The collective health plan is one contracted by a company, council, union, or association to provide medical and/or dental care to people linked to that organization and their dependents. It can be a collective business plan or a collective membership plan.
Organizations that wish to contract a collective health plan through a broker, a benefits administrator, or directly with the operator.
But, do you know the difference between the types of the collective plan? Or, who can hire them and the role of brokers and benefits administrators? These and other frequently asked questions about collective health plans will be answered below. So keep reading!
What is the difference between a business plan and a membership plan?
The main difference between the types of collective plans is that, while a company contracts business plans; Councils, unions, or professional associations contract collective membership plans.
Who can be a beneficiary in a business plan?
All employees or civil servants and dismissed and retired partners, administrators, and interns of the company can benefit from the contracted medical and/or dental assistance. Your family members can also participate, as dependents, as long as the kinship degrees determined in the Health Plans Law (nº 9.656/98) are respected:
- spouse or partner in a stable union;
- up to the 3rd degree of kinship by blood or adoption (parents, children, nephews, grandchildren, and grandparents);
- Up to the 2nd degree of kinship by affinity (in-laws, brothers-in-law, son-in-law, stepchildren, grandparents, and grandchildren of your partner).
Who can be a beneficiary in a membership plan?
All employed, unemployed, self-employed, or retired professionals who are legally linked to an entity that represents their professional category can join a collective health plan by the membership. It is also possible to include your family members as dependents, as long as the rules of the Law are followed.
What should my health plan cover?
The ANS defines a list of consultations, exams, and treatments, called List of Health Procedures and Events, which operators are required to offer, according to each type of health plan – outpatient, hospital with or without obstetrics, referral, or dental care. Therefore, before checking whether you are entitled to a procedure, be sure to check the assistance segmentation of your plan.
The Rol is valid for plans contracted from January 2, 1999, the so-called new plans. It is also valid for plans contracted before that date, but only for those that were adapted to Law nº 9.656/98.
Is it necessary to fulfill a grace period in collective plans?
It depends. In business plans with a number of participants equal to or greater than 30, beneficiaries who join the plan within 30 days of signing the contract will not need to comply with a grace period or temporary partial coverage (CPT). Thus, new employees or dependents will need to have 30 days of connection to the company to use CMS health care services. This rule also applies to collective membership plans, but, in addition, there is no grace period if the ticket takes place on the anniversary of the contract.
However, if entry into the plan occurs after these periods or the plan has fewer than 30 participants, the operator may require compliance with the following grace periods:
- Urgent situations (accidents or complications during pregnancy): 24 hours;
- Emergency situations (immediate risk to life or irreparable injuries): 24 hours;
- Delivery (except premature deliveries and those resulting from complications): 300 days;
- Other situations: 180 days.
Remember that these limits are the maximum grace period stipulated by the ANS. Operators may request a shorter time.
What happens when the beneficiary has an illness or injury prior to contracting the collective plan?
If it is a collective membership plan, temporary partial coverage (CPT) may occur. This means that the health plan may or may not cover, for a maximum of 24 months, surgeries, hospitalizations in high-tech beds (ICU/ICU), and high-complexity procedures exclusively related to the disease or injury that the consumer already had when purchasing. The service. After these 24 months, the operator is obliged to cover all these services.
On the other hand, if it is a collective business plan with more than 30 beneficiaries – and the employee has joined the plan within 30 days of the date of formalization of the contract with the operator or his admission to the company – partial coverage cannot occur.
Is the readjustment of collective plans the same as that of individual plans?
No. The readjustment limits of individual health plans are imposed by the ANS. The rate of collective plans is determined in the contract, as negotiated between the operator and the organization, and there is no limitation established by the Agency.
Health plans have monthly fee readjustments in two moments: (1) when there is a change in age group, according to criteria defined by the ANS, and (2) once a year, due to cost variation, on the contract anniversary date.
It is important to say that the variation in medical and hospital costs is due to both the increase in inflation and the inclusion of new technologies in the List of Procedures since more modern and effective treatments and medicines tend to be more expensive.
What does a health insurance broker do?
The main function of the brokers is to inform the client about the coverage of the health plan and to mediate the contract with the operator, ensuring that everything that is present in the contract is fulfilled.
In addition, qualified brokers, such as Barela Seguros, have extensive knowledge of specific terms and clauses for the products, which facilitates the understanding of customer needs in order to indicate the best plan, according to their reality.
In short, the broker will be by your side, playing an advisory role at the time of the sale. And, after the negotiation, she should offer all the support and guidance whenever necessary.
On the other hand, the operator’s full responsibility is to guarantee resources and a network of health services (hospitals, clinics, laboratories, and professionals) to serve the beneficiaries.
What does a benefits administrator do?
A benefits administrator is a company that assumes part of the work that would be done by the company, council, union, or professional association that contracts the health plan. For example, it is responsible for issuing slips, representing beneficiaries in negotiating readjustments, and, depending on what is contracted, absorbing the risk of the contracting organization in the event of delay or non-payment of monthly fees to prevent beneficiaries from being harmed. In these situations, the administrator usually receives a percentage of the monthly fees paid, according to what is negotiated.
Both health plan operators and benefits administrators are required to register with the National Supplementary Health Agency (ANS) to be authorized to operate. This ensures that the ANS monitors their activities and, therefore, that they comply with a series of quality rules required by the Agency.
When can a collective plan agreement be terminated?
In collective plans, the conditions for termination or suspension of coverage must be provided for in the contract. Even so, apart from these cases, the service can only be interrupted by the operator if there is fraud or without justification after 12 months from the contracting date, provided that the contracting party is notified at least 60 days in advance.
