What Is it a Health Plan with Co-participation?

Health Plan with Co-participation

Choosing a health plan is often not an easy task, as there are several different options available, including whether the plan will include co-pays. Co-pays have become increasingly popular among users, especially among companies.

It's estimated that approximately 741 companies use this plan model for their employees. Therefore, to better understand what co-participation is, how it works, and its benefits, we've written this article. Here, you'll be able to answer all your questions on the subject.

What is a co-pay health plan?

A health plan can be co-pay or non-co-pay. But what does that mean? The co-pay model allows beneficiaries to pay a lower monthly premium.

However, when using the services provided by the operator, a fee will be charged.

Above all, it will be added to the monthly amount received in the monthly payment.

Some companies even cover the monthly cost, meaning you only pay when you use it. By paying part of the medical expenses, beneficiaries can enjoy the same coverage and quality of services as other plans.

In other words, those who use the services less often pay less than those who use them more frequently. Therefore, the most important thing when purchasing a co-pay plan is to consider how often you use the services provided.

The services:

• Medical consultations: charged per consultation, but in case of return in less than 30 days, there is no charge.
• Simple tests: The charges are for the tests themselves, not the collections. This means that even if only one tube of blood is collected for four tests, the amount to be paid will be for all four tests.
• Specialized exams: are charged individually
• Hospitalizations: Only the hospitalization will be charged, regardless of the number of days. However, tests performed during the hospitalization will not be charged.

What are the ANS rules?

It is important to understand the ANS rules so that you can defend your rights.

Procedures that CANNOT be charged for

• Firstly, 4 consultations per year in the office or at home, carried out by a general practitioner, such as a pediatrician, general practitioner, geriatrician, gynecologist and family doctor;
• Secondly, Mammography (1 exam every 2 years for women aged 40 to 69);
• Third Pap smear (1 exam per year in women aged 21 to 65);
• Fecal occult blood (1 test per year in adults aged 50 to 75);
• Colonoscopy (adults aged 50 to 75);
• Fasting blood glucose (1 test per year for those over 50 years old);
• Glycated hemoglobin (2 tests per year for diabetics);
• Lipid profile (1 exam per year for men over 35 years old and women over 45 years old);
• HIV and syphilis testing (1 exam per year)
• Chronic treatments: no number limit for hemodialysis, radiotherapy and intravenous and oral chemotherapy, chronic hemotherapy and immunobiologicals for diseases defined in the Utilization Guidelines (DUTs);
• Prenatal exams: serology for syphilis, HIV and hepatitis, serum iron, Pap smear, urine culture, blood typing and RH, 3 ultrasounds, EAS, fasting blood glucose, direct COMBS test, 10 obstetric consultations and toxoplasmosis;
• Neonatal screening tests: heel prick, ear prick, eye prick and heart prick tests.

Main rules

• Firstly, the maximum amount per beneficiary cannot exceed the value of the monthly payment (monthly limit) or 12 monthly payments (annual limit);
• Then, if this annual limit is exceeded, the costs of using the health plan.
• And they will be fully covered by the operator, with the charging of excess amounts in the following year being prohibited;
• Exemption from charges for more than 250 procedures, such as preventive exams, treatment of chronic diseases and prenatal and neonatal exams;
• It is prohibited to use co-participation and deductibles based on illness or pathology;
• All services and procedures during hospitalization or emergency room have a single price;
• There must be detailed information in the contract;
• Operators must publish a statement of the use of procedures with the amounts applied on their websites;
• Maximum co-participation percentage cannot exceed 40% of the cost of the procedure.

What are the advantages of a health plan with co-participation?

The main advantages of this plan are:

• Lower monthly fee: because there's a fee for each procedure performed, the co-pay plan ends up being cheaper compared to traditional plans.
• Coverage is the same as a regular plan;
• Ideal for those who don't have chronic illnesses but want more peace of mind regarding their health.

When is a co-payment health plan useful?

Small and medium-sized companies and individual micro-entrepreneurs (MEIs) are the most interested in and benefit from health plans with co-participation.

Because overuse can increase expenses, especially since the amount charged to users is capped, meaning the excess is paid by the company. Therefore, it's important to conduct a study to understand employee profiles and thus assess accident rates.

However, a health plan with co-participation can also be very useful for those individuals who are looking for an individual or family plan and use it little.

Generally, a comprehensive plan will meet your needs and will end up being more affordable than a co-participation plan, as the cost is fixed and will not vary with the number of procedures performed.