Health plan operators are only required to pay for procedures listed on the National Supplementary Health Agency (ANS) coverage list. This is the new understanding signed by the Second Section of the Superior Court of Justice (STJ). By six votes to three, the Court decided that the list was exhaustive. The decision, however, provides for cases in which extra-role treatments may be covered by operators.
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Operators will have to pay for procedures for which there are other similar ones provided for in the ANS list. When there is no substitute, exceptionally, they will have to offer coverage for the treatment indicated by the doctor. For this to happen, four conditions must be fulfilled.
Understand the criteria:
- There should be a recommendation for what has been called “institutional dialogue” between magistrates and experts in the field, before any decision is made.
- It will also be essential that the requested procedure has recommendations from renowned national technical bodies, such as the National Commission for the Incorporation of Technologies in the Unified Health System (Conitec), or foreigners.
- It is necessary to prove the effectiveness of the treatment “in the light of evidence-based medicine”.
- The procedure, although not provided for in the list, cannot have been submitted for incorporation to the ANS and have been rejected.
Recognizing that in some cases innovative technologies may not yet have been incorporated into the list and that it will not be possible to attribute the cost to the operator of procedures outside the list, Minister Villas Bôas Cueva also provided for the possibility of contracting extra coverage.
The user will be able to look for his plan to negotiate an amendment or an extended coverage contract so that he can have access to procedures that are not on the ANS list.
According to Renato Casarotti, president of the Brazilian Association of Health Plans (Abramge), such an expedient is already possible, but tends to be increasingly rare in the face of the continuous process of updating the list implemented by the ANS.