How They Work the Collective Plans?

How Collective Plans Work

First, health insurance providers are increasingly offering more ways to ensure quality medical care. With this in mind, they created group plans, an option that has gained traction in the market and sparked interest among many.

In addition to more affordable prices, they have other advantages over individual or family plans and, for this reason, they are gradually replacing them.

But do you know what it is, how it works, and who can join? The answers to these and other questions are here; keep reading to learn more.

What does collective plan mean?

From now on, when a company, council, union or association contracts a health plan to offer the benefit of medical and/or dental assistance to the people linked to them, together with their dependents, but we are talking about a collective health plan.

However, collective plans can be of two types:

• Business: the company that hires the operator and includes the employees, that is, the beneficiaries have an employment relationship with the contractor. 
• By adhesion: the entity that hires the operator, with members having the option of joining or not, as they have no employment relationship.

What are benefits administrators?

In group plans, companies and entities typically use a benefits administrator. This is to facilitate the process for legal entities, as the administrator will be responsible for:

• Issue bills
• Represent beneficiaries in negotiating monthly fee increases with the plan operator
• Absorb the risk of the contracting company, council, union or professional association regarding late or non-payment of monthly fees, to prevent beneficiaries from being harmed.

However, administrators must be registered with the National Supplementary Health Agency (ANS), ensuring oversight and compliance with all rules required by this body.

What are the responsibilities of the operator and administrator?

First, know that they are different companies, with different functions, but the same goal: to guarantee a health plan for you.

Therefore, if you know what each one does, it will be easier to solve your problem, after all, you will know exactly who to turn to.

Benefits administrator

• Represents the contracting company, council, union or professional association;
• The administrator's identification appears on the invoice and can be obtained from the human resources department of the contracting company, council, union or professional association;
• Performs administrative tasks, such as issuing payment slips and changing beneficiary registration data;
• Negotiates with the health plan operator the monthly fee adjustments, changes in the accredited network and the forms of access control to the plan's services, representing the contracting legal entity;
• Depending on the contract, it can absorb the health plan operator's risk when there is a delay or non-payment of monthly fees by the contracting legal entity.

Health insurance company:

• The operator's identification appears on the health plan card;
• Ensures resources and a network of health services (hospitals, clinics, laboratories and professionals) to serve beneficiaries;
• It is responsible for the health plan and the services it provides to the ANS and beneficiaries.

Who can be a beneficiary in a corporate collective plan?

To be able to participate in a corporate collective plan, you must meet at least one of the following requirements:

• Public employees or servants
• Dismissed and retired employees of the contracting company
• Partners of the contracting company
• Administrators of the contracting company
• Interns of the hiring company
• Dependents: family members respecting the degrees of kinship provided for in the legislation: up to the 3rd degree of blood kinship, up to the 2nd degree of kinship by affinity and spouse or partner.

What documents and information must the operator provide when signing the contract?

Person contracting the plan:

• Copy of the contract containing the following information: grace periods, contract validity, adjustment criteria, geographic scope, type of accommodation (shared, in a ward, or individual, in a room) and care segmentation (outpatient, hospital, dental, obstetric coverage);

Each beneficiary

• Copy of the plan’s regulations or general conditions;
• Guidance Manual for Contracting Health Plans;
• Contract Reading Guide.

Can the collective plan contract be terminated?

The terms and conditions for contract termination or suspension are set out in the contract itself. However, the contract can only be terminated without the company's approval in the following situations:

• Fraud;
• Without legal justification after 12 months from the date of signature and provided that the company that contracted the plan is notified at least 60 days in advance;
• The beneficiary ceases to be employed by the contracting company;

How does it work if I had an illness or injury prior to purchasing the health plan?

Therefore, if the beneficiary has an illness or injury prior to purchasing the health plan, if it is a group plan, the provider may establish temporary partial coverage (TPC). This means that the health plan may or may not cover, for a maximum of 24 months:

• Surgeries;
• Hospitalizations in high-tech beds (ICU/CTI);
• Highly complex procedures.

However, this only applies to services related exclusively to the illness or injury the consumer already had when purchasing the health plan. For example, if you already have myopia, the provider will certainly cover the correction surgery only after 24 months. After this period, the health plan is required to cover all such services.

Finally, in relation to corporate plans with more than 30 beneficiaries, if the consumer has joined the plan within 30 days of the date of formalization of the contract or of his/her connection with the contracting company, for example, partial coverage cannot occur.

How does the grace period work in collective plans?

The waiting period, as well as its exemption, will vary according to the number of beneficiaries and the type of plan contracted.

For corporate plans with more than 30 beneficiaries, those who join the plan within 30 days of signing the contract will not be required to meet the waiting period or temporary partial coverage (CPT). Therefore, new employees or dependents may only join the plan after 30 days of joining the company.

However, after these periods, or if the plan is for fewer than 30 lives, the carrier may require a grace period. So be aware of the deadlines.

How do the adjustments occur?

After all, adjustments can only occur annually or when changing age groups. Adjustments are determined through negotiations between the contracting company and the operator.