The health plan must inform in writing a reason for negative coverage; See other changes

The health plan must inform in writing a reason for negative coverage; See other changes


New rules have already entered into force and try to resolve the main claims of users regarding compliance with the agreements

The new rules for the relationship between operations and beneficiaries of health plans in Brazil, established by Additional National Agency (ANS). The rules are regulated in Regulatory resolution (RN) n. 623/2024 And they try to guarantee faster answers, a 24 -hour digital service and greater transparency in case of negative coverage.

According to the agency, the measure marks a new additional health inspection model, focusing on the prevention of failures and promoting good practices. “First, Ans’s performance was mainly repressive. Now we want to stimulate the resolution of the problems of origin,” explained Eliane Medeiros, supervision director of ANS, in a note.

According to the institution, since 2016, ANS has already had rules for this type of service, but the significant increase in 2019 complaints has shown the need for review.

Therefore, the new resolution establishes that operators should:

  • Treat requests not connected to the coverage of the procedures;
  • Allow beneficiaries to follow the progress of their requests;
  • Clearly disseminate the service channels on the operator’s website, including the civic defender;
  • Provide clear answers and within the deadlines determined by ANS (see below);
  • Clarify, necessarily, the reasons for the negative coverage, even without the consumer asking for him.

The administrators for benefits – the companies that mediate the management of the collective plans – will also have to follow the new rules.

What changes?

See below for more details on the main news and how they can help beneficiaries:

  • Chiara response deadline

It is strengthened that the health plan follows a deadline to respond whether or not to authorize an exam, surgery or other procedures. Therefore, the operator will not be able to use generic terms such as “under analysis”, “in elaboration”, precisely because it does not satisfy what is expected from a final response.

Therefore, the consumer must be definitively informed about these decisions in the following deadlines:

  • Immediate answer: urgency and emergency;
  • Up to 10 working days: highly complex or assistance procedures on elective hospitalization;
  • Up to 5 working days: applicable for other cases not framed in previous ones.

For other requests that do not refer to the coverage of the procedure, the final response period is 7 working days. These are the cases of incomplete, cancellation of the contract, portability, among others.

ANS warns that the final response period is not confused with the guarantee period. The maximum times for the procedures have not been changed.

For example, if the plan has to call medical advice (a group of doctors to evaluate the case), this can delay the answer, but does not change the deadline to perform the procedure when authorized.

  • Protocol and follow the number

ANS also stresses that operators are required to provide protocol or registration at the end of the service. A novelty is that it is guaranteed that the beneficiary can follow the progress of his request by the channel indicated by the operator.

  • Access to negative written coverage

Another relevant point of the new Ans resolution is that the operator must inform the reasons for all negative procedures in writing, regardless of the beneficiary’s request. This document must be made available by the operator in a format that allows its impression and the beneficiary must be informed to access it.

  • Mandatory virtual service

In addition to the face -to -face and telephone service channels, which were already requested, operators should offer service channels, available 24 hours a day, seven days a week, accessible for website, application or other digital technologies.

  • The plans will have to show if the service really works

The new standard requires the operator to measure the resolution of its service channels. ANS can request information on this measurement.

  • The civic defender earns more strength

Even the civic defender of the operator, who is the sector responsible for listening to customers’ complaints, plays a more important role. It should help check if the service channels work well and revalue net requests from the call center. Operators must also facilitate access to the civic defender.

  • Recognition of good practices

Finally, ANS will recognize operators who stand out in good practices through the objectives of excellence and the reduction of the general complaint index (IGR). Performance can influence, for example, in the application of aggravating or massacre in the quantities of fines in sanction processes.

  • Monitoring and inspection

According to ANS, the new rule is part of a series of measures to improve the way the agency supervises the health plans. “Attention focuses on avoiding failures, act in advance and induce improvements in the sector,” says the agency in a note.

The inspection will be made on the basis of the tools that ANS already uses, in particular in the analysis of the complaints made by the beneficiaries themselves.

Improvements for the consumer

According to the lawyer Marina Paullelli, coordinator of the health program of the consumer protection institute (idec), the new resolution advances in the quality of the care to the beneficiaries of the health plans, satisfying a frequent question.

