The decision of the Second Jury of the High Court of Justice (STJ) established that the National Health Agency (ANS) has a detailed list of mandatory coverage procedures, which requires that only the treatments and events on the list be covered.
However, the collegiate STJ set parameters for plans to pay for unforeseen procedures on the list, in exceptional circumstances, such as in the case of medically recommended therapies with no therapeutic alternative on the list and with technical evidence. approval of bodies and bodies governing the sector.
Beneficiaries can consult the procedures included in the ANS list in the “Consumer Space” section. In the section entitled “What your plan should cover,” consumers can inquire about mandatory coverage, the ANS reported.
Currently, the list of compulsory coverage prepared by the ANS is already in force under Law 9,961/2000, which means that the health procedures and events on this list cannot be denied by operators under penalty of receiving a fine or marketing plans. extended.
From the ANS’s point of view, there is no change, said CEO Paulo Rebello. “The Agency has always worked with a list of health procedures and events that are mandatory for regulated health plans (after the adoption of Law 9,656 / 1998 or adapted to the law). The agency’s audit is always based on compliance with the aid provided for in the list and in the contracts. “
Rebello also stressed that operators cannot offer less than the list, but can include additional coverage properly established in the contract.
Rebello said the ANS is systematically improving the process of updating the list to make it smoother and more accessible, as well as ensuring broad social participation, “and prioritizing the safety of embedded procedures and health events, based on what. it is at the forefront of Health Technology Assessment (HTA), prioritizing evidence-based health ”.
It is reported that the list includes 3,365 procedures, including consultations, examinations, therapies and surgeries, which includes all the diseases listed by the World Health Organization (WHO). The two-year list review period has already been reduced.
The flow of submitting proposals for listing procedures became constant, as did the examination of proposals. “This year alone, six updates have already been made, including six studies and 14 medicines, or new indications for the use of medicines.”
According to Rebello, the role of the ANS provides legal certainty to the sector, specifying what should be offered to the beneficiaries and enabling an actuarial calculation that determines the price of the plans. “Furthermore, without documenting the effective obligations of health plans, the ANS would not be able to accept in detail its regulatory actions, such as the inspection of coverage coverage, charging for the refund of the Integrated Health System (SUS), definition. the solvency and liquidity margins of the operators, and many other actions, ”he explained.
In addition to the lack of standardization of coverage, Rebello said the exemplary nature of the list, given the unpredictability of the procedures and events that could be used, would increase the amounts charged by operators as a way to maintain it. the durability of their wallets.
Disorders like autism have been reported to have a treatment covered by health plans, based on a list of ANS procedures. “The current list includes a number of procedures aimed at ensuring multidisciplinary care for beneficiaries with Autism Spectrum Disorder (ASD), which are mandatory coverage, once the beneficiary’s doctor has indicated, provided they meet the guidelines for use. ”
Since July 12 last year, beneficiaries of private plans with ASD have had unlimited access to autism treatment sessions with psychologists, occupational therapists and speech therapists, in addition to the unlimited coverage that was already guaranteed for the sessions. physiotherapists. Therefore, the number of sessions will be as indicated by the patient’s physician.
Rebello explained that there are many ways to approach TEA, from individuals to professionals trained in a specific field to those with multidisciplinary care. “Therefore, the ANS emphasizes that the coverage list for these patients is established through consultations or sessions with doctors, psychologists, speech therapists, occupational therapists and physiotherapists, depending on the choice of the most appropriate method by the professional. a case ”.
The STJ answered questions of a legal nature through its press office. One of the questions was about people who are not on the ANS list and, in most cases, are undergoing treatment through a court. It was a question of whether the person lost support or whether the right obtained by the court ruling was in force.
“According to the decision of the Second Section, in various situations, the Judiciary allows the plan to guarantee coverage to the beneficiary of the procedure not provided for by the regulatory body, according to technical criteria and proof of need. and the relevance of the treatment, ”the STJ replied. The court stressed, however, that “it is necessary to assess the specific case, and that it cannot be answered in a generic manner.”
Another question that the STJ answered was whether the decision of the STJ to state the specific role of the ANS could strengthen a new jurisprudence on the matter and whether it could serve the lower courts. According to the court, the decision standardizes understanding of the issue in the STJ and serves as a guide for other instances of Brazilian justice on how interpretation should be in future judgments.