What is the loss ratio of a Brazilian health plan?
The loss ratio, or sinistralidade, is the share of a health plan's premium revenue that goes to paying for its members' care. ANS (Agência Nacional de Saúde Suplementar), Brazil's National Agency for Supplementary Health and the regulator of private health plans, defines it as the “percentage of care revenue used to pay care expenses” [1].
The term comes from insurance: each paid claim is a sinistro (or event). It is one of the key gauges of a health plan's (operadora's) results, as the Supplementary health pillar guide shows.
For a hospital, the starting point is simple: much of a health plan's care expense is hospital revenue. When a health plan talks about controlling its loss ratio, it is also talking about what it pays its network.
How the loss ratio is calculated
The basic formula divides care expenses by premium revenue (contraprestações) and multiplies by 100 [1]. Premium revenue is the monthly fees paid by members and employers.
Illustrative example: a health plan that collects BRL 100 million in premiums and recognizes BRL 82 million in care expenses has a loss ratio of 82%. The remaining 18% covers administrative and sales expenses, taxes and margin.
| Element | What goes in | Where it appears |
|---|---|---|
| Numerator: care expenses (claims, events) | Payments to providers, reimbursements, claims still to be settled | Financial statements filed with ANS |
| Denominator: premium revenue (contraprestações) | Monthly fees from individual and group plans | Financial statements filed with ANS |
| Adjustments that change the number | Technical reserves and ceded co-responsibility (care risk passed on to another health plan) | Depend on the publisher's methodology |
| Result | Share of premium revenue used for care | ANS, Anahp Observatory Reports, health plan reports |
The adjustment is the most confusing part. In the June 2026 Anahp Observatory Report, the first quarter of 2026 shows BRL 63.68 billion in claims and BRL 86.07 billion in premiums [4]. Simple division gives about 74%, but the published loss ratio is 80.8%: according to the report's note, this ratio follows the ANS criterion and includes the effect of technical reserves and ceded co-responsibility [4]. In the same edition, a measure that excludes technical reserves, calculated for 578 health plans, reaches 76.55% [4].
So before comparing two loss ratios, check three things: the period (year, quarter or year-to-date), the set of health plans and how reserves are treated.
Brazil's health plan loss ratio, 2014 to 2026
The loss ratio of Brazil's medical-hospital health plans stayed between 82.9% and 84.5% from 2014 to 2019, plunged during the pandemic, rose to 89.2% in 2022 and has fallen since [2][3].
See the numbers as a table
| Year | Loss ratio |
|---|---|
| 2014 | 83.1% |
| 2015 | 83.0% |
| 2016 | 83.7% |
| 2017 | 82.9% |
| 2018 | 83.2% |
| 2019 | 84.5% |
| 2020 | 77.7% |
| 2021 | 87.1% |
| 2022 | 89.2% |
| 2023 | 86.8% |
| 2024 | 83.4% |
| 2025 | 81.5% |
| Year | Loss ratio | Year | Loss ratio |
|---|---|---|---|
| 2014 | 83.1% | 2020 | 77.7% |
| 2015 | 83.0% | 2021 | 87.1% |
| 2016 | 83.7% | 2022 | 89.2% |
| 2017 | 82.9% | 2023 | 86.8% |
| 2018 | 83.2% | 2024 | 83.4% |
| 2019 | 84.5% | 2025 | 81.5% |
| Q1 2026 | 80.8% |
Source: ANS open data processed by Arquitetos da Saúde, in the Anahp Observatory Reports of December 2024 (2014–2023 series), March 2026 (2024 and 2025) and June 2026 (first quarter of 2026) [2][3][4]. The series excludes dental-only health plans and benefit administrators. Years run through the fourth quarter; 2026 covers only the first quarter. Figures may differ from those released by ANS. Anahp (Associação Nacional de Hospitais Privados) is Brazil's National Association of Private Hospitals.
Two takeaways matter for hospitals:
- 2020 was an outlier. In the first year of the pandemic, the loss ratio fell to 77.7% and then jumped to 87.1% in 2021 [2].
- The recovery came from revenue. From 2023 to 2025, premium revenue grew from BRL 272.81 billion to BRL 336.66 billion, while care expenses went from BRL 236.56 billion to BRL 272.13 billion [3]. Revenue grew faster, and net income rose from BRL 1.93 billion to BRL 23.43 billion [3]. Full figures are on the Industry data page.
The ANS figure and the Anahp figure are not the same
ANS publishes its own calculation, which may differ from the Anahp series. On September 16, 2026, ANS reported a loss ratio of 81.9% for medical-hospital health plans in the first half of 2026, 0.8 percentage points above the same period of 2025 [1]. The agency attributed the result partly to unusual factors, such as a voluntary technical reserve set up by a large health plan [1].
