Price Adjustments of Health Insurance Plans – Understand the Rules



The readjustment of health plan usually gives headache for many that contract this type of service.

Every year, the National Agency of Supplementary Health, ANS, announces the index for authorization of price adjustments of health insurance plans. They may or may not also include dental coverage.

ANS is the body responsible for controlling the price adjustments of health insurance plans.

Once the price adjustments of health plans are defined, they begin to be valid only after the operators receive ANS authorization.

Control of readjustments

Control of readjustments

The responsibility to control the amounts of health insurance monthly payments, as well as the increase in prices, is attributed to ANS by Law 9.961 / 2000. The measures change according to the type of contract.

If you have an individual or family contract, be aware that the maximum annual adjustment limit for 2018 is 10%. This amount was recently defined by the National Supplementary Health Agency, ANS, and is valid for plans contracted as of January 1999 or adapted to Law 9,656 / 98.

Therefore, the operators that are authorized by the ANS (only those authorized!) Can apply the health plan readjustment, as determined by Normative Resolution nº 171/2008.

But if you have a collective plan by membership or business, that maximum percentage has almost doubled. Many contracts of adhesion health plans or business had increase of up to 19% this year.

A very relevant information that deserves to be taken into account is: on what date was your plan hired?

If you have contracted the health plan before 02/01/1999, it has not entered this new Law, it has not changed. Therefore, it is part of the category entitled “Old Plans”.

Plans belonging to this group follow only what determines their contracts. Therefore, these new measures provided for in more recent laws do not apply to you.

Differences in individual and collective health plan readjustment

Differences in individual and collective health plan readjustment

To begin to understand how the readjustment of collective health plan works, it must be known that the decision on the increases that are applied in these types of plans does not belong to ANS.

Well, who comes on the scene in these cases are the operators of the plans. Therefore, the negotiations are made with the administrators, without any limit of value.

Another question that may surround your mind right now is whether it is worth having a collective health plan. This is because the main differential or call for their hiring is precisely the economy that is made at the cost of an individual plan.

To evaluate this question, it is important to know some rules followed by the plans.

We already know that the readjustment of the collective health plan is not the responsibility of the ANS. In addition, another difference that exists and that must be of public knowledge concerns the cancellation of the contract.

ANS does not allow operators to cancel the contract on an individual basis unilaterally. It is necessary for both parties to reach an agreement for the contract to be terminated.

Already in the collective plans, the operators can rather cancel the contract after the first year of service.

For these and others, experts recommend hiring individual plans for those who want to be more protected.

Another suggestion of the professionals of the segment for those who are in the process of hiring a plan or even for those who have and are dissatisfied, is to do accounts.

In general, collective plans are cheaper at the outset, but when the first readjustments occur, that advantage falls apart.

It is also important to consider that the readjustment of the individual plans authorized by the ANS is the highest. However, operators can apply lower rates or even keep monthly amounts, without adopting the adjustment.

Business Plans

Business Plans

Another possibility is that your health plan, as is very common, has been contracted by the company in which you work. In this case, it is important to know that price adjustments of health plans do not go through the definition of the Agency.

What happens is this. The ANS will monitor the readjustment of the values, that is, the negotiation between the interested parties – company and operators. They must notify the agency one month before the adjustment begins.

That is if the contract is intended to cover at least 30 beneficiaries. Otherwise, the adjustment works quite differently. It enters into the so-called “Contract Grouping” (or Risk Pool), in which the readjustment that your contract will receive will be the same as other contracts with less than 30 beneficiaries.

The same adjustment will be applied for all contracts belonging to that grouping. The information will be disclosed by the operator of your health plan, on her website. The amount can be applied to the contract in his birthday months.

Therefore, it is good to keep an eye on the price adjustments of health insurance annually. It is also worth looking at the number of related beneficiaries. It is a way of planning whether or not your contract enters into this “risk pool” in the following year.

Exceptions

Exceptions

There are still some exceptions, so write them down as well. It may be that even when the collective bargaining agreement involves less than 30 beneficiaries, it falls within any of these exceptions. Are they:

  • Plan signed before January 1, 1999, and is not adapted to Law 9,656 / 1998;
  • It is a dental contract only;
  • It is a contract that only covers former employees who have been dismissed without just cause or retired, or even exonerated;
  • It is a contract signed before 01/01/2013 and not added by RN 309/2012 by the contracting company.

The readjustment of collective plans, therefore, is not regulated by the ANS, even though these are the majority in the market.

The choice is yours – health plan portability

The choice is yours - health plan portability

It is worth remembering that the consumer can always choose the plan that, in addition to better serving the needs, also fit comfortably in the pocket. Despite having a plan for years, nowadays everyone can opt for portability for other operators.

But to know the options available in the market, to make the hiring or even the exchange via portability of deficiencies, it is valid to make comparisons. For this, the ANS Guide, which can be accessed on the Agency’s website, is a real ally.

Currently, this guide presents 458 operators that market individual health plans in our country. Worth consulting!

Attention to the readjustment modalities

Attention to the readjustment modalities

Okay, the health plan readjustment has already been established. Everyone already knows the percentage. But what are the situations in which it can be applied?

There are some adjustment modalities authorized by the ANS: annual, via the change of age range of the consumer, by accident or technical review.

Annual readjustment

In this case, as the name implies, the health plan readjustment is applied once a year when the anniversary of the contracting of the health plan occurs.

Readjustment due to age change

Here the health plan readjustment occurs according to the change of the age of the health plan user. The old plans present in contract the age groups foreseen for the adjustment, as well as the percentages.

But since 2004, due to the Statute of the Elderly, it was prohibited to readjust by age group for those who are over 60 years of age. The date of hiring directly influences the values ​​and corrections undergo changes depending on the age group. Thus, in addition to the annual adjustment, whenever the age group established in contract is extrapolated, the price of the health plan increases.

The new price applies to the initial age of the established age group, including the direct beneficiary and dependents. If the dates between the anniversary of the plan contract and age change coincide, the beneficiary of this health plan will have two monthly adjustments.

Adjustment for claims

Increase determined by the operator due to the large number of procedures and covered services that were performed in a given period, being larger than expected.

Technical review

This model of price adjustments of health insurance plans was suspended. It was realized when an operator was in financial trouble, in such a way that the economic imbalance would jeopardize the continuity of the services to its clients.

It is mandatory to offer the client two monthly payment alternatives that aim to rebalance the plan economically. One of these alternatives is the monthly price increase itself. But, remembering that they must be approved in advance by the ANS.

In addition, it is important to know that such price increases and adjustments should be presented to customers as options, not obligation.

Keep an eye on the ticket!

Users of individual health plans should be aware of payment tickets. They must verify that the percentage used by the operator is equal to or lower than that determined by the ANS. They should also check whether this increase is being made in the contract’s anniversary month.

Therefore, it is important to know that retroactive amounts are allowed for the months of lag between the application of the adjustment and the anniversary date of the contract.

In conclusion: the payment slip must clearly show the following items:

  • Index of readjustment authorized by ANS;
  • Authorization number of the ANS;
  • Name, code and registration number of the health plan, as well as the month foreseen to apply the next adjustment.

In any case, before choosing or changing health plans, it is important to know about values, coverage and accredited network. Make an online health insurance quote and compare.