Health plan: How to choose yours in 2021
Choosing an individual or family health plan is no easy task. It means looking for good medical and hospital coverage, which meets individual needs, but which fits within the budget.
a public health system, SUS (Unified Health System), which offers universal and free care. However, problems such as overcrowding, long queues and poor conditions at service points in some places lead some to seek a private solution.
And for that, it is essential to research and compare several different plans before hiring yours. In this article, we will show you the aspects that need to be considered, in order to help you understand the dynamics of this market and make the best choice for your profile.
First, the most important
- Health insurance is a service offered by insurance companies and health operators that involves medical, outpatient and hospital assistance. It is a paid service, unlike the public health system, which is free.
- After contracting the plan, you must make monthly payments for the entire term of the service. Price adjustments are made once a year. There is also a price change as the age group changes – elderly people, for example, usually pay more.
- Some of the aspects that must be observed when hiring a health plan are: type of care; geographical coverage; network of doctors, clinics and hospitals available; additional services; and price. An objective analysis of these criteria will help you to make a choice that best suits your needs.
The best health plans: Our recommendations
A good way to start looking for the health plan that best suits your profile is to search for the largest carriers. Typically, the largest companies offer more plan options and have a broader service network. As there are large operators that serve all states, we have separated for you the largest ones, which offer individual health plans.
- The operator with the largest number of beneficiaries
- The reference plan in preventive medicine
Hiring guide: What you need to know about health plans
Nowadays, there are basically two types of health plans: collective (corporate and subscription) and individual. who do not have access to a collective plan – and there are many! -, the individual health plan is the only option. The plan can be purchased only for an individual or for family members.
The cost of a health plan, however, can be significant. According to the Credit Protection Service. National Confederation of Shopkeepers (CNDL) last year, pays an average of R $ 440 in monthly health insurance, that is, in a family of four people, spending on this type of service exceeds R $ 1,700 per month. ( 1 )
Below are the main differences between collective and individual plans and how to contract a plan for you and your family.
Individual or collective health plan: What are the differences?
Most collective health plans are in the business category , where the company you work for contracts with an insurance company or insurance company and offers the product to its employees.
The collective health plan can be corporate or made through a union.
This plan may have the full cost paid by the company, or it may have the amount divided between the employer and the employee. It is a great option for those who have a permanent job, which unfortunately is not the situation.
There is also the collective plan for adhesion , in which the individual member of a union, class entity or some legally recognized association adheres to the health plan contracted by that entity for its associates.
The operation is similar to the corporate collective: it requires a link with the entity that contracts the product, has coverage defined according to the contract and list of procedures, there may be unilateral termination by the service provider and the value is negotiated contractually.
Individual or family plans are those contracted by an individual, particularly, without any connection with any business organization.
See the main differences between the collective and individual plans in the table below:
How to make a health plan?
You can contract an individual health plan directly with the health care provider or through an authorized agent.
The contract can be directly with the operator or authorized agent.
The plan can be purchased only for one person or for all family members.
Despite the large number without access to a collective plan, the portion that hires an individual health plan is still small, largely because of the cost. there are 47 million health plan beneficiaries, according to ANS (data from July 2019).
Of these, almost 38 million have collective plans, which corresponds to 80% of the total. Only nine million are individual or family contracts. If you want to join the group of individuals with individual health plans and the family, a lot of research is needed.
The first step, as mentioned, is to contact an authorized operator or agent.
Is it worth making a plan for the whole family?
If you have a family, the most interesting thing is to look for a plan that suits all family members at once. This is because it tends to be more economical to hire a family plan than an individual plan for each family member.
In this type of plan, there is usually a holder, who is responsible for the obligations of the contract, and their dependents (children, spouses or partners).
Some operators may limit the number of dependents or the time of inclusion of the family in the plan. Be aware of these details before hiring yours.
Who regulates health plans?
The health insurance sector is regulated by the National Supplementary Health Agency (ANS). This government agency authorizes the operations of operators, registers the products sold and monitors and inspects their activities.
