The Government has established a new regulatory framework to regulate health plans, allowing prepaid health insurance and social security entities to limit coverage for medications and treatments. These can only be prescribed by doctors who are part of the respective health insurance agent's network. The measure was formalized through Resolution 3934/2024 last Monday.
In the arguments for the decision, it was explained that allowing prescriptions and orders in closed plans to be made by any professional represented a risk of underfunding for Health Insurance Agents. This is because coverage for practices or medications not adequately foreseen in health plans could compromise the financial sustainability of the system.
Social security entities and prepaid health insurers had been requesting a change in the system, arguing that while coverage by any professional is not mandatory for closed plans, they often provided it voluntarily or due to legal action. The new regulation differentiates between types of coverage, establishing that in open plans the beneficiaries can choose to receive care from listed providers or external ones, while in closed plans they must receive care exclusively from providers included in the list.
The measure states that prescribing doctors must prove they belong to the Health Insurance Agent's provider network and submit a sworn statement ensuring the absence of conflicts of interest with the prescribed technologies or medications. The Superintendency of Health Insurance explains that these controls will be essential to validate coverage and request subsidies or reimbursements for services rendered outside the list.
Furthermore, the regulation also establishes that each health plan must be accompanied by its service provider list, detailing the professionals, medical centers, and authorized providers, as well as the specific conditions for access and coverage. The main objective of this measure is to ensure transparency in the offering of open or closed plans, as well as to guarantee that benefits are provided in accordance with current regulations and respecting the contracted services.
