Complete Guide to Health Plan Exchange

Complete Guide to Health Plan Exchange

Sometimes, health insurance providers tend to be extremely inefficient. For some, meet deadlines for consultations and procedures and respect the provider network is a real ordeal. But we know how important it is to have a health insurance – in addition to the savings in the most expensive procedures, we can rest knowing that we are safe. Depend on the SUS is dangerous, especially with family and young children. The solution therefore is to exchange health plan.

Do you want to make the change, but do not know exactly how this works? Afraid of grace periods, and do not want to be unprotected at times when more accurate? Read on and know all the details necessary for change!

What is a health plan?

It is impossible to predict the need for medical care. Life is full of uncertainties, and the risks we take do not necessarily have to do with our lifestyle: from childhood we are brought down by disease, can suffer accidents or presenciarmos catastrophic natural events.

When we arrived at adulthood, we can even get to the point of accepting voluntary admissions: pregnancy, for example, a period full of care in the life of a woman , must be provided by a health plan.

Ie health plans are human attempts to predict certain risks, monthly paying a fee to maintain security. If there is any illness, the cost paid to providers of health plans should be used to provide the individual excellence of care.

Operators of a health plan together thousands of people in one discipline. So the risks are diluted: some people actually get sick and need to extensively use the health plan, while others remain healthy, benefiting only routine visits and preventive health.

The plans are marketed by operators properly regulated by the National Health Agency (ANS), which regulates the industry and supervises certain irregularities.

As a health plan works?

The payment of health plan is made directly to the provider. At the time of hiring, it is possible to analyze the provider network , that is, to know which shops and offices you can use the contracted plan to pay for the service. The health plan passes the money paid by the contractor to doctors and institutions to which it uses in the treatment.

In some cases, it is also possible to receive treatments in unaccredited network. In this case, the payment will be made directly to the service provider. The health plan contractor shall take all necessary documents to the operator in order to receive the refund queries .

What does it cover?

By hiring a health plan, it is common to consider only accredited network, forgetting the procedures provided by the operator. The NSA has the function of determining the list of mandatory procedures to be provided by the provider. The list is called the List of Procedures.

The List of Procedures is only valid for contracts entered into from 1999 and is reviewed every two years. The contracts agreed before then follow the mandatory list of the health plan itself. The coverage of health plans varies according to the plan mode engaged. Currently, ANS organizes the procedures in five different types:

  • dental plan;
  • outpatient plan;
  • hospital plan with obstetrics;
  • hospital plan without obstetrics;
  • reference plane.

dental plan

Required procedures include consultations (scheduled and emergency), topical application of fluoride, treatment for plaque etc. Treatments focused on aesthetics – as maintenance and dental whitening machine – should be borne by the patient’s pocket.

However, most health insurance providers usually cover only 50% of the costs and, in cases of procedures, the plan may cover only a percentage of the costs.

outpatient plan

The plan covers outpatient medical consultations, treatments and tests, but emergency treatments are covered only during the first 12 hours. The method has great advantage in acting in preventive medicine. Dressings in cases of burning or cutting accidents are also covered by mode.

For those who can not afford to pay a full plan, opt for outpatient plan may be the best choice, because of the preventive and hospital coverage in emergencies.

hospital plan with and without obstetric

The two hospital modalities cover situations where there is the need for hospitalization. Examination and consultation can even be met, but only if they occur within one hospital. The hospital plan with obstetrics covers the mother’s hospitalization and provides assistance to the child (including adoptive) over a period of 30 days after delivery.

Remember that if the baby has complications after the 30 – day mother’s health plan coverage, the procedures should be credited for the baby ‘s health plan or paid in full by those responsible.

Reference plane

The reference plane is the fusion of outpatient and hospital plans obstetrics, the contractor providing a coverage area greater than that offered by other separate planes. In case of necessity hospital, the only obligation of the plan is to present hospital ward in default. If there is the need for hospitalization in a room, by preference of the recipient, it must change the background mode.

Deadlines to meet

It is important to be aware of the approval period for each procedure. Not knowing this information can lead to problems in important moments, such as dialing a serious surgery or the need for a faster service.

The term is also defined by the NSA and is divided into the categories of service. emergency procedures and emergency need to have immediate approval by the health plan. In the case of basic queries in specialties such as pediatrics, gynecology and internal medicine, approval must occur within a maximum period of 7 days.

