Lista da ANS é agora , apenas ‘exemplificativa’, e não a cobertura total que os convênios médicos devem bancar
O governo sancionou nesta quarta-feira (21) a lei que obriga planos de saúde a cobrirem tratamentos e procedimentos fora do rol da Agência Nacional da Saúde (ANS).
O projeto passou no mês passado por votações na Câmara e no Congresso, e aguardava sanção presidencial.
A nova lei derruba o entendimento do Superior Tribunal de Justiça (STJ), que decidiu, em junho, que a lista de procedimentos da ANS era “taxativa” — ou seja, que os planos só precisariam cobrir o que está na lista, que atualmente é composta por 3.368 itens.
A cobertura exemplificativa significa que os planos de saúde não se limitam a cobrir apenas o que está na lista da ANS, pois ela serve exatamente como exemplo de tratamento básicos.
Já a cobertura taxativa entende que o que não está nesta lista preliminar da ANS não precisa ter cobertura das operadoras. Ela depende, no entanto, do tipo de cobertura contratada: ambulatorial, internação, parto e odontológico, além das combinações entre esses tipos.
A lista da ANS era considerada exemplificativa pela maior parte do Judiciário. Isso significa que pacientes que tivessem negados procedimentos, exames, cirurgias e medicamentos que não constassem na lista poderiam recorrer à Justiça e conseguir essa cobertura. Isso porque o rol era considerado o mínimo que o plano deveria oferecer.
Os planos, assim, deveriam cobrir outros tratamentos que não estão no rol, mas que tivessem sido prescritos pelo médico, tivessem justificativa e não fossem experimentais.
Com a nova decisão, as operadoras de planos podem ser obrigadas a autorizar tratamentos ou procedimentos que estejam fora do rol da agência.
Para isso, no entanto, o tratamento ou medicação devem atender a um dos seguintes critérios:
- ter eficácia comprovada;
- ter autorização da Anvisa;
- ter recomendação da Conitec (Comissão Nacional de Incorporação de Tecnologia no SUS); ou
- ter recomendação de pelo menos um órgão de avaliação de tecnologias em saúde que tenha renome internacional e que tenha aprovado o tratamento para seus cidadãos.
Entre as entidades de renome citadas no projeto estão: Food and Drug Administration, União Europeia da Saúde, Scottish Medicines Consortium (SMC); National Institute for Health and Care Excellence (Nice); Canada’s Drug and Health Technology Assessment (CADTH); Pharmaceutical benefits scheme (PBS); e Medical Services Advisory Committee (MSAC).
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