Types of hospitalization in health plans: what the ANS requires

When signing up for a health plan, hospitalization coverage is one of plan members’ biggest concerns. After all, no one wants to be caught off guard by a refusal of care at a critical moment.

In Brazil, the types of hospitalization a plan must cover vary according to the contract and the rules of the ANS (Brazil’s National Supplementary Health Agency). In this article, learn about the types of hospitalization, the coverage rules, waiting periods and the rights the law guarantees.

What are the types of plans and how do they affect hospitalization?

Health plans are classified by care segmentation, which determines the breadth of coverage the payer offers the plan member.

1. Outpatient plan

This plan focuses on outpatient care and does not include hospitalization in its basic scope.

• Coverage: medical appointments, lab and imaging tests and procedures that do not require a stay of more than 12 hours.

• Critical limitation: in urgent cases, the plan covers only the first 12 hours in the emergency room. If hospitalization or surgery is needed, financial responsibility passes to the patient, or the patient must be transferred to SUS (Brazil’s public health system), with transportation guaranteed by the payer if the patient is clinically stable.

2. Inpatient plan (without obstetrics)

Guarantees full hospitalization for clinical or surgical treatment.

• What is included: daily rates, operating room fees, tests and medications during the hospital stay, plus ICU with no limit on time or amount.

• Highlight: covers kidney, cornea and bone marrow transplants, as well as chemotherapy and radiotherapy sessions started during the hospital stay.

3. Inpatient plan with obstetrics

Offers all the benefits of the standard inpatient plan, adding full maternity coverage.

• Benefits: prenatal care, delivery care and immediate postpartum care.

• Protection for the baby: guarantees care for the newborn in the first 30 days of life. If the baby is enrolled in the plan as a dependent during this period, the baby fully benefits from the waiting periods already served by the primary holder (usually the mother).

4. Reference plan

This is the standard model established by Law No. 9,656/98. It is the most complete in terms of legal certainty, because it combines outpatient and inpatient coverage (with obstetrics) in a single product, with ward accommodation. Its main advantage is the guarantee of full emergency care after just 24 hours of contract.

Post-hospital home hospitalization today

Currently, the ANS does not require all plans to cover home hospitalization after hospital discharge. However, there is a bill moving through Congress (Bill No. 2,708/2019) that could make this coverage mandatory for plans that already include hospitalization, as long as there is a medical indication and the agreement of the plan member or their guardian.

Waiting periods that apply to hospitalization

Law No. 9,656/98 sets maximum waiting periods for the main hospitalization events, according to legal provisions:

• Urgent and emergency care: coverage 24 hours after signing up.

• Elective hospitalizations (surgeries, scheduled treatments): waiting period of up to 180 days.

• Full-term delivery: up to 300 days.

• Pre-existing diseases or conditions (CPT): up to 24 months, with restrictions if the member does not opt for the premium surcharge.

It is essential to check the specific periods in your contract, as they may vary according to the type of plan (individual, family or group).

Hospital accommodation and coverage priorities

Hospital accommodation (ward or private room) depends on the contract signed between the plan member and the payer. If no bed is available in the contracted accommodation, the hospital must admit the patient to a higher-level accommodation at no additional cost to the plan member.

• Ward: shared room;

• Single room (private room): private room with a bathroom.

Companion rights during hospitalization

Under the law:

• Children and adolescents (under 18) are entitled to a companion paid for by the plan during the hospital stay.

• Older adults aged 60 and over are also entitled, under the Statute of Older Persons and current regulations.

• People with disabilities and pregnant women may be entitled when there is a medical indication (including meals and accommodation for the companion).

Conclusion

The types of hospitalization in Brazilian health plans are defined mainly by the contracted care segmentation and by ANS rules. Knowing whether your plan is outpatient, inpatient (with or without obstetrics) or reference is crucial to securing your rights when you need them.

Knowing these contractual and legal details helps avoid unexpected costs and ensures that you can demand from the payer the coverage you are owed under the law.