Despite regulating healthcare operators, ANS does not regulate agents authorized to market plans. Health insurance brokers, who can represent these companies in contact with consumers, are regulated by another federal government agency, the Superintendency of Private Insurance (SUSEP).
On the ANS website, it is possible to find various information about plans, companies and the market in general.
What is a health plan shortage?
One aspect that always worries those looking for a health plan is the grace period, that is, the time that one must wait to use the services and coverage contracted.
The maximum grace periods are fixed by law.
The grace period may vary from one product to the other, but be aware that the maximum terms are fixed by law (see below).
That is, your operator may have other deadlines, but never exceeding the legal limit. There are also operators that require prior authorization to perform procedures, such as some exams and hospitalizations.
This must be observed when contracting the plan.
Criteria: What to consider when hiring an individual or family health plan
The market today has a multitude of companies providing individual health plans.
As large insurance companies linked to banks left this market to concentrate on business plans – where there is scale and the rules for price adjustments are more flexible, varying from direct negotiation with the business group -, the companies that currently provide services are in many minor cases, dedicated exclusively to this.
Many of these companies are also more regional, which means that they may have a good service network in one location, but not necessarily in others.
There are also a multitude of different types of plans, which vary in relation to the type of service offered, location of service, network size, type of charge, etc.
Below, we will list all the criteria that you must take into account when hiring an individual or family health plan.
- Type of service
- Geographical coverage
- Accredited network
- Hospital Accommodation
- Additional coverage
- Plan evaluation
So that you have no doubts when choosing your health plan, we will detail each of these criteria:
Type of service
The first thing to ask yourself before starting the search for the ideal health plan is what type of care is desired. There are several types of assistance, and, of course, the more complete the assistance, the more expensive the plan.
ANS divides the types of care into five main categories: outpatient; hospital without and with obstetrics; ambulatory + hospital without and with obstetrics; and reference.
The choice will depend on your needs. For a family that intends to have children, midwifery care tends to be the most suitable, since the expenses with prenatal care and childbirth are high and there will be a need to change plans after the news of the pregnancy.
Those who want a cheaper plan may prefer to opt for a hospital-only service, leaving consultations and exams for the public network, for example.
But if there are already people in the family with illnesses that require constant monitoring, it is important to consider the possibility of hiring a health plan that includes exams and routine consultations, in addition to hospitalization.
Another important aspect to consider when choosing a health plan, which can have a great influence on the monthly amount to be paid, is the geographical scope of the service.
According to the ANS, the main categories are: National Plan, with coverage throughout the territory; State Group Plan, which provides assistance in a pre-defined number of states; State Plan, which serves a single state; Municipality Group Plan, which offers services in a number of municipalities; and Municipal Plan, which serves a single municipality. However, there are also plans that offer international coverage.
For those who travel a lot, a national plan may be more appropriate.
To decide how comprehensive your plan needs to be, you need to ask yourself where you plan to use the services. If you believe that you will use the health plan only where you live and if you do not often travel, a good option may be a regional plan (municipal or state), which naturally costs less than a national one.
If you travel a lot or want to guarantee coverage even in the few times you are away from home, a national or even an international plan may be right for you.
Knowing the accredited network will allow you to assess whether the quality and location of the services offered by the plan are adequate for what you want. The accredited network is the network of doctors, clinics, outpatient clinics and hospitals that you can use if you hire the plan.
It is good to assess, for example, whether the plan has doctors, hospitals and laboratories close to your home or workplace, offering easy access. If you already use services from certain doctors or hospitals, the ideal is to know if they are part of the network of the plan you want to hire.
Some operators have their own network, others operate only with professionals and accredited service points.
There are also operators that use a mixed structure.
All operators are obliged to disclose and keep updated the provider networks on their websites.
Sometimes the plan features a large number of service providers to attract consumer attention. But what matters most here is whether the service will be done in quality and reference locations and by experienced professionals.
Some health plans also have a free choice contract. This means that you can use services from professionals and hospitals not belonging to the accredited network and then request a refund from the plan.
The reimbursement can be full, which is generally only valid for plans aimed at customers with high purchasing power, or partial, limited to a ceiling defined by the operator.
