The Government issued a resolution that will establish modifications in plan coverage. It will allow some beneficiaries to access external professionals, while others will only be able to receive care from the providers of their card.
Within the framework of the deregulation of the private health systemthe Government authorized prepaid companies 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.. Thus, new criteria were defined for private and mutual health benefits, to establish limitations in their closed plans. In these systems, only the professionals who appear on the list of each entity will be authorized to issue “prescriptions and treatment orders.”
Among the arguments, the Government highlighted that the measure aims to “guarantee the sustainability of the system.” Thusthose who have Closed plans must be attended exclusively to authorized providersin order to avoid saturation in the care systems of each entity.
Prepaid: limit the scope of coverage for affiliates
The objective, according to the authorities, is reduce costs related to high-priced medications and treatments that, when issued by outside doctors or non-contracted specialists, put the financial sustainability of health entities at risk.
The regulations make a distinction between open plans, in which it is possible to choose both internal and external providers, and closed plans, where the beneficiary must only seek care from the professionals on the list. In addition, Each plan must specify the conditions of access, coverage and authorized providers.
This change aims to improve the “transparency and optimization of resources” and requires health entities to periodically present their updated lists, adapted to these guidelines.
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Prepaid: what is an open plan
An open plan allows members to choose between listed providers or outside doctors. This expands your options for selecting the right specialist. In this way, the open plan offers more flexibility by not restricting care to a closed list of providers.
The regulations also stipulate that health entities must update their processes for equitable and sustainable resource management, minimizing possible financing problems that may affect coverage, especially for expensive treatments.
Prepaid: what is a closed plan
On the other hand, Closed plans require that the beneficiary receive care exclusively from professionals included on the entity’s list. If a member of a closed plan consults a doctor outside this list, the prepaid will not cover the cost. Thus, any care received outside of authorized providers will be excluded from coverage, which implies that the member must assume the cost privately.
How do I know if my plan is open or closed?
Generally, the prepaid They inform their members from the moment they contract the service. The difference in the exclusive use of the professionals on the list indicates the type of regimen. If in doubt, it is best to consult with customer service to find out if a refund is applicable when a professional is chosen outside the plan’s list.
Source: Ambito
