End of the tax role can cause ‘mass expulsion’ from health plans, says federation

The end of the exhaustive nature of the list of procedures of the National Supplementary Health Agency (ANS) “places Brazil against the best world practices” and can lead to a “mass expulsion” and an increase in the price of health plans, says the National Federation of Supplementary Health (FenaSaúde).

The federation says that the measure “hampers the adequate pricing of plans and compromises the predictability of care expenses, which may lead to a rise in tuition prices and mass expulsion of beneficiaries of supplementary health” and threatens to resort to justice. (see more below).

The position of the entity (which represents 14 groups of private health care and dental care plan and insurance operators) was released this Thursday (22), after President Jair Bolsonaro (PL) sanctioned law 14,454/ 22, which in practice expands the coverage of health plans in relation to exams, medicines, treatments and hospitals.

Among the operators that are affiliated to FenaSaúde, there are several companies listed on B3, such as Bradesco Saúde, by Bradesco (BBDC4); NotreDame Intermédica and Hapvida (HAPV3); Itauseg Saúde, from Itaú Unibanco (ITUB4); OdontoPrev (ODPV3); Porto Seguro Saúde, from Porto (PSSA3); and SulAmérica Saúde and SulAmérica Odonto, from SulAmérica (SULA11).

Other companies that do not have capital on the stock market, such as Amil and Unimed, are also part of the federation. Together, they serve 75.9 million beneficiaries, 48.2 million of which in medical assistance and 27.7 million in exclusively dental plans..

FenaSaúde says in the note that private operators of health care plans and insurance have an operating loss of R$ 9.2 billion in the last five quarters. “The entity also warns that such a measure [o fim do rol taxativo] can further impact the financial situation of the sector”.

“Since April 2021, the assistance expenses of the set of private health care plan and insurance operators have already exceeded the revenues obtained from considerations, leading to an operating loss of R$ 9.2 billion, considering the accumulated of the last five quarters. ”, says the entity. “For these factors, FenaSaúde is considering going to the Judiciary”.

Tax roll vs. exemplary

Law No. 14,454/22 was sanctioned by Bolsonaro after the approval of PL 2,033/22 by the National Congress at the end of August (click here to access the law). The project was a reaction by Congress (and by civil society, which pressured deputies and senators) against a decision by the Superior Court of Justice (STJ).

The Second Section of the court ruled in early June that the ANS list was actually exhaustive (that is, health plans would only be required to cover the procedures provided for in the regulatory agency’s list), which would restrict the coverage of operators.

Until then, the Court’s interpretation was that the role of the ANS was just an example (it did not have a definitive character). Thus, many people appealed to the judiciary to force health plans to cover procedures or treatments that were not yet on the agency’s list.

The ANS list was created in 1998, has been updated since then and currently has a list of more than 3,000 procedures that health plans need to offer to customers.

The agency itself expressed itself in favor of the exhaustive list and defended that expanding the range of mandatory medical procedures, beyond those foreseen, could make health plans more expensive for the final consumer. In a session in the Senate, the Minister of Health, Marcelo Queiroga, also criticized the change.

What does the law 14.454/22 say

With the enactment of Law 14.454/22, the role of ANS became definitively exemplary. She amended another law, 9.656/98, which deals with private health plans, to establish the criteria that allow coverage of treatments that are not included in the ANS list.

Law 14,454/22 amended item 12 of article 10 of law 9,656/98, to provide that “the list of procedures and events in supplementary health, updated by the ANS with each new incorporation, constitutes the basic reference for the plans contracted private healthcare providers”.

But not just any procedure should be covered by health plans. The new law determines that health plans will have to cover treatments prescribed by doctors or dentists as long as they meet at least one of the following requirements:

  • Are demonstrably effective, “in the light of health sciences, based on scientific evidence and a therapeutic plan”; or
  • Have a recommendation from the National Commission for the Incorporation of Technologies (Conitec) into the Unified Health System (SUS) or from at least one other internationally renowned health technology assessment body.

FenaSaúde’s position on PL 2033/22

“The National Federation of Supplementary Health (FenaSaúde) regrets the sanction of PL 2.033/2022, which establishes hypotheses for coverage of health exams or treatments outside the list of ANS Health Procedures and Events. The change puts Brazil in the opposite direction of the best global practices for evaluating the incorporation of medicines and health procedures, makes it difficult to properly price plans and compromises the predictability of care expenses, which can lead to high monthly fees and mass expulsion of beneficiaries from the supplementary health.

The entity also warns that such a measure could further impact the financial situation of the sector. Since April 2021, the assistance expenses of the group of operators of private health care plans and insurance have already exceeded the revenues obtained from considerations, leading to an operating loss of R$ 9.2 billion, considering the accumulated of the last five quarters.

Due to these factors, FenaSaúde is considering going to the Judiciary, in defense of the approximately 50 million beneficiaries who today depend on health plans in the country.”

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