The Superintendence of Health Services (SSS) established the conditions for prepaid medicine companies for the collection of copayments or coinsurance, as well as the practices and patients that are exempt.
The measure was ordered through resolution 2/2023, in compliance with the instructions issued by resolution 1/2023 of the Ministry of Health, both published in the Official Gazette.
Entities registered in the National Registry of Prepaid Medicine Entities (Rnemp) must submit, for verification and registration, the plans with the co-payments offered and, together with them, the fee schedules with the detail of the co-payment values for each service. included.
“These co-payments must fall within a defined range and may not be applied until they are verified by the Superintendence of Health Services”the Ministry said in a statement.
Copayments or coinsurance may only be charged for certain first and second level services.
among the first, medical consultations appear; psychology; laboratory practices, diagnostic-therapeutic tests; kinesio-physiotric practices; speech therapy/phoniatric practices; home care (green and yellow codes) and dentistry.
Second level benefits reached by the standard are Computerized Axial Tomography (CT); Nuclear Magnetic Resonance (NMR); Radio Immuno Assay (RIE); Biomolecular, genetic laboratory; Nuclear medicine; Imaging studies that require prior preparation and/or use of contrast media; Diagnostic/therapeutic endoscopic practices, excluding those neurosurgical and cardiovascular, in all its modalities, whether central or peripheral.
Excepted from the collection of co-payments
The resolution also establishes that the following are exempted from the collection of co-payments: pregnant persons, girls and boys up to three years of age (Law No. 27,611); cancer patients, transplant recipients and people with disabilities, in accordance with the regulations applicable in each case; preventive programs; emergency practices and benefits and all those cases that are excepted or may be excepted in the future by application of specific coverage regulations.
For this purpose, Prepaid medicine entities must complete and generate, for each of the comprehensive coverage plans that they market to the general public, the affidavit form for the registration of comprehensive coverage plans with copayment, which will be available on the website institution of the Superintendence of Health Serviceswhich will publish the reported copayment lists.
In the recitals of the SSS resolution, it is recalled that Decree 743/2022 set a maximum limit, from February 1, 2023 and for a term of 18 monthsto the authorized increases in the value of the installments of the prepaid medicine contracts owed by the contracting parties who have a net income of less than six Minimum, Vital and Mobile Wages, equivalent to 90% of the Average Taxable Remuneration Index of Stable Workers (Ripte ) of the immediately preceding month published.
As the net income of the contracting parties constitutes an amount that varies from month to month for most of them, “it corresponds to regulate the way in which the aforementioned ceiling must be verified and applied,” he added.
The Ministry of Health established in 2002 the Compulsory Medical Program (PMO), in which the essential basic benefits that Health Insurance Agents and Prepaid Medicine Entities must guarantee were determined.
In this PMO, the coinsurance that Health Insurance Agents and Prepaid Medicine Entities can receive for certain medical practices with their corresponding values were established.
Given the lack of updating of the established coinsurance values, in 2017 the amount of the expected fees was modified and their automatic updating was provided, in the same terms and percentages established for the Minimum, Vital and Mobile Wage.
Already in 2022, Decree 743 provided that prepaid companies must offer as of January 1 “identical coverage plans to the one they currently have without copayments, with the inclusion of copayments on first and second level benefits (at a price of at least 25%) lower than the plan without copayments”.