“In general, consumers always complain about the difficulty of care with health insurance operators,” he explains. According to the lawyer, they often say they are not able to finalize a telephone complaint or not to receive any response to a request made.

“It is precisely this type of scenario that this new regulation intends to overcome. The new rules are quite positive,” he says.

Procon Paulista claims to have received complaints this year for delay in the authorization of procedures, exams or hospitalizations “, which compromises timely access to health treatment,” he said in a note.

Already on the side of the operators, the support of the new standards comes with warnings. In a declaration, the National Federation of additional health (Fenasúde) states that the rules have as a merit “further qualifying health insurance, trying to reduce conflicts”.

However, it underlines that the changes require complex operational changes, in particular as regards the integration of the various service channels.

“Therefore, Fenasúde claims that the adoption of new rules and any penalties from ANS is gradually done,” adds the entity.

THE The Brazilian Association of Health Plans (Abramge) also expressed concern, in particular with the immediate effects of the resolution article that expands the sanctions applied to operators.

According to Abramge, the penalties are included in the “administrative requests that do not involve direct assistance for the beneficiaries and, in particular, in the opening of preliminary intermediation (NIP) (NIP), that is, that the operator of the health plan has shown to be right”.

The Association sent an ANS letter on May 30, requesting the postponement of the resolution for 12 months. The purpose of the application, affirms the entity, is to guarantee the time necessary to adapt complex systems and processes in a safe and responsible way, and therefore avoid unwanted impacts on the beneficiaries.

Other statements

Marina stresses that, historically, the health plans are on top of the complaints that are made to IDEC, responding to 29.10% of the total complaints that the Institute receives. Among the main topics claimed are:

  • Abusive adjustments, especially in collective plans;
  • Problems relating to contracts, as questions about reimbursement, difficulty in cancellation;
  • Abusive practices, such as unilateral breakage, exclusion of dependent people and negative coverage.

For the lawyer, despite progress, it is still essential that other market practices are overcome so that the new ANS resolution has a deeper effect. “An example are complaints about unilateral adjustments and on the cancellations of the collective plans,” he says.

At the end of June, ANS The maximum annual increase limit set at 6.06% allowed for individual and family health plans regulated in the country. This limit is valid for May 2025 in April 2026 and applies to all the plans taken from 1 January 1999.

According to the lawyer Caio Henrique Fernandes, partner of Vilhena Silva Advogados, specialized in health rights, this is the lowest rate applied since 2008, with the exception of the pandemic period, when there was actually a discount. The measure affects over 8 million beneficiaries, equivalent to 16.4% of the 52 million users of medical plans in the country.

However, the income does not apply to collective plans, such as those offered by companies to their employees or hired through unions and associations. These modalities are the majority in the additional health market.

Given the measure, IDC has issued a position, in which it questions the lack of a ceiling for this part of the users. “It is very important that, especially in the raises, the ANS defines the rules to be fixed within reasonable levels for collective plans”, strengthens Marina.

According to Fernandes, there are cases of annual adjustments applied to collective plans with a percentage from 30% to 40%. The good news, according to the lawyer, is that the ceiling applied to the individual plans can act as a parameter to combat offensive raises in the collective plans, which correspond to 80% of the market.

This is because, says Fernandes, the applied ceiling indicates that studies on the municipality itself shows that it is possible to read school taxes with lower rates. “In legal actions, we ask that operators clearly justify how they have reached the percentage of applied adjustment. If there is no evidence, we judge that the values ​​are replaced by the 6.06%index”, exemplifies.

However, the expectation is that, in the near future, the rules will be defined for this group. “Or a way to limit these increases more equally to the consumer,” says Marina.

What to do if the rules are not satisfied

In case of non -compliance with the rules, the consumer can present a complaint to Procon. In the State of Saint Paul, for example, the service can be done in person, at the headquarters of Largo Do Pátio do Colégio, n. 5, in the historic center of San Paolo, or through an electronic service available on portal 156.

You can also record the complaint directly on ANS, by accessing the Agency’s website, in the consumer space, by clicking on “service channels” or, if you prefer, calling 0800 9656.

Source: Terra

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