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The National Agency for Supplementary Health (ANS) announced new rules for the collection of co-ownership and deductibles in health plans. These different types of plans, in which the consumer pays a fixed monthly fee and does not have to pay additional fees, have existed since 1998, but regulations have been necessary to clarify the conditions, criteria and limits of 39, application, according to the regulatory body. .
See below questions on the new rules:
What is a health plan with partnership?
The recipient pays a separate amount for the execution of a procedure or event whose percentage can not exceed 40% of the value.
What is the health insurance franchise?
The consumer pays a monthly fee and is entitled to certain basic procedures. If you need other consultations, exams or surgeries, you must pay up to the amount of the deductible provided in the contract. Once you use the full deductible, the health plan is that you have to bear the expenses.
Percentage and Limit Imposed
Operators could charge the consumer any percentage for procedures performed in co-participating plans.
As before and what changes? There was no definition of a collection limit per procedure nor a maximum value per monthly or annual period.
There will be a maximum percentage of 40% to be paid for procedures in case of co-participation. There will also be limits to the amount paid per month or year in the event of co-participation and deductible (these limits will not be applied to dental plans):
- Annual limit: the maximum amount to be paid by the beneficiary in the period of one year can not
- Monthly ceiling: the maximum amount to be paid by the beneficiary each month can not exceed the amount of the monthly payment due by the recipient
For example, if the beneficiary pays 100 USD The monthly limit for the co-participation or deductible can not exceed R $ 100. The beneficiary will then pay a maximum of R $ 200. In the case of the annual limit, the value of the co-participation or deductible will be R $ 1,200
Invoicing may apply to any procedure. And it also allowed differentiated fees for illness or pathology and in case of event hospitalizations.
Co-payment and deduction are prohibited in more than 250 procedures, including consultations with general practitioners, prenatal and preventive examinations, and chronic treatments such as cancer and hemodialysis. It is also prohibited the collection of participation and franchise differentiated by disease or pathology, except in the event of a psychiatric hospitalization.
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Procedure (Photo: Reproduction / ANS)
The limit to pay can it be increased? In which situation?
The limit may be increased by 50% in the case of health insurance plans that provide for this increase by means of agreements or collective agreements. Thus, the monthly and annual limits for co-participation and franchise would increase from 120 to 1,200 reais, 150 and 1,500 reais, respectively.
If the established limit is exceeded, the costs of using the health plan will be entirely the responsibility of the operator, and it will be prohibited to bill the surplus the following year.
When will the new rules come into effect?
In 180 days from June 28, which is December 28th.
In 10 years, the market share of health plans with co-participation and franchise has increased from 22% to 52% – 24.7 million beneficiaries of the closure of 48 million beneficiaries are in these terms, according to YEARS.
According to the ANS, when the co-participation modality provides for a percentage of the amount actually paid to the provider, the operator will be required to provide information on the amount charged at the request of the suppliers. beneficiaries.
In addition, the beneficiary may consult in advance the value of the price of the procedure practiced by specific providers.
How should co-participation be applied?
The following procedure is provided:
- Percentage of the monetary value of the procedure, procedure group or health event actually paid by the operator to the health service provider;
- Percentage of the values in the reference table which contains the list of procedures, groups of procedures and health events on which the co-participation will focus;
The new rules provide for the following:
- Deductible deductible deductible:
- Fixed value on procedure, procedure group or health event due to joint participation. the operator is not responsible for the coverage of the badistance charges accumulated in the 12-month period, from the signing or the anniversary of the contract, until the end of the amount established in the contract is reached as a franchise;
- Limited Franchise Access: The Operator is not responsible for covering the cost of badistance up to the amount defined in the contract, whenever the Recipient accesses the network. referenced and accredited cooperative or, in contracts where there is a free choice, accesses a supplier outside the network of service providers
How the impact of co-ownership and franchise in admissions to the hospital and emergency rooms
and single – regardless of the amount and type of procedure performed. The amount must be previously known by the beneficiary and can not be greater than 50% of the value of the monthly payment, nor greater than the amount paid by the operator to the provider.
In the case of hospitalization, the amount will be fixed and unique and may not exceed the monthly amount.
The fixed amounts and the single amounts stipulated in the contract must be applied to all emergency medical establishments that are part of the approved plan network contracted by the beneficiary, without distinction.
What should the contract establish?
- Procedures and services in health that will affect the joint venture and deductible and also exempt collection;
- The application form and the values and / or the percentage, including
- The limits of the financial exposure,
- The criteria for readjustment of the values, where there is forecast,
- Fixed values for emergencies and hospital care
What are the contracts already signed before the new rules?
Contracts signed before the coming into force of the regulation do not comply with the new rules.
How are new contracts signed before the rules come into force?
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