Dentre mais de 170 sugestões enviadas à ANS (Agência Nacional de Saúde Suplementar), apenas 15 foram selecionadas para incluírem a proposta de revisão do rol de cobertura obrigatória dos planos de saúde. Para a advogada e pesquisadora do Idec Ana Carolina Navarrete, a recomendação da agência foi insuficiente.
O novo rol, que entra em vigor em janeiro de 2018, irá definir uma lista de consultas, exames e tratamentos que as operadoras são obrigados a oferecer, conforme cada tipo de plano de saúde – ambulatorial, hospitalar com ou sem obstetrícia, referência ou odontológico.
Segundo a ANS, o objetivo de uma atualização a cada dois anos é garantir o acesso ao diagnóstico, tratamento e acompanhamento das doenças à medida que a medicina se desenvolve.
A consulta pública previa a incorporação de uma lista de novos procedimentos, como a inclusão de medicamentos orais para o tratamento de cânceres, endoscopia para o tratamento de refluxo em crianças, entre outros. Além disso, era possível sugerir a alteração das regras da resolução anterior sobre o rol, a RN 387/2015.
Em sua contribuição à consulta pública, o Idec defendeu a inclusão no rol de todos os transplantes já oferecidos pela rede pública, como transplante de coração, pulmão, pâncreas e fígado, reforçando seus posicionamentos anteriores.
“A revisão do rol deve acompanhar também a incorporação de procedimentos pelo Sistema Único de Saúde. Cabe à ANS a definição da amplitude das coberturas, inclusive de transplantes e de procedimentos de alta complexidade”, afirma Ana Carolina Navarrete.
Mamografia a partir dos 35 anos
Outra sugestão enviada pelo Idec foi a inclusão de exames de mamografia para pacientes a partir dos 35 anos. “O Ministério da Saúde e o INCA [Instituto Nacional de Câncer] indicam que o procedimento deve ser realizado a partir dessa idade para que se possa prevenir ou tratar a doença ainda em seu início”, comenta a advogada.
Segundo o rol existente hoje, este exame só tem cobertura obrigatória para mulheres na faixa etária entre 40 e 69 anos.
Rol de cobertura obrigatória
O rol de procedimentos da ANS, muitas vezes, é usado pelas operadoras para negar procedimentos. Para o Idec, como o objeto do contrato da operadora é a assistência integral à saúde, e não a parte dela, o rol não deve ser entendido como taxativo, mas sim exemplificativo: ou seja, procedimentos que não constam nele também devem ser cobertos, prevalecendo a prescrição médica.
“A Lei de Planos de Saúde garante aos consumidores de planos de saúde a cobertura de todas as doenças listadas pela OMS [Organização Mundial da Saúde]. Assim sendo, caso um procedimento seja negado pela operadora, o usuário pode recorrer à justiça para garantir o direito à cobertura”, conclui Navarrete.
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