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Health Plan Coverage Shifts After Supreme Court Ruling: What you Need to Know
BRASÍLIA – A recent decision by the Brazilian Supreme Federal Court (STF) restricting health plan coverage to treatments and procedures listed by the National Health Agency (ANS) has sparked widespread concern among patients. While the ANS list remains a key reference, experts clarify that coverage isn’t automatically limited to it, and doctors retain crucial power to justify treatments not on the list.
The ruling has prompted numerous questions about how it impacts access to care. Here’s a breakdown of key concerns and expert answers, based on details from legal counsel Fernandes:
What if my doctor recommends a treatment not on the ANS list, but considers it superior to an available option?
You are not automatically limited to the ANS list. According to Fernandes, the doctor must provide a detailed justification in the prescription report explaining why the chosen treatment is necessary, rather than an equivalent option already included on the ANS list.
My child has Autism Spectrum Disorder (ASD) and ADHD, and a recommended therapy lacks “proven effectiveness.” Will my health plan deny coverage?
Coverage isn’t automatically denied. The doctor is responsible for demonstrating the therapy’s effectiveness and necessity for the patient’s treatment, explains Fernandes.
I have a rare disease requiring a medication costing millions of reais. Does the STF ruling change anything?
No. Fernandes emphasizes that the cost of the medication should not be a factor in coverage decisions. If the drug is registered with Anvisa (the Brazilian Health Regulatory Agency) for the specific treatment, prescribed by a qualified doctor, and either has no equivalent on the ANS list or a justifiable reason for being diffrent, the plan should authorize it.A negative response cannot be based on the drug’s price.
I underwent bariatric surgery or mastectomy and require reconstructive plastic surgery, but my plan denies coverage. Has this changed?
Yes. While previously requiring court decisions, the superior Court of Justice (STJ) has established a precedent requiring health plans to cover reparative or functional plastic surgeries, including those following bariatric surgery or mastectomy for breast cancer treatment.
This is a developing story, and patients are encouraged to consult with their doctors and health plans for specific guidance.