For complex procedures such as magnetic resonance imaging, health plan should follow a period of 21 days. On return visits, the deadline for compliance is the physician’s discretion. It is important that the professional also aware of certain requirements of the plans he is accredited.

exceptional cases

Some procedures are listed in the List of Procedures are not open to all individuals. Some tests require specific health conditions for being authorized by the plans. Health plans can also standardize the number of sessions given to a certain professional such as a nutritionist, for example. The cover of this professional is required to outpatient plans and reference.

Teenagers and elderly at nutritional risk, obesity or women up to 6 months after delivery can take advantage of 12 annual sessions of consultation. For individuals who do not fit in these situations are allowed only 6 sessions per year.


Sometimes the procedures provided by the NSA are not met, even with all the regulations of the Agency. In such cases, the patient may complain directly to the health plan provider or trigger the agency.

However, it is difficult to take certain actions when the health situation of a certain individual requires urgency. In case of breach, the patient may trigger the Justice and demand an injunction to ensure compliance.

It’s time to change my health plan?

The reasons for changing the health plan may be many, based on the lifestyle of the patient, their current financial situation and even problems with the previous operator. Whatever the reasons, it is essential to be settled with pending and finalized cases. Breaking a troubled contract to enter another can mean more headaches.

What to take into account the exchange of health plan?

Grace period

ANS allows portability between deficiencies in the procurement act of an individual health plan or by collective membership. To use the benefit for the first time, the contractor must have kept your plan for at least 2 or 3 years, and can not be in the grace period.

The second time, the contractor may have completed only one year in their original plan. In either case, portability can only be done in a period of 4 months after the plan’s anniversary date. If this period is lost, the contractor will wait until next year to start the process of health insurance exchange.

Mode plan

The exchange can be made between an individual and collective level, either by adhesion or business. The contractor may also choose to change a plan of municipal scope for regional arrangements in several states, or national coverage.

Portability is assured only for health plans contracted from 1999, with both health plans marketed by the same operator. The contract will be changed only when absolutely necessary details, such as changing the tuition.

Care when hiring a new plan

The ANS annually publishes lists the ranking of operators while respecting economic and operational categories. In it, you can see outstanding debts and find companies that are in bankruptcy.

Every three months, the agency provides the names of the organizations that have been suspended for not complying with the periods of marking procedures. Look for the carrier name in the ANS site and see if the plans are not being marketed illegally. If the plan is sold illegally, the recipient may have difficulty in solving possible problems with the ANS and justice.

It is important to pay attention to the operator’s position in the ranking of claims in assessments made by the customers themselves. Also, inquire if the institution maintains the status of good paying. Some doctors refuse to attend the accredited some health insurance network.

How to choose between the individual or collective?

individual plan

The individual plan is the plan contracted directly with the operator, without intermediaries. The monthly fee these modalities usually higher, but the annual adjustments are guided by the resolutions of the ANS, which points to a value of 9% per year, compared with 15% of the business plan.

The individual plan of the grace period is usually long, depending on the procedure in question. The lack of health insurance is to prevent, for example, that a pregnant woman hire a health plan and later have their spending on labor paid by the institution.

For routine consultations, the grace period comes down to 180 days. For deliveries, the grace period is for 300 days. Plans contracted after the discovery of a patient’s disease require a period of 24 months.

business plan

The business plan can only be obtained through an intermediary, and if a company creates agreements for the employees themselves. Including, negotiations are made between institutions with CNPJ. Because of the volume of paying the price of tuition is lower: companies with 1000 employees have more bargaining power than companies with 50.

Thus, the risk of spending are diluted. As a part of the contractors use the health plan at length, the rest of paying – which makes up the majority – will enjoy only routine visits and preventive health.

Also, the grace period for business plans is much lower compared to individual plans. For diseases contracted after signing the contract, the period is 30 days. Depending on the number of contractors in the plan, the period for surgeries and childbirth can reach 0.

collective level of adhesion

This is the mode provided by organizations and entities, and certain companies offer plans for contractors with no connection to each other. In group plans, the adjustments take place freely without the approval of the ANS, a practice that can make the most expensive long-term plan.

In both collective, business and membership arrangements, operators of health plans may terminate the contract unilaterally and unjustified manner. This can leave many contractors lost at first.

