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ANS (National Agency for Complementary Health) issued new rules on health insurance plans on Thursday (28). Among the changes, the main one is that operators will be able to charge customers a contribution of up to 40% of the value of each procedure performed.
The rules will come into effect in 180 days and will only apply to new contracts . Several issues and concerns have emerged from these changes, such as paying for expensive surgeries or treatments such as chemotherapy and hemodialysis.
contracts No, the rules only change in 180 days and for new contracts . Anyone who is already badociated with a health plan today will have nothing more to pay. But if you change your health plan when the new rules are valid, then you will have to pay the extra amounts.
Does my monthly health insurance plan increase?
No, the monthly payment is not changed. The additional charge of 40% for new contracts will be in the form of co-participation, when the customer uses the services.
What happens is that total spending may even double according to usage according to consumer advocates.
Health plans say
I have to pay for treatment of chronic and serious diseases, such as cancer?
Treatments like chemotherapy and hemodialysis remain on the outside and cost nothing more.
Here are some examples of free admission:
- four consultations per year with a general practitioner: pediatrics, general practice (19459003) (one exam every two years), HIV test and syphilis (one exam per year) [19659013] chronic treatments: no number limit for hemodialysis, radiotherapy and chemotherapy, for example
- prenatal examinations: urine culture, at least three ultrasound examinations, ten obstetric appointments and others [19659015] Will I have to pay 40% for surgery or hospitalization?
No. Emergency visits and hospitalizations (including surgeries) have their own rules and are not subject to co-participation or deductible. For them, it has been stipulated a single and fixed value, to be established in the contract, but also respecting pre-stipulated ceilings: for hospitalizations and surgeries, the limit is one month
Because they are fixed, they do not change
What happens if I have an emergency and I go to the emergency room?
For emergency care, the rule is similar to that of hospitals. You do not pay 40% more, but a fixed fee, limited to half a month of your health insurance plan.
In the case of a person who pays a monthly payment of $ 200 to the health insurance plan, (19659002) If the procedure applied in the emergency room is less expensive than 100 R $ (a single consultation of R $ 1,000), she will not pay more than half a monthly fee (R $ 100). $ 80, for example) is worth less.
If this patient is hospitalized, even for a period of several months, he will only pay the extra expenses once. But in this case, it will be the equivalent of a monthly fee ($ 200 in this hypothetical case) because it falls under the rule of hospitals and hospitalizations.
Will I have to pay 40% of a delivery?
Parturitions are in the same rule of admission to the hospital. For hospitalizations and surgeries, the limit is a monthly fee for your plan.
Is there a limit for additional fees?
Yes. In total, the additional fees can not be higher in a month than the amount of monthly fees paid into your health plan, or in a year, than the amount of 12 monthly payments added. This means that someone who pays $ 200 per month of covenant can pay up to another maximum of $ 200 a month.
If the franchise or co-participation of the patient's procedures in a given month exceeds this limit, they continue to be billed in installments up to R $ 200 in the coming months, until such time as that they add to the total amount owed.
In one year, however, no more than the equivalent of 12 monthly installments, or R $
The limit for the collection of co-participation, a model that transfers to the client part of the value of each procedure performed, was set at 40% of the total value of the service. This means that if the patient performs a procedure that costs $ 100, the agreement can charge him up to $ 40, in addition to the amount of the monthly fee. It works for consultations, exams and treatments (like physical therapy). Hospitalizations, births and emergencies in PS have a fixed value (see above).
Can co-participation be fragmented?
Whenever the value of the co-participation or deduction of a procedure carried out during a given month exceeds the monthly limit (the amount of a monthly fee), it may be invoiced in the coming months, respecting this limit, until it is withdrawn. The accumulation of all these sums, however, can never exceed the annual limit, equivalent to 12 monthly payments.
If the client who pays $ 200 a month in a plan with co-participation, performs in a given month an appointment and a series of exams that, in total, cost 2,000 R $, he must pay 40% of R $ 800, in co-participation. Since the plan can not charge more than a monthly fee (R $ 200), this R $ 800 will be billed in four installments of R $ 200 in the following months.
These payments may continue to be billed the following year provided that, in the total of each year, the additional account paid by the user never exceeds 12 monthly payments (2,400 reais in the case ).
How will the franchise work?
The agreement stipulates a minimum value from which it provides coverage. Franchise can appear in two modalities: for access and accumulated .
In a plan with access franchise a valid minimum value is established for each procedure. If the customer has a $ 200 deductible, he will pay in full each time he performs a procedure that costs up to $ 80 as a consultation or a $ 150 exam.
Procedures with values greater than
In the accumulated deductible plan the minimum amount is established by the operator at no cost to the recipient. per year. In this case, if the beneficiary has a deductible of R $ 1,000, he will continue to pay for all procedures throughout the year until his total bill reaches R $ 1,000 – three consultations of R $ 100, a R $ 500 exam and a $ 200 exam, for example. Thereafter, all the care you have will be covered by the plan, regardless of the amount.
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