Therefore, it is necessary to be very attentive to the services of your health plan to avoid private consultations for what you have already paid. To help you, Zelas Saúde has compiled a complete list of benefits that health plans offer to their customers. Output check!
1. Unlimited consultations and exams
These should be the most basic services of a health plan, but they are also the most needed and used. When recruiting, you can carry out all consultations and exams in the accredited network at your disposal.
Be aware that ANS legally prohibits operators from limiting the number of times a beneficiary can use the service. However, appointments and exams are not covered enough for the hospital’s back-office staff, which is an exclusive benefit of some premium plans like Amil One and Omint (Premium Line).
2. Emergency service
The biggest advantage of hiring a medical plan is not having to wait months for an appointment or hospitalization. So even if you don’t find a place at the hospital you want, operators must find workable solutions to the problem and ensure that beneficiaries are served promptly.
3. Hospitalizations, including in the CTI
All health plans are required to offer unlimited hospitalization in their accredited network, including intensive care centers. According to the ANS, if you find that there are no accredited hospitals or vacancies in your region, you should ask your operator for help. In these cases, the operator must proceed as follows:
- Authorize and pay for services at private locations that are not part of the network;
- ensure that approved services are available at nearby locations;
- Personalized service in specific locations.
Remember, if the operator authorizes the program outside an accredited network, they will have to pay for it. If your plan does not include reimbursement, the company will not have to pay the beneficiary later. In case of an emergency, prior authorization is not required.
4. Accredited network
Operators must provide approved networks that include all mandatory procedures on the ANS list. Whether owned or owned by third parties, there must be reliance on hospitals, laboratories and qualified medical personnel.
In the case of hospitalization, there is no limit to the coverage of treatments such as psychotherapy, speech therapy, physiotherapy, etc. In other cases, sessions are limited and require the necessary medical certification. The minimum number of sessions for each diagnosed disease was considered.
However, whoever decides this should not be a healthcare operator, but a professional. In that case, for example, if your audiologist recommends 10 sessions, your insurance will only cover those.
Many people wonder if more complex diseases like AIDS and cancer can be treated, and the answer is yes, and health plans are obligated to provide services. All treatment is divided according to your plan, that is, if only exams and consultations are covered, you will not be hospitalized by insurance.
7. Pre-existing diseases
Health plans cannot refuse to hire customers with pre-existing conditions, but they can impose a grace period of up to two years for pre-existing conditions. However, please be aware that only procedures related to your condition are restricted during this period and other procedures will be released.
8. Prosthetics and orthotics
Health plans are required to cover prostheses and orthotics whenever their implantation requires surgical intervention. If your plan does not have a hospital segment, these procedures cannot be performed, even if they are mandatory.
9. Refractive Surgeries
Your health plan needs to cover refractive surgery, but there are some requirements, in principle, you must be at least 18 years old and have a stable one-year degree. To be eligible for surgery, the patient must meet the following criteria:
- Myopia : from 5 to 10 degrees, if you have astigmatism, it should reach 4 degrees;
- Farsightedness : Up to 6 degrees, if you have astigmatism, it should be up to 4 degrees.
Only kidney, cornea and bone marrow transplants are required, the latter can be from the patient’s own bone marrow or from a donor. Some plans, such as Amil One (3000, 4000, 5000 and 6000), cover lung, heart, liver and pancreas transplants, but this is a differentiated coverage that the ANS does not require.
11. Complex procedures
The health plan must include the following procedures, without restrictions on use:
- physical recovery;
- preoperative examination;
- monitor patients undergoing transplantation;
- Tube or intravenous nutrition.
12. Bariatric surgery
Bariatric surgery is covered by the health plan as long as the patient:
BMI between 35kg/m² and 50kg/m² in the placement of the gastric band;
The BMI for gastroplasty is greater than 50kg/m².
In addition, the ANS requires health plans to cover redundant skin procedures if the subdivision of the contract provides hospital services.
If your Medicare has outpatient staging, it may cover immunobiological drugs to treat the following conditions:
- Crohn’s disease;
- Ankylosing spondylitis;
- Psoriatic arthritis;
- Rheumatoid arthritis.
14. Infectious diseases
In the case of an infectious disease such as dengue, yellow fever or Zika, beneficiaries are entitled to coverage from diagnosis to treatment. Simple or more complex tests can be done, as long as your coverage has a hospital breakdown, hospital stays and all medications needed for this period are covered.
Keep an eye on your health plan benefits to get the most out of this service. However, if you signed up before 1999, your coverage may vary, check with your carrier.