This fact does not occur in individual sports, where, generally, it is difficult to break the contract by both parties. In this sense, the beneficiary of an individual plan runs the risk of paying high penalties for breach of contract, while the operator can be sanctioned by the NSA and have suspended their marketing.

Also, if the case results in a process, the beneficiary usually win the case when it is proven that the contract termination was motivated by the operator’s failure to pay the patient’s expense.

Migration to the individual plan

In cases of termination of the business contract, contractors must be arguably transferred to individual sports. The health plan can not refuse to do so, citing the lack of an individual plan, for example. To provide the business plan, the operator must rely on the individual plan in its catalog, for problematic cases.

When it comes to the same operator, with the termination of business contracts, the grace period at the individual level is canceled. The patient can use the health plan from the moment the contract is signed.

The NSA only guarantee the absence of need, but can not guarantee the price of maintenance. As individual plans are more expensive, the contractor will need to cope with the new values.

Migration to the collective or business plans

Lack – during some procedures that are not validated – it is best administered in the business plan. Regardless of portability, the lack of business plans usually 180 days for complex procedures such as surgery, and 24 hours for emergency procedures.

It’s good to keep an eye only on annual adjustments, which can greatly endear the business mode as the years passed, ending the advantages of corporate health plan on the individual.

Do I need to change my health plan?

Some documents are required to prove certain conditions and thus have access to cases of special portability. In cases of death of the plan holder, you must submit documents certifying the death of the individual and have saved paid slips.

How to reduce the lack of my health plan?

Everything will depend on the conditions under which the exchange of health plan was made. In contract termination forced by corporate health plan, the contractor shall be automatically transferred to the individual mode of the same health plan and have their period of grace subscriber.

Special portability needs

The special needs of portability is activated when the provider of the health plan goes bankrupt regime or in case of death of the plan of the contract holder. In such cases, it is set a period of 60 days to the Special Portability.

There is no need to meet the birthday rule of the health plan. It is also not necessary to follow the requirement of minimum stay. The only requirements are the payments, ie, absence of debts or late payments and the new health plan must have a monthly fee equal to or less than the previous plan. To find out if you can take advantage of the special needs of portability, you need to consult the ANS guide to identify plans compatible with yours.

The operator of destination health plan will require various documents:

  • in case of death of the contract holder, you must submit a copy of the last 3 losers and pay slips;
  • for portability former employed, the number of slips displayed increases for the last 4 months;
  • Copy the link with proof of the contracting entity, if the target plane is by collective membership.

The target plan contract shall enter into force 10 days after the approval of the operator. At the end of the process, the NSA recommends that the contractor contact the source plan to communicate the use of particular portability needs, informing the start of the new plan effective date.

health plan contract migration

Within the same health plan, migration allows the exchange of a plan not included in the new rules of the ANS (approved in 1999) to a plan provided by these guarantees. In this case, the contractor will not need to meet new grace periods.

To perform the migration, consider whether you are included in an unregulated plan and later, see the Health Plan Guide ANS plans consistent with the required migration. The request must be made directly on the carrier’s health plan by the contractor itself. The new plan will take effect from the date of signature of the recipient.

contract by

In the case of contract by some predetermined information of the plan are changed to better meet the contractor. There is an exchange of health plan, but a new contract must be drawn up and signed.

The original contract was signed by 1 January 1999, indicating a health plan not assured by the new rules of the NSA. The target agreement must belong to the same operator of the health plan and the same mode. changes in the monthly fee are prohibited.

health plan marketed by the same operator

When the contractor has the desire to get a health plan higher than contracted, the operator may not require new grace periods if they have already been fulfilled. If new procedures are included in the new plan, the beneficiary need not meet the surplus shortage.

How to ensure support for the exchange of health plan?

Portability should be requested in a period of 120 days after the plan’s birthday. In this period and during the plan amendment process, the beneficiary is assured in all the procedures you need to do. However, it is necessary that all documents are properly delivered in these four months.

Otherwise, the contractor loses coverage of the original plan while waiting for the acceptance of the original plan. This can be a disaster in case of unforeseen events.

The health plan has become indispensable in our lives. It’s hard not to have one and depend on the length of care provided by SUS. However, like any institution, this method can present problems and it is important to know the rights and duties of the recipient to effect the exchange of health plan safely.

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