The Sustainability Network and the Brazilian Institute for Consumer Protection (Idec) have filed a questioning with the STF (Federal Supreme Court) against a provision of the ANS (National Supplementary Health Agency), which provides for the list of events and procedures to cover the health insurance.
Last week, a judgment carried out by the STJ (Superior Court of Justice) ratified this understanding by prioritizing coverage only to the procedures contained in the official list of the ANS.
According to the STF press office, the Argument of Noncompliance with a Fundamental Precept (ADPF) was distributed to Minister Luís Roberto Barroso, rapporteur of actions dealing with the same issue.
According to the party and the entity, for the first time, the ANS uses the word “taxative” to characterize the list of procedures that, in this understanding, consolidates obstacles to the service of the user and goes against the object of the health plan contract, which it is the right to health, arising from the right to life and guarantor of the dignity of the human person.
“They maintain that, because the consumer cannot predict future diagnoses or medical treatments that will be available at the time, the ANS role has always been understood as a minimum list to guide the provision of services by operators, with costing being mandatory. of eventual treatments absent from the regulation, as long as they are within medical and scientific guidelines”, says the press office of the STF.
The authors of the questioning ask for the granting of an injunction to suspend the effectiveness of the exhaustive list, establishing the exemplary character (wider and allowing the entry of new treatments) in the list of procedures and health events.
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 point of view of the ANS, there is no change, said the director-president, Paulo Rebello, in a recent interview after the decision of the STJ. “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.
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 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. .
With information from Agência Brasil