What Your Health Plan Should Cover

What Your Health Plan Should Cover

Before signing up for a health plan, or if you already have one, you should be aware of which procedures are covered. To this end, the National Supplementary Health Agency (ANS) established the List of Procedures and Health Events in 1998, which has been updated ever since.

This regulates the consultations, exams, and treatments that health plans are required to offer, depending on the type of plan. However, the provider has other obligations to the client. Therefore, see what your health plan should cover in this post.

Consultations, exams and treatments

Health plans must offer consultations, exams and treatments that are listed in the List of Procedures and Health Events, according to each type of health plan: outpatient, hospital with or without obstetrics, referral or dental.

All plans purchased after January 2, 1999, must comply with this list. For plans purchased before that date, the rule only applies if they were adapted to the Health Insurance Law.

However, before you know whether you are eligible for a procedure or not, make sure you know what type of plan you have purchased.

List of Procedures 2018 (as of 02/01/2018)

On January 2, 2018, the List of Procedures was updated, adding 18 new procedures. These include exams, therapies, and surgeries, covering various specialties.

What Your Health Plan Should Cover

In addition, coverage was expanded to include seven other procedures, including oral cancer medications and, for the first time, a medication for the treatment of multiple sclerosis.

However, in 2020, due to the new Coronavirus pandemic, ANS included tests that aid in the diagnosis and treatment of this disease for outpatient, hospital and referral segments.

Hospitals, laboratories and doctors

When it comes to hospitals, laboratories, and affiliated doctors, you should once again pay attention to the type of plan you're signed up for. It turns out that only hospital-type plans, with or without obstetrics and referrals, cover hospitalization.

Additionally, you should pay attention to your plan's accredited network. Therefore, before signing up, check which hospitals, laboratories, and doctors are affiliated with your provider. Consider their quality and reputation.

Regarding hospitals, be aware that your provider may only remove you from its network in exceptional circumstances. If this happens, it is required to replace the hospital with an equivalent one and notify its customers and the National Health Agency (ANS) 30 days in advance, unless the change is due to fraud or a health or tax violation.

Coverage for orthoses and prostheses

Some plans do not cover orthoses (devices that assist the functions of a limb, organ or tissue) and prostheses (devices that totally or partially replace a limb, organ or tissue).

According to Law No. 9,656 of 1998, coverage is mandatory for prostheses, orthoses and their accessories that require surgery to be placed or removed (implantable materials).

However, the insurer does not need to cover the provision of orthoses and prostheses not related to the surgical procedure (or not implantable), such as glasses, orthopedic braces, and limb replacement prostheses.

Healthcare Segmentation

Before purchasing a health plan, you should consider the type of coverage that best suits your needs. The plan's segmentation is precisely the composition of the coverage. It will determine the type of care you're entitled to.

Outpatient

The outpatient plan only covers:

• Medical consultations in clinics or offices;
• Exams;
• Treatments;
• Other outpatient procedures.

Therefore, hospitalization is not included, and therefore, emergency care is limited to the first 12 hours of treatment. After this period, the patient can choose to be transferred to a SUS network or remain in the private hospital, but paying all medical expenses.

Hospital without obstetrics

The hospital plan only guarantees hospital admission, with the exception of childbirth care, for an indefinite period.

However, if emergency care is needed during the waiting period, the procedure is the same as for outpatient coverage. In other words, hospitalization will be free for only 12 hours.

Hospital with obstetrics

In addition to hospitalization coverage, the hospital plan with obstetrics also provides the beneficiary with maternity care. The plan also covers care for the newborn, whether natural or adopted, of the contracting party, or their dependent, during the first 30 days after birth.

However, if you are still within the waiting period, coverage works in the same way as outpatient coverage, with free hospitalization only for the first 12 hours in emergency cases.

Exclusively Dental

In this segmentation, coverage is only for dental assistance, which corresponds to:

• Consultations;
• Exams;
• Dental emergency and urgent care;
• Auxiliary or complementary exams;
• Treatments;
• Other procedures performed in an outpatient setting requested by the dentist to assist in the patient's diagnosis.

Reference

The Referencia plan is the most comprehensive, encompassing outpatient and inpatient medical care, including obstetrics and ward accommodations. Additionally, urgent and emergency care must be provided within 24 hours of purchase.

Combinations

• Outpatient + Dental
• Outpatient + Hospital without obstetrics
• Outpatient + Hospital with obstetrics
• Hospital with obstetrics + Dental
• Hospital without obstetrics + Dental
• Outpatient + Hospital without obstetrics + Dental
• Outpatient + Hospital with obstetrics + Dental

Finally, don't forget that for each segment, there is a list of procedures with mandatory coverage described in the List of Procedures and Health Events.

In which regions of the country can your plan be used?

Health plans can be:

• National
• State
• Group of states
• Municipalities
• Group of municipalities.

Additionally, some plans cover emergency and urgent procedures abroad. Therefore, check your contract for the coverage area to avoid surprises.

What Your Health Plan Should Cover