ANS: taxation does not change the list of mandatory coverage

Decision of the Second Panel of the Superior Court of Justice (STJ), taken on the 8th, established that the list of mandatory coverage procedures of the National Health Agency (ANS) is exhaustive, that is, it requires coverage only of treatments and events listed. Despite this, the STJ collegiate set parameters for the plans to pay for procedures not provided for in the list, in exceptional situations, such as in the case of therapies with medical recommendation, without a therapeutic substitute in the list and that have proof of technical bodies and approval of institutions that regulate the sector.

Beneficiaries can consult the procedures that are included in the ANS list on the agency’s portal, in the Consumer Space section. In the item named What should your plan cover?the consumer can consult about the mandatory coverage, informed the ANS to Agência Brasil.

Currently, the list of mandatory coverage prepared by ANS is already exhaustive by virtue of Law 9,961/2000, which means that the health procedures and events on this list cannot be denied by the operators, under penalty of being fined or having the commercialization of plans suspended.

From the ANS point of view, there is no change, said the CEO, Paulo Rebello. “The agency has always worked with a list of health procedures and events of mandatory coverage for regulated health plans (contracted after the enactment of Law nº 9.656/1998 or adapted to the law). The inspection of the agency has always been based on compliance with the assistance provided for in the list and in the contracts”.

Rebello also highlighted that operators cannot offer less than the list, but can include additional coverage, duly established in the contract.

Mergers

According to Rebello, the ANS has been systematically improving the process of updating the list, in order to make it more agile and accessible, as well as ensuring extensive social participation “and prioritizing the safety of the procedures and health events incorporated, based on what is state-of-the-art in Health Technology Assessment (HTA), striving for evidence-based health”.

He reported that the list includes 3,365 procedures, including consultations, exams, therapies and surgeries, which cover all diseases listed by the World Health Organization (WHO). The period for reviewing the list, which was two years, has already been significantly reduced. The flow of sending proposals for inclusion of procedures in the list became continuous, and so did the analysis of proposals. “This year alone, six updates have already been made, with the incorporation of six exams and 14 drugs, or new indications for use for drugs already included”.

According to Rebello, the role of ANS provides legal certainty to the sector by determining what has to be offered to beneficiaries and enabling the actuarial calculation that determines the price of the plans. “In addition, without having the effective obligations of the health plans documented, the ANS would not be able to precisely adopt its regulatory actions, such as the inspection of coverage coverage, collection of reimbursement to the Unified Health System (SUS), definition of margins of solvency and liquidity of the operators, and many other actions”, he explained.

In addition to the lack of standardization of coverage, Rebello said that the exemplary character of the list, as it does not provide predictability regarding the procedures and events that may be used, would tend to increase the amounts charged by operators as a way of maintaining the sustainability of their portfolios. .

Autism

He informed that disorders such as autism have treatment covered by health plans, based on the list of ANS procedures. “The current list includes several procedures that aim to ensure the multidisciplinary care of beneficiaries with Autism Spectrum Disorder (ASD), which have mandatory coverage, once indicated by the beneficiary’s attending physician, provided that the criteria of any guidelines for use are met. .”

Since July 12 of last year, beneficiaries of private plans with ASD have access to an unlimited number of sessions with psychologists, occupational therapists and speech therapists for the treatment of autism, in addition to the unlimited coverage that was already guaranteed for the sessions. with physical therapists. Therefore, the number of sessions will be the one indicated by the patient’s attending physician.

Rebello explained that there are several ways to approach ASD, from individual ones, performed by professionals trained in a specific area, to those composed of multidisciplinary care. “For this reason, the ANS emphasizes that coverage for these patients is established in the list through consultations or sessions with doctors, psychologists, speech therapists, occupational therapists and physical therapists, leaving it up to the professional to choose the most appropriate method, depending on of the case”.

Justice

Legal inquiries made by the Brazil Agency were answered by the STJ, through its press office. One of the questions was about people who are currently undergoing treatments that are not on the ANS list and that, in most cases, were obtained through a court decision. The question was whether the person loses the assistance or whether the right acquired by the court decision is still valid. “According to the decision of the Second Section, in several situations, it is possible for the Judiciary to determine that the plan guarantees the beneficiary coverage of a procedure not provided for by the regulatory agency, depending on technical criteria and the demonstration of the need and pertinence of the treatment”, he replied. The court stressed, however, that it is “necessary to evaluate the specific case, and it is not possible to respond in a generic way”.

Another question answered by the STJ was whether the decision of the STJ that the role of the ANS is exhaustive can consolidate a new jurisprudence on the subject and serve the lower courts. According to the court, the decision standardizes the understanding on the subject in the STJ and serves as a guide to other instances of the Brazilian Justice on how the interpretation should be in future judgments.

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.

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