On September 1, the Short Isapre Law came into force. It involves a series of changes to health plans and provides a mechanism for them to return excess charges. It comes in response to a Supreme Court ruling in 2022, which ordered ISAPREs to return more than US$1.2 billion in overcharges to their affiliates. This law seeks to comply with the ruling without causing the collapse of the private healthcare system in Chile.
The new regulation, designed with fairness in mind, introduces the Single Factor Table (TFU) from Circular IF 343 to all health plans that have not yet adopted it. This table, uniform for all contracts regardless of gender, will not lead to price increases but will either reduce or maintain current contributions. This eliminates past practices that allowed ISAPRES to offer cheaper plans, resulting in surpluses. ISAPRES will be required to enhance their plans if the plan’s value remains below 7%, ensuring a fair deal for all.
The surpluses accumulated by the affiliate before the entry into force of the law, which are generated when the cost of the health plan is less than 7% of the mandatory contribution and are accumulated in an individual account to pay medical benefits or contributions in the event of unemployment, are freely available and do not have an expiration date. Although the plans will be adjusted to 7%, this will be accompanied by new benefits or alternative plans in line with the latest price. In this way, the surpluses generated before the law are maintained, but the conditions for developing new ones, which cannot exceed 5%, are significantly reduced. The measure aims to ensure that contributions are allocated more efficiently to health coverage and eliminates the accumulation of surpluses that are not clearly managed.
The ISAPRES has to mail a proposal that makes good use of the affiliate’s difference in his favor. Depending on the magnitude of each person’s surplus, they could offer to change the plan, offer additional complements to the current plan, or improve the plan’s coverage, among other things.
Plan for payment of overcharges
ISAPRES are required to submit a Payment and Adjustment Plan (PPA) to the Superintendence of Health, which is currently under review. This plan, which includes the amounts to be reimbursed to some 700,000 users and the method of payments, differentiated by the affiliate’s age, is a transparent process. The details of the reimbursement and the payment must be disclosed by November 30, 2024, ensuring that all parties are well-informed and involved in the process.
The regulator indicates some of the reasons why contributors can complain to the institution:
- Because they did not receive the letter, the TFU and the 7% adjustment were applied to them.
- If there is an error in the application of the TFU,
- Because they had a table other than the TFU, their ISAPRE did not incorporate the TFU.
- Errors in the calculation of the 7% adjustment.
- To grant additional irrelevant benefits for the contributor and their dependents.
- If the ISAPRE does not offer additional benefits or a plan close to its 7%, having adjusted.
- Because the new plans offered do not adjust to its contribution closer to 7%.
FONASA
The law also introduces the Complementary Coverage Modality (MCC) in Fonasa, offering affiliates a wider range of options to receive care in private centers as an alternative for those migrating from ISAPREs due to their financial crisis. This modality is voluntary and allows users of groups B, C, and D of the public health provider to access a wider range of options to receive medical care in private centers of free choice.
See the law here