Understand how health plan adjustments work

Understand how health plan adjustments work

There is no doubt that having a good health plan is a guarantee of many benefits. However, pay for it can weigh the pocket at the end of the month. Without knowing why the monthly payment be adjusted, many users end up canceling the service due to verify adjustment rates higher than inflation in the period.

Do you have any questions about it? In today’s article, we will explain how the rules implementing health plans adjustments are incorporated into consumer tuition according to the type of contract.

Types of contract

The National Health Agency (ANS) is responsible for overseeing the increased monthly payment of health plans and disseminate the adjustment rate to be applied by operators every year.

However, the amount of increase varies depending on the type of contract for individuals (individual and family plans) and legal ( collective plans for membership or business).

annual adjustment

In order to return inflation, the annual adjustment is permitted for health plans contracted from January 1999 or old plans that have been adapted to Law No. 9,656 / 98.

The annual adjustment for individual and family plans is applied from the month of the anniversary date of each contract, that is, the month in which it was signed. To calculate this increase, the ANS is based on the average percentage of the adjustments offered to group plans. In addition, there may be the first charging a retroactive value because the difference between the application of the increase and the contract anniversary date.

Therefore, the user should be aware of the retroactive amount and really the authorized percentage is equal to or lower than that established by the ANS.

Even in this context, it is noteworthy that the old contracts before January 2, 1999 and not adapted, the annual adjustment rules should follow what is in the contract, provided that it is clearly specified.

Adjustment for change of age

This type of reset occurs when the change in the age of the owner or dependent exceeds one of the age groups in the contract. For plans contracted from 1999, the adjustment for change of age is up to 59 years of age or with 10 or more years of contract. On the other hand, the older contracts to age could reach 80 years.

Thus, the consumer must also observe that the change in the health plan’s monthly fee can match to occur in the same year, for annual adjustment and age.

Reset by accident

Tax fees in the corporate segment, the increase in accidents is increasing commonly used by operators. The aim is to replace the cost of health care which were higher than expected in a given period.

However, the increase in accidents is often considered abusive by health plans. That’s because in addition to the variation of the unilateral value, which is not normally provided in the user contract, the operators do not provide data that could justify the proper adjustment.

For not being defined by ANS, the void left by the legislation has been one of the main topics discussed in court, where the health insurance companies mostly have been won by the consumer.

According to Articles 39 and 51 of the Consumer Protection Code , the increases applied by the health insurance companies represent excessive advantage for them and damage to the consumer, since in most cases the criteria are based on unclear terms and difficult understanding.

As a result, beneficiaries of health plans should watch for annual increases and adjustments being applied so that they are not harmed.

Adjustment in the individual health plan and business

As mentioned here above, the increase in individual health plan takes place annually and is supervised, regulated and limited by the National Health Agency (ANS). Thus, no matter how the operator intends to increase the percentage, the ANS as regulator will prevent this action. Consequently, this ends up generating greater comfort and safety for the user, since the Agency is responsible for assessing the decisions of health plans.

The ANS analyzes both the adjustments applied to individual plans and for the business. However, the business group plans, whether old or new, are contracts signed by a legal person (association, company or union). In this case, the adjustments are not set by the ANS.

For the Agency, the entity has a greater bargaining power close to the operators. In this case, the adjustments take place through free negotiation between the health provider and the legal representative, without interference from ANS. This type of contract is allowed, provided that the increase is made every 12 months and the adjustment rules are clearly stated in the contract.

If the business plan with more than 30 employees , the legal entity must negotiate with the operator the percentage to be adjusted. However, if the collective agreement have up to 30 beneficiaries the operator must apply the same percentage to the other contracts with up to 30 people.

In addition, the cost at the beginning of the individual level is usually higher than the business, since the health provider receives a single monthly fee, but the adjustments made are smaller over the years.

Already at the collective level are various fees and consumers in one agreement, which often ends up being cheaper. This practice has caused small groups and families hiring plans as well, not realizing that because it is a free contract and without control by the NSA, the risk increases may be higher.

Therefore, the beneficiaries should always observe what is provided in your contract to avoid possible grievances that may arise in your health plan.

Now that you know how the criteria in health insurance adjustments are applied, how about analyzing which one is right for your needs? Please contact us and discover how we can help you make the best choice!


Spread the love

No comments.

Leave a Reply