Individual Health Plans: Readjustment

Year in and year out, the discussion is always the same: the health plan sector complains that the maximum readjustment to individual plans does not match care costs, and consumer protection agencies defend that collective plans should have the same policy of readjustment.

“This is a discussion that has yet to begin. There is a provocation on the part of the sector for the agency. We have an obligation to talk, deal with and discuss any matter that may be presented. We are not discussing yet [sobre o reajuste]we haven’t established what the priorities will be, but I think this is an issue that we need to face”, says Paulo rebelCEO of the ANS (National Supplementary Health Agency) in an exclusive interview with UOL.

Read key excerpts from Rebello’s interview:

UOL – Does the ANS already have a definition on the readjustment of individual plans for this year?

Paulo Rebello – We have not yet completed the study on this year’s readjustment. We are waiting for the consolidation of the information and, as soon as we have an internal preview, we will send it to the Ministry of Economy.

The sector estimates a record increase of up to 16.3%. In the midst of soaring inflation and the population’s loss of purchasing power, can’t the readjust make the payment of plans unfeasible by many families?

The readjustment formula takes into account the variation in care expenses from the previous year, such as the issue of changing the age group and inflation, excluding everything that is not related to the health area.

These other factors you mentioned are taken into account in this calculation. In 2020, the year the pandemic began, people criticized the agency for giving a positive adjustment, but the value was a reflection of 2019.

The following year, the reflex was in 2020. Due to the lower claims ratio, there was a reduction in the adjustment for the first time (-8.19%).

This year will be a reflection of the variation in assistance expenses from the previous year.

Is the possibility of changing the readjustment of individual plans an issue that is being discussed at ANS? Is there a deadline for this to happen?

We are awaiting the appointment of two other directors so that we can begin to discuss the regulatory agenda for the next three years.

This topic is still to be debated. There was a provocation on the part of the sector, and we have an obligation to discuss every subject presented.

We’re not discussing it yet, we haven’t established what the priorities will be, but this is the issue we really need to tackle.

Every discussion related to the individual needs to include an analysis in relation to the collective. I’m not going along the lines of establishing the percentage of collective readjustment, but we need a joint discussion.

The logic is to increase competition, so that the beneficiary becomes more aware of their rights and more empowered to make the most correct decision for themselves.

The subject is on the radar, but nothing is defined? Can’t talk about the date?

Not. The problem is the percentage of the adjustment itself? The fact of not being able to do a technical review? There is also the issue of unilateral termination, which is a topic I have no desire to discuss. This is a beneficiary’s right.

Any other topic related to readjustment is important and needs to be discussed. I’m not saying that we’re going to move forward on the topic, but we need to discuss it. Whether the topic is sensitive or not, we need to open up opportunities for dialogue and find solutions, if there is a problem to be faced.

Is there any discussion to put a maximum readjustment in collectives? What makes individual readjustments different from collectives?

For plans with up to 30 lives, the operator takes all contracts with the same characteristics to dilute the risk [e aplica o mesmo reajuste].

They have plans with more than 30 lives, in which the contracting party and the operator are free to reach an agreement. We understand that there is a possibility for the contracting party to negotiate on an equal basis with the operator, which does not happen with the individual.

Regarding what may have caused this difference, there is a study of ours that shows that collectives and individuals walk in line. There is a distinction of two or three points more overall.

Of course, there are situations in which an operator, because of a higher loss ratio, ends up giving a greater readjustment.

Today, individual plans are a minority in the market. Do you believe that the population is harmed by this lack of supply?

Indeed, this is a problem. But is the readjustment the problem to be faced? Does it discourage operators from selling individual plans? We need to do a regulatory impact analysis to see what the problem is and listen to the industry as a whole.

At the same time that we see that there is a difficulty in marketing an individual plan, we have new market entrants, such as these health techs (startups in the health sector) that only sell individual plans.

It will be an opportunity to include in the regulatory agenda with broad participation of beneficiaries, operators and providers. We need to understand what would be the necessary adjustment so that we can give this incentive or not for the sale of the individual.

If the companies’ request were met (they say the readjustment does not reflect care costs), could this make the plans more expensive?

It’s too early to speak. We need to have this data to move forward. We face a game of information and disinformation, with a lot of speculation.

At the beginning of the pandemic, they painted a scenario of extreme difficulty for the entire sector. At first, people stopped leaving their homes, reducing the amount of care provided.

They mentioned that there would be a high default rate, but we saw exponential growth, with almost 2 million beneficiaries in the sector.

Is there still any chance that Amil can get the transfer [dos planos] for the APS?

There is no way for there to be any kind of secrecy or omission of information for the regulator. If we don’t have the information, we can’t check. Amil started to move forward in a process without sharing the information with ANS. That’s why we stopped the operation.

The companies presented some information that we had requested. Once again, we decided to suspend the transfer of Amil’s portfolio to APS, because the first information that had been presented, that it would remain within the economic group, was not confirmed.

We observed problems related to the economic-financial capacity of the operators, the investors to run the operation and the network structure to support the operation.

We decided that we would suspend the transfer and gave operators a period of time to present their reasons. We are waiting to decide.

Was the transfer authorization hasty?

It wasn’t, because we looked at the scenario presented by the operators. When the company said that it would make the transfer and that the portfolios would be within the same economic group, there is no irregularity.

We authorized following the steps so that the beneficiaries were informed. In this case, I didn’t see any problems, but then yes. There was this omission of information, and the ANS had to interfere.

There are people who go to court against health plans. How to reduce this judicialization?

When we look at studies that say the number has increased, we need to look further. We want to have more information to change the conduct of operators.

There are cases in which the operator failed to serve the beneficiary, and this type of situation needs to be curbed. It is commendable to seek justice when your right is being denied.

There are cases of lawsuits for what is not covered in the list [lista de procedimentos cobertos pelo plano], as a drug under study. These are situations where we need to make a distinction. Is this judicialization due or is it about something that is not in the regulatory framework?

Judicialization is the last resort. The ideal is that we deal with it in an administrative way, because we need a faster response, and sometimes the processes take a long time in court.

Private assistance is still for a minority in Brazil. How to increase access?

We already had almost 50 million beneficiaries [frente a 49 milhões em 2022]. The number has dropped in recent years and started growing again in June 2020.

Supplementary health is linked to economic conditions. Ideally, everyone should have access to the SUS, but we know that there are budgetary issues that make this impossible. It is a discussion that is on our regulatory agenda.

About Jenni Smith

She's our PC girl, so anything is up to her. She is also responsible for the videos of Play Crazy Game, as well as giving a leg in the news.

Check Also

State of health of ex-candidate for councilor ‘Dudu da Kombi’ worsens: ‘very serious’ | Rio de Janeiro

Rogério Nunes de Oliveira, the ‘Dudu da Kombi’, is hospitalized at the General Hospital of …