed concern in relation to the proposal that the agency start inspecting service providers. He says that today there is no capacity for the ANS to inspect over 250,000 service providers.

---

See some of the proposed changes to the law of plans

Tuition readjustment – readjustment limit, as already occurs in individual plans, and greater transparency of information from operators that justify proposed increases.

Termination or suspension of the contract – Prohibition of unilateral termination of contracts by operators.

Lack of health plans – reduction of grace periods for maximum coverage of health plans, especially for coverage of pre-existing diseases, prenatal procedures and high-risk pregnancies.

Hospitalized patient follow-up – guarantee that every hospitalized patient has the right to the presence of a companion, including the coverage of their food expenses. The idea is to include this right in law, which is already included in ANS regulations.

List of specific procedures – inclusion of procedures such as gastric bypass surgery, reconstructive cosmetic surgeries, assisted reproduction and vaccines, among others.

Consumer rights – inclusion of additional rights for beneficiaries, such as waiver of authorization, maximum service deadlines, denial justification, discounts, participation and deductible.

Dismissal, retirement or death of the holder – increase in the term of maintenance of the plan after dismissal or death, or reducing the grace period for the retiree to guarantee lifetime assistance.

Accreditation, free choice of professionals and reimbursement – changing the parameters of the contractual relations between the plans and physicians and other health providers, modifying rules for accreditation, remuneration, free choice of professionals and reimbursement for care outside the accredited network.

Reimbursement to SUS – there are projects that define how health plans should reimburse the federal government when plan beneficiaries are assisted by the SUS, either in public hospitals, contracted by the government or contracted.