Individual health plans in the spotlight, with stricter regulation by the ANS – Economy

The controversial process of transferring individual plans to Emil To a group led by Director Fiord – Pinned by National Health Agency (ANS) – He drew attention to a specific niche of health plans that lost more and more space and left customers apprehensive: those individual plans. In addition to the 337 thousand beneficiaries of the Amel program, who still do not know whether their service will be transferred to a third party that does not have a tradition in this sector or not, there are another 8.6 million individual plans in the country.

This is a business that, in general, is no longer attractive to sector giants, due to the stronger organization of the ANS. The adjustment of these portfolios is determined by the agency – in 2021, for example, the rule was to reduce the monthly fee by 8.19%. In group plans, the increase is determined by the operator, according to the “loss ratio” of the portfolio – the more a certain group is used, the higher the value.

Therefore, many operators have abandoned individual contracts. But those who already have this service are entitled to keep it. As these clients are getting older and therefore needing more services, the process becomes more expensive.

Among factor clients, an air of apprehension due to lack of definition regarding change. So much so that an association is created to defend the company’s clients. “This hostile environment was crucial to the resistance,” says attorney Fanosa Morta Agrelli, the group’s board coordinator.

The group includes Neusa Grolla Barbosa. She is the mother of Guilherme Barbosa Ribeiro, who has cerebral palsy. When he was born in 1992, the family had a Golden Cross plan, but he went to Amil precisely because of the deterioration of the service. “My son is at the AACD Hospital in Sao Paulo. When I made this agreement, it was a requirement. In the middle of last year, when I went to make an appointment, they told me that Guilherme’s plan, Blue 300, had been discredited,” he recalls.

USP Director of Civil Law, José Fernando Simão stated that the contracting party must be notified in advance of the change of service provider. On the other hand, the ANS asserts that operators have the right to sell their beneficiaries’ wallets, “provided they comply with the rituals stipulated in the regulations.”

United Health, the owner of Amil, claims to have shared with ANS “measures that have been implemented to improve the experience of beneficiaries of individual plans transferred from Amil to APS (the company set up by Amil to receive individual plans which will be transferred to Fiord).”

The abandonment of the individual plan began in the first decade of the twenty-first century

Large health operators began to stop offering individual plans in the early 2000s, after a law came into force that made regulation of these contracts much stricter. Currently, of the 48.9 million Brazilians with health insurance coverage, fewer than 9 million have individual contracts, a volume that is declining year by year.

In addition to Amil, whose transfer of beneficiaries has been suspended, the leaders in the individual health plans sector (excluding dental plans) are Notredame and Hapvida, who have just received approval to join. Together, they own about 17% of that market. Amil has 6.1% and Prevent Senior has a 5.8% stake, BTG Pactual calculates.

Another big company in the sector, Bradesco Saúde, has seen a decline in the size of its individual portfolio, having stopped selling this type of plan in 2007, focusing on companies and category (sold to unions, for example). Today, individual contracts represent just 3% of Bradesco’s total portfolio, according to a survey by BTG Pactual. The Prevent Senior plan, a health plan focused on seniors, is the most exposed with 94% of individual plans.

absence of security

“Health plan operators assert that individual or family plans generate greater insecurity, and that controlling for adjustments implemented by the ANS makes such plans unsustainable,” says Luis Gustavo Miranda, Partner at Rolim, Viotti, Goulart and Cardoso Advogados. “Adjustments to these plans have been lower than those for group membership and business plans in recent years, as disclosed by operators and their associated entities.”

According to experts, one of the solutions operators came up with was to sell plans to individual micro-entrepreneurs (MEIs), who are nothing more than individuals with CNPJs. In this section, companies can mark their modifications without ANS approval.

Companies that continue to sell individual plans, such as Notredame/Hapvida, use the strategy of verticalizing the process – that is, they create their own service networks. As a result, they are able to reduce costs. For example, Hapvida has seen the number of individual plans rise 20% in the past year, to about 4 million customers, in the face of the Brazilian’s increased search for health plans amid the covid-19 pandemic.

One of the challenges for Brazil’s health plans is precisely the issue of increasing costs, says FGV economics professor Joelson Sampaio, and that this vertical shift ends up being an interesting solution. “Some are still focused on preventive health policies, and the use of technology by these companies has increased,” he says.

Presence

Miranda, do Rolim, Viotti, Goulart, Cardoso Advogados, states that beneficiaries of regularly contracted health plans are entitled to cover all diseases listed in the International Statistical Classification of Diseases and Related Health Problems, of the World Health Organization.

Aside from that, he points out, there’s also a list called the Actions and Events List in Complementary Health, which informs which medications, products, or procedures should be administered. “Failure or incomplete service allows for complaints to be registered in both the ANS and consumer protection entities.”

Inspection needs to be more thorough, says IBDS chief

President of the Brazilian Institute of Insurance Law (IBDS), Ernesto Czerulnik, says that in the past, individual plans were viewed by consumers with a great advantage in relation to the group, especially with regard to greater legal stability, that is, without the surprise of termination of contracts or higher prices suddenly. “But that has changed, and there is now regulatory easing,” says the attorney.

For him, insurance companies end up pressuring consumers to leave individual plans, with higher rates and worse service. “She (the insurance company) is gradually adjusting the plan so that there comes a time when it’s no longer useful,” he says.

At this rate, Cerulnik predicts that health plans in Brazil may be doomed to fail, even group plans that are getting more expensive. He estimates that a change of direction will be possible by changing the behavior of inspection, which in his opinion should be more detailed about the firms.