Resolution of the Superintendency of Health Services – No. 3934/2024
The Health Law – Life Sciences Department Report | Resolution of the Superintendency of Health Services – No. 3934/2024
On October 25 of this year, Resolution No. 3934/2024 (the “Resolution”) of the Superintendency of Health Services (the “SSS”) was published in the Official Gazette , establishing, among other matters, that under closed health plans, coverage of practices and medications by Health Insurance Agents will only be provided if prescriptions are made by physicians listed in the corresponding Health Insurance Agent’s provider network.
As noted in the Resolution’s preamble, entities covered under Art. 1 of Law 23,660 — as amended by Decree 70/2023 — offer beneficiaries different types of health plans, which are categorized as open or closed.
While beneficiaries in open plans may choose to receive coverage from either in-network or out-of-network providers, closed plans require beneficiaries to seek care exclusively from providers listed in the network.
Health Insurance Agents must submit their provider lists to the SSS, indicating the type of health plan they apply to, to ensure transparency and operational validity.
The Resolution’s preamble also highlights the importance of the SSS having precise and accurate information about the medical professionals authorized to prescribe practices and medications covered under closed plans. It emphasizes that such verification is essential to authorize the financial support or reimbursement requested—whether through administrative or judicial channels.
The Resolution’s preamble explicitly expresses the SSS’s concern about the risk of financial strain on Health Insurance Agents due to coverage for practices or medications not included in their health plans, noting that coverage for such practices or medications is often mandated by judicial orders.
For this reason, it is held that restricting the prescription of practices and medications to physicians included in the provider lists for closed health plans would mitigate financial risks and prevent endangering the continuity of healthcare services.
Within this context, the SSS has established, first, that Health Insurance Agents must accompany each plan offered with a list of providers detailing the professionals, medical centers, and authorized suppliers under that plan, clearly indicating whether the plan is open or closed, along with conditions of access, coverage, and specific characteristics governing beneficiary care.
Secondly, for closed health plans, it states that medical coverage will only be granted for prescriptions issued by physicians included in the Health Insurance Agent’s network list.
Additionally, oversight and monitoring are foreseen to verify compliance with the Annex of the Guide to Good Practices for the Efficient Compliance with Judicial Mandates from the Ministry of Health, as established in Resolution 4912/24.
It is also clarified that both prescriptions by network physicians and compliance with the provisions of the Annex to Resolution 4912/2024 are: (i) mandatory for any request for coverage, subsidy, or reimbursement of medical practices and medications, including those submitted through administrative or judicial channels; (ii) required for Health Insurance Agents to submit to the SSS for analysis the expenses associated with a medical practice and/or medication.
The Resolution has come into effect as of today.
Best regards,