5 Rights of health plan users

In December last year, more than 330,000 individual plans were transferred from one health plan operator Amil to another, Personalized Health Assistance (APS). The process was approved by the National Agency for Complementary Health (ANS) and at the time of the transaction, APS was part of the same Amil group, the US company UnitedHealth Group (UHG).

Many users were unsure of their rights with this change. However, these rights must be maintained by APS. The new operator must guarantee assistance to its beneficiaries with the same standards as Amel. According to the ANS, ongoing treatments cannot be interrupted and appointments made prior to the transfer must be maintained. In addition, all contractual terms must be preserved, otherwise the user can file a complaint with the ANS or go to court.

Here are 5 rights that must be guaranteed to users of health plans:

1. Providing home medicines by the HMO in case of emergency;

2. The decision on the materials (prostheses, orthoses) to be used by the patient must be made by the doctor;

3. The patient’s expenses must be borne by the plan in the absence of a dedicated specialist in the approved network;

4. The retiree can keep the plan he had before retirement;

5. Change the operator without having to meet a new grace period.

Emergency home medicine

When dealing with emergency and urgent cases, the health fund should provide home medicines. Most health plan operators do not offer home medication coverage to their customers.

When we talk about an emergency or an emergency, we are not facing a common disease, it is necessary to understand the concept of treatment in the broadest way, that is, the actions and medicines necessary to get out of the emergency situation and preserve the health and life of the patient.

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This right is supported in Section 35-C of the Health Plans Act.

The decision on the materials (prostheses, orthotics) to be used by the patient must be made by the doctor.

Only the consumer’s physician can select the items needed for the most appropriate treatment and it must be funded by the plan. This resolution finds support in the first clause of Art. 7 of Resolution No. 424/ 2017 for the National Agency for Complementary Health (ANS) and Art. 1 of Resolution No. 1956/2010 of the Federal Council of Medicine (CFM).

The patient’s expenses must be covered by the plan in the absence of a specialized specialist in the approved network

Insofar as the consumer plan is the most complete on the part of the operator, not all areas of medicine are always covered by the approved network and geographical scope of the contract. There are medical areas that are not covered largely by the plans and this attracts an obligation to cover expenses when the profession or clinic that the consumer is looking for is not included in the approved network, i.e. in this case, the operator must reimburse the user in full. This limitation is included in the first and second items of Article 4 of Resolution No. 259/ 2011 from ANS.

Retirees can keep the plan they had before retirement

A retiree, upon employment, who has contributed for more than ten years to the reimbursement of the health insurance plan (in whole or in part) is entitled to remain a beneficiary of the plan indefinitely.

In turn, if a person retires before completing 10 years of contributing to that company, he is entitled to remain in the health fund for the same period of contribution. That is, if the employee / retiree has contributed in whole or in part to the monthly payment for 6 years, he / she will remain in the active contract for another 6 years.

Regardless of the situation, the retiree continues the current contract only if he assumes full payment of the monthly fee.

This warranty is backed by art. 31 of the Health Plans Act.

Change the operator without having to meet a new grace period

This procedure is governed by Resolution No. 438/2018 and stipulates some specific requirements for the consumer to change the operator and does not have to meet the new deadlines.

A major limitation is that the consumer must be bound to the existing plan for two years and the destination health plan operator has a 10-day period to respond whether or not to accept the portability, if he does not respond, the portability is automatically considered valid.

Another important decision is that the consumer, after joining the new plan, must request the cancellation of the previous plan directly to the operator within 5 days, and failure to comply with this requirement exposes the consumer to comply with the needs of the new plan for non-compliance with the terms of the decision.

With information from Estadão and the JusBrasil portal.