ANS issues warning about health plan coverage after Chamber decision

ANS issues warning about health plan coverage after Chamber decision

The National Supplementary Health Agency (ANS) reaffirmed its concern regarding the definition of mandatory coverage for health plans, with the approval on Wednesday (3), by the Chamber of Deputies, of the bill 2033/22, and highlighted that the competence to prepare the List of Procedures and Events in Health is attributed to it by law 9.961/2000.

He added that, in the process of including a procedure in the list, its technical examination “is an indispensable condition for expanding or restricting the use of a certain technology in the supplementary health sector”.

The bill approved by the Chamber establishes coverage hypotheses for health examinations or treatments that are not included in the list of ANS procedures and events. The proposal will still undergo analysis by the Senate.

The reason for the approval is to continue treatments that could be excluded from the coverage of health plans.

If the text is confirmed by the Senate, operators must authorize health plans to cover treatment or procedures prescribed by a doctor or dentist who are not on the ANS list, if among the criteria is the existence of proof of effectiveness, in the light of the sciences of health, based on scientific evidence and a therapeutic plan, of recommendations by the National Commission for the Incorporation of Technologies in the Unified Health System (SUS) and of, at least, one health technology assessment body that is internationally renowned, provided that they are also approved for their national counterparts.

Evaluation

The ANS stated that, to carry out the technical examination, it uses the Health Technology Assessment (HTA), a methodology that analyzes all information on scientific evidence related to the efficacy, effectiveness, accuracy and safety of the technology, economic evaluation and budgetary impact and provider network availability. The use of technology also involves the approval of professional councils, among other points.

“The new technologies to be incorporated into the list also undergo a broad debate with society, through directed and expanded social participation, through technical meetings, public consultations and public hearings, in order to allow decision-making whether or not to incorporate the technology into the Rol takes place in a robust, impartial, transparent and systematic manner”, explained the agency.

The ANS also stated that there will be serious impairment of the clinical parameters of effectiveness and safety of use of the procedures included in the Rol, if the validation of ATS studies with solid scientific evidence does not occur. According to the regulatory agency, without this “there will be no certainty of the clinical benefits nor the potential side effects associated with the technologies”.

For the ANS, it would be important if at least the bill considered not only the criterion of existence of proof of effectiveness based on scientific evidence or approval by a technology assessment body, but the two associated criteria.

“It is also necessary to point out that, in a mutual system such as the health insurance sector, all the costs of consultations, surgeries, hospitalizations and other services are shared among the beneficiaries and, in this way, it is possible to dilute the expenses, making them viable for the consumer”, he clarified.

In the agency’s understanding, the degree of uncertainty regarding the economic impacts of carrying out procedures not provided for in the current list will cause the risk of raising readjustments to levels above the payment capacity of beneficiaries, even those controlled by the agency, as occurs in individual plans , “which may lead to the exclusion of a group of beneficiaries from the supplementary health system”.

Enhancement

The ANS also informed that the Rol review process has been systematically improved, making it more agile, participatory and transparent.

“Until 2021, the update was done every two years. The publication of Normative Resolution No. 470, in that same year, the reception and analysis of proposals started to be done on a continuous basis, giving dynamism to the review of mandatory coverage”, he said.

Also in 2021, the National Congress voted on a Provisional Measure that, in March 2022, would be converted into Law 14,307, which brought even shorter deadlines for updating the Rol.

According to ANS calculations, in 2022, 24 coverages were already included. Among them, seven are procedures and 17 medications. In addition, there have been important expansions for patients with pervasive developmental disorders, such as coverage for any methods and techniques indicated by the attending physician to treat conditions such as Autism Spectrum Disorder; and the end of limits for consultations and sessions with psychologists, speech therapists, occupational therapists and physical therapists.

Justice

On June 8, the Superior Court of Justice (STJ) decided – by 6 votes to 3 – that health plan operators would no longer be obliged to cover medical procedures that are not included in the list of the National Health Agency.

The decision, however, was subject to appeal. In the session, the understanding of the rapporteur, Minister Luís Felipe Salomão, whose vote was given in previous sessions, prevailed.

According to the understanding of the Second Section of the STJ, the List of Procedures defined by the agency is exhaustive, which means that users are not entitled to exams and treatments that are outside the list.

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