ANS changes rules for health plans and presses operators to reduce complaints

From next Tuesday (1st), a new set of rules that promises to change the way Health Plans Operators deal with your customers. Published by National Supplementary Health Agency (ANS), Normative Resolution 623/2024 It imposes stricter standards of care and transparency, with the objective of ensuring that responses to beneficiaries are faster, clear and affordable.

THE new standard It replaces the former RN 395/2016, and arrives at a moment of increasing wear of the sector. With the increase of Complaints against health planswhich today lead consumer complaints rankings, the pressure for firmer regulation also grows.

Among the main news is the definition of objective deadlines for responses of care requests: 5 business days for low complexity procedures and 10 days for high complexity. For non -care demands, the deadline is 7 business days.

The resolution, which was published in December, but will only now come into force in full, also requires operators to provide clear and specific information on the progress of the requests, with traceability.

“They must provide service protocol at the beginning of the request and allow the beneficiary to follow the progress, without generic terms such as ‘In Analysis’,” explains Bruno Marcelos, a lawyer specializing in health law.

Another important point is the formal possibility of the beneficiary to request negative revision directly from the Ombudsman’s Office healthcare operatorwith a comprehensive response and understandable justification.

Lighter rights and shorter way to complain

With the new standard, the consumer gains more objective instruments to demand answers and can trigger the ombudsman in case of negative. “The expectation is that the SAC and the Ombudsman are effectively used to resolve conflicts even before reaching the ANS,” says Marcelos. If this does not occur, the consumer can resort to channels of the regulatory agency itself.

It is worth mentioning that the agency intends to create incentive mechanisms for operators who adjust rapidly and regulatory sanctions for those who fail to comply with complaints. “It is an initial and fundamental pillar for the inspection changes that we want to implement,” says Eliane Medeiros, ANS’s supervisory director.

Complaints continue on the rise

Recently, the Consumer Protection Institute (Idec) has published data showing that health plans led the complaint ranking between associates in 2024. In all, they accounted for 29.10% of complaints. The main causes were:

• abusive adjustments (25.85%);
• Problems with contract and reimbursement (19.49%);
• abusive practices as unilateral cancellation (13.14%);
• coverage negative (13.14%).

This portrait is corroborated by the data of the ANS itself. Between January and May 2025, the agency received thousands of Preliminary Intermediation Notifications (NIP), which are formal complaints made by beneficiaries – in a kind of “administrative mediation” that precedes judicial measures or sanctioning processes.

Notredame Intermediate leads on average complaints (3,027.8), followed by Bradesco Saúde (2,497) and Unimed RJ (2,266). However, only the number of complaints does not tell the whole story.

This is because the RESOLVED INTERMEDIATION RATE (TIR) ​​shows the efficiency of operators to resolve conflicts. Prevent Senior, for example, has a high resolution rate (90.4%) even with relevant volume of complaints. On the other hand, Unimed RJ, with high demand and 73.2%, indicates lower performance in consumer service.

Most protected consumer

Given the new standard, consumers are expected to feature more effective channels and greater predictability in requests made to operators. In addition, ANS gives signs that it aims to hardens supervision, which can create a cycle of service improvement.

“With lighter information and faster answers, consumers are back, and operators are more accurately charged by regulatory organs,” summarizes Marcelos.