The prioritized application of the mandatory procedures list in private healthcare system (pre-print)

Abstract

In this preliminary version, which summarizes part of my research hypotheses, I argue that the best interpretation for the coverage limits in health plans, even after the enactment of Law No. 14.454/2022, is the one that recognizes the existence of a priority application of ANS regulation. The possibility of prescribing unregulated treatment is exceptional in the system and presupposes simultaneously: (1) the insufficiency of regulation for the treatment of the pathology; and (2) scientific evidence of effectiveness.

I also present a brief summary of the argument I defended in my doctoral thesis on the coverage limits of health plans, a thesis developed before the modifications made to the legislation. At the time, I stated that the list of coverage was, in principle, exhaustive but allowed for expansion when the costs of the unregulated procedure reached the costs of the equivalent regulated procedure.

It is possible to affirm, based on the comparison between the two arguments, that the system previously found its operational limit in the concept of cost. Now, with the new legislation, the functioning of the contract revolves around the concept of effectiveness.