Health Plan Coverage Shiftsโ After โฃSupreme Court Ruling: What you Need to Know
BRASรLIA – A recent decision by the Brazilian Supreme Federal Court (STF)โค restricting health plan coverage to treatments andโค procedures listed by theโฃ National Health Agency (ANS) has sparked widespread concern among patients. While the ANS list โขremains a key reference,โ experts clarify that coverage isn’t automatically limited to it, and doctors retain crucial power to justify โtreatments not on the list.
The ruling has prompted numerous questions about how it impacts accessโ to โฃcare. Here’s a breakdownโฃ of key concernsโ and expert answers, based on details from legal counsel Fernandes:
What if my โฃdoctor recommends a treatment โnot 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 โdoctorโ must provide a detailed โjustification in โฃthe prescription report explaining whyโ the โchosen treatment is necessary, rather than an equivalent option already included on the ANS list.
My child has Autismโ Spectrum Disorder (ASD) โand โADHD, and a recommended therapy lacks “proven effectiveness.” Will my health plan deny coverage?
Coverage isn’t automatically denied. The doctor isโฃ responsible for demonstrating the therapy’s effectiveness and necessity for the patient’s treatment, explains Fernandes.
Iโค haveโฃ 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 shouldโ not be a factor in coverage decisions. If the drug is โregistered with Anvisa (the Brazilian Health Regulatoryโฃ Agency) for the specific treatment, prescribed by a qualified doctor, and either has no equivalent on the ANS listโข or a justifiable reason for being diffrent, the plan should authorize it.A negative response cannot be โbased on the drug’s price.
I underwent bariatric surgery or mastectomy and require reconstructive โฃplasticโข surgery, but my plan denies coverage. Has this changed?
Yes. While previously requiring court decisions, the โsuperior Court of Justice โฃ(STJ) hasโค established a precedent requiring healthโ plans to cover reparative or functional plastic surgeries, including those following bariatric surgeryโฃ or mastectomyโ for breast cancer treatment.
This is a developing story, and patients are โencouraged โto consult with their doctors andโค health plans for specific guidance.
