According to a resolution published in the Official Gazette, it was decided that in the closed plans, which the majority of members have, only registered doctors can prescribe remedies and treatments.
Within the framework of the deregulation of the private health systemthe Government enabled the prepaid to limit the coverage of affiliates. According to Resolution 3934/2024 published this Monday in the Official Gazette, Only certified doctors will be able to prescribe medications and treatments. Among the arguments, it was highlighted that the measure aims to “ensure the sustainability of the system”
In a section of the resolution, the Government differentiates open plans from closed ones. It is worth clarifying that open plans are usually more expensive and closed plans are more accessible.
Prepaid: the Government sets limits on open and closed plans
“In the open plans Beneficiaries can choose to receive medical-care coverage through card providers or external providers; while, in closed plans, the beneficiaries must be served exclusively by the providers included in the bookletwho turn out to be the authorized to prescribe a medical practice or a medication,” the resolution explained.
In practice, and as can be seen from what the measure seeks to avoid, today it happens that the prescriptions can be done not only by the registered doctors, but by other professionals who do not work for the institution. And the focus of the issue is placed especially on the high cost medications. One of the recurring complaints of prepaid and social works in recent times has been that “any doctor” makes a prescription and that, voluntarily or judicially, in the short or long term must be covered.
Furthermore, it was established that, within the framework of the closed health plans, “Medical-care coverage of practices and medications will be granted exclusively on the basis of prescriptions made by doctors who are part of the record of the corresponding Health Insurance Agent.”
This condition is mandatory nature “for all coverage requests, subsidy or reimbursement for medical practices and medications, including those presented through administrative or judicial means.”
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What obligations must the prepaid companies comply with?
On the other hand, it was ordered that the health plans offered by health insurance agents should: accompany each plan with its provider card, detailing the professionals, medical centers and providers authorized to provide services within the framework of the plan; clearly specify whether the plan is open or closed, indicating the conditions of access, coverage and the particular characteristics that regulate the care of beneficiaries.
Prepaid: what will happen to judicial resolutions
Finally, the eventual disbursement for coverage not only affects at prepaid and social works. The resolution recalls that “judicial resolutions may force the Health Insurance Agent to grant the requested coverage or, failing that, impose on the National State, to the Ministry of Health or this Superintendency the total or partial payment of the medical benefit or medication in question.”
And he emphasizes that “this situation reflects a risk of definancing for Health Insurance Agents, given that coverage of practices or medications not adequately provided for in their health plans may compromise the financial sustainability of the system”.
Source: Ambito
