Every year, in anniversary of contracting, health plans have the right to increase the amount of monthly payments for beneficiaries.
Let’s understand the situation better. ANS is the acronym for National Supplementary Health Agency, which since 2000 has regulated health plans. Only there is differences between individual and collective plans. Individual ones are only acquired by an individual from the company or operator. If dependents are included, it is called a family plan. “In these cases, there is a direct relationship between the consumer and the health plan operator, with the ANS understanding the need for greater protection, so that there is balance between the parties” explains Ana Beatriz Henriques, PROTESTE specialist.
Collectives can be of two forms: business (hired by companies that have CNPJ or MEI, as a benefit to employees and their dependents) and by accession (hired by a class entity, requiring the beneficiary to be linked to it). There are also membership plans offered and negotiated by administrators created for this purpose, in which contracting is done collectively with other associated users.
In this modality, the contracting is not done directly by the beneficiary with the operator, but rather by a legal entity (employer, professional entity or administrator), which leads the ANS to establish less rigid rules, under the argument of the existence of greater parity between the parts. “In view of this, individual plans are readjusted based on the percentage stipulated by ANS, which does not happen in collective plans, which follow the contractual forecast, according to the accident rate of the portfolio”, highlights Ana Beatriz.
By changing age group
Changing the beneficiary’s age is one of the two ways allowed by the ANS to make adjustments to health plans.
The rule is valid for both individual and collective plans. However, the adjustment ranges vary according to the date of hire (see opposite page). Those hired between January 2, 1999 and January 1, 2004 have seven age groups (ranging from 0 to 17 years old to 70 years old or more). “Here, the value of the last band cannot be more than six times the value of the first band, and beneficiaries over 60 years of age with an active contract for more than ten years cannot suffer this type of adjustment”, advises specialist PROTESTE.
Plans contracted after January 1, 2004 have ten ranges (from 0 to 18 years old to 59 years old or more) – and it is worth mentioning that the member’s son jumped from the second range (19 to 23 years old) to the third (24 to 28 years). The ANS establishes that the value of the last age group cannot be greater than six times the value of the first and that the accumulated variation between the seventh age group (44 to 48 years) and the tenth cannot be greater than the accumulated variation between the first and the seventh. “The health plan contract must have a percentage increase for each age group. The consumer needs to be aware of this”, warns Ana Beatriz.
Adjustment is also done annually
The second way to increase the monthly fee is through an annual adjustment, on the anniversary of contracting the plan. For individuals hired after 1999, companies must consider the maximum index established by the ANS. Those prior to this date follow the contractual provisions. “Despite the rule, the judiciary has also been making it more flexible in cases where exorbitant adjustments are observed, which place the consumer at an excessive disadvantage”, comments specialist PROTESTE.
Collective plans do not have this fixed adjustment rule, and operators can establish the values, according to the number of beneficiaries. With up to 29, the same percentage will be established in all grouped contracts from the same operator, the grouping and percentage of which are published annually by ANS. Above 30 beneficiaries, the increase is based on what is established in the contract and negotiation between the contracting company and the operator, and is not regulated by the agency.
There is also another form of readjustment for collective plans, but it is also not regulated by the ANS: by accident rate. In other words, the correction in the monthly fee is due to the costs generated for the operator, with the justification that the beneficiary used the service more times than expected. However, the operator must justify the percentage applied, otherwise this will result in legal consequences in favor of the customer. Furthermore, this form of increase must be in the contract.
Doubt
If you have any doubts about any billing irregularity, dispute it directly with the company and contact ANS (tel.: 0800-7019656) to open the complaint. Remember to write down the protocol number. And the PROTESTE Consumer Protection Service (tel.: 4003-3907) is also available to clarify any necessary doubts.