That way, if your doctor is not in the accredited network of the plan you want, the plan may still be right for you if he offers reimbursement for payments for services used outside the network.
The most traditional health insurance payment model is a fixed monthly amount: whether or not you use the plan’s services, the monthly fee will be the same. But there are also other ways.
Some health plans charge a lower monthly fee, but add to the monthly fee an additional amount (or co-participation) to be paid for each service, consultation or exam performed during that period.
For seniors, a plan without co-participation is generally more worthwhile.
Thus, if the person has excellent health conditions and only uses the plan eventually, the payment model with co-participation may be a more economical option.
On the other hand, if the person is older or has a chronic illness, such as diabetes or hypertension, or a health problem that requires constant treatment, it is likely that the cost of the monthly fee plus the services provided in the month is higher . In these cases, the most advantageous may be the monthly fee without co-participation.
When the health plan includes coverage for hospitalization, it can be done in the ward or in a private room. And that influences the price charged.
- Infirmary . The patient is hospitalized in the same environment as other patients and usually has more restricted hours for visits. In this type of accommodation, the patient is usually unable to keep a companion by his side. On the other hand, the price of health insurance tends to be lower.
- Private room . The patient will have a separate apartment, a more flexible time for visits and the possibility of being accompanied or not by a relative, according to what is established in the plan contract regarding a companion. Because of this convenience, the price is higher than in the infirmary plan.
All health plans are required to offer mandatory minimum coverage. For each type of service, there is a list of procedures with mandatory coverage described in the List of Procedures and Events in Health, edited by ANS and reviewed every two years.
In addition to this list, operators can provide additional coverage, such as pharmaceutical assistance, home care and hospitalization and home rescue, for example, which must be specified in the contract.
Remember that these additional coverages may cost you.
Regardless of the type of service, the scope or the accredited network you have chosen, it is important to know if the service you will receive will be of quality.
In addition to researching whether the registration number of the operator and the plan in question is regular on the ANS website, you should research some performance indicators and the opinion of other customers about the company.
For example, ANS assigns a score to health plan operators based on an annual assessment of companies’ performance.
It is important to research the operator’s record and performance indicators.
This is the Supplementary Health Performance Index, the IDSS, which takes into account the quality of health care provided to beneficiaries, the guarantee of access to assistance networks, the sustainability of the operator (including its economic and financial balance) and the process management and regulation, which is the fulfillment of technical and registration obligations of those of ANS. The score ranges from 0 to 1 point.
See below the IDSS of the largest individual health plan operators. As a basis for comparison, the sector’s IDSS, considered the average of the operators, was 0.7295 in the last survey released by ANS, for the base year 2017.
ANS also has the General Complaints Index, the IGR, which is a kind of thermometer of the behavior of the operators in the sector in addressing the problems pointed out by the beneficiaries. The index includes the average number of beneficiary complaints received in the previous three months and classified up to the date of data extraction.
In the list of large carriers with the most complaints per beneficiary in August 2019, Amil appears in 12th place, Notre Dame, in 34th place and Hapvida, in 43th place.
The Reclame Aqui website offers other indicators on the operators’ performance. You can find, for example, the percentage of complaints resolved in Claim Here in a given period. You can also consult the operator’s average score (from 0 to 10), according to the evaluation of consumers.
Althoughhas a public health system, problems related to the quality of the services provided make many prefer to seek an alternative form of medical assistance. Health plans are packages of services sold by health operators that involve medical, outpatient and hospital care, depending on the contract.
To choose the ideal plan, it is necessary to do a good research.
The market today has a multitude of companies providing individual health plans, one in which an individual can contract directly with the operator or through an authorized agent.
There are also numerous different types of plans, for all budgets. To choose the ideal plan for you and your family, it is necessary to do a good research and compare the various products on the market.
Some of the criteria that must be observed when hiring a health plan are: type of care; geographical coverage; network of doctors, clinics and hospitals available; additional services; and price. It is also important to observe the operators’ performance history. An objective analysis of these criteria is essential to make the right choice.