Both start from the data health plans file with ANS, but they differ in scope and adjustments. For full-year 2025, the Anahp series shows 81.5% [3].
| Source | Latest period | Loss ratio | Best use |
|---|---|---|---|
| ANS (Painel Econômico-Financeiro da Saúde Suplementar, the supplementary health financial dashboard) | First half of 2026 | 81.9% [1] | Official industry figure; quarterly series since 2018 |
| Anahp Observatory Report (ANS data processed by Arquitetos da Saúde) | First quarter of 2026 | 80.8% [4] | Long series, by size and type of health plan, next to Anahp hospital indicators |
Rule of thumb: always cite the source and period with the percentage, and do not mix the two series in the same chart.
Is sinistralidade the same as the US medical loss ratio?
No. Both measure the share of premiums spent on care, but they work differently. Under the Affordable Care Act, US insurers must spend at least 80% or 85% of premium dollars on clinical services and quality improvement, and must pay rebates to customers when they miss that standard [7].
In Brazil, sinistralidade is a performance indicator, not a legal floor: there is no rebate rule tied to it. The formulas also differ, since the US MLR counts quality improvement spending and the Brazilian ratio is built from the accounting data health plans file with ANS. Comparing a Brazilian loss ratio with a US MLR is useful as a reference, but not as a direct benchmark.
Why does the loss ratio vary across health plans?
The average hides big differences by type and size of health plan. In 2025, in an Anahp measure that excludes technical reserves, self-insured employer plans (autogestões) reached 91.72%, medical cooperatives 80.31%, insurers 78.32% and group medicine companies 75.09% [3]. By size, large health plans reached 78.75%, mid-sized ones 81.83% and small ones 81.52% [3].
Health plan types also pay their networks in different ways: in 2025, bundled payments accounted for 25.3% of insurers' care expenses and 18.0% of group medicine companies' [3]. The Hospital payment models guide explains these formats.
For a hospital, knowing each health plan's type and size helps interpret the number it brings to the table: the industry average says little about a specific health plan.
A falling loss ratio did not mean relief for hospitals
The years of a falling loss ratio coincided with worse indicators on the hospital side. At Anahp member hospitals, the initial denial rate was 15.93% in 2025, and the average collection period rose from 69.91 days in 2024 to 77.35 days in 2025 [3]. These hospitals' EBITDA margin was 11.05% in 2025 and 9.45% in the first quarter of 2026 [3][4].
The data do not prove cause and effect, but they show that health plans' improvement did not reach the network as lower denial or faster payment. Anahp itself notes that, beyond accepted denial, hospitals accept discounts in settlements in order to get paid [3].
In practice, four points of the relationship with each health plan are worth watching:
| Point | What to watch | What the hospital can do |
|---|---|---|
| Contract fee adjustment | A low or zero increase proposal justified by the loss ratio | Cite the RN 503/2022 ban and negotiate on costs and quality |
| Audit and denial | Changes in the denial rate and in documentation requests | Track the denial rate by health plan and review claims before submission |
| Payment period | Time between claim submission and payment | Track the contractual deadline and formally pursue late payments |
| Payment model | Proposals for bundles, fixed fees or the plan's own network | Calculate the real cost before accepting a fixed price |
The denial rate and collection period by health plan are covered in the Denial rate and Late payment by health plans guides.
What RN 503/2022 says about fee adjustments and the loss ratio
RN 503/2022 (ANS Normative Resolution 503/2022) bars contracts between health plans and providers from setting “forms of adjustment conditioned on the health plan's loss ratio” (art. 5, VII) [5]. The next item bars forms of adjustment that keep or reduce the nominal value of the contracted service (art. 5, VIII) [5].
The two bans work together: a hospital's fee adjustment cannot depend on an indicator of the health plan's results, nor be zero or negative by contract rule.
The resolution also sets what the contract must say on the subject:
- Clear criteria. Fees and the criteria, form and frequency of adjustment must be in the written contract (art. 4, II) [5], and payment and criteria must be “expressed clearly and objectively” (art. 12) [5].
- Annual adjustment. The adjustment applies every year, on the contract anniversary (art. 12, § 2) [5].
- Free negotiation with a deadline. If the contract provides for free negotiation, the period is 90 calendar days, with no extension (art. 12, § 3) [5]. Law 9,656/1998 provides that, without agreement within 90 days counted from January 1, the index set by ANS applies (art. 17-A) [6].
The loss ratio may come up in the conversation, but not as a clause that blocks or conditions the adjustment. The full contract checklist is in the RN 503/2022 guide, and the negotiation calendar in the Fee increase negotiation with health plans guide.
One caveat: Public Consultation 170/2026 (Consulta Pública 170/2026), which consolidates RN 503/2022 and RN 512/2022, closed on July 3, 2026, and the final rule had not been published by October 17. When it comes out, check whether the ban was kept.
What we see in operations
At Accrua, we do not treat a health plan's medical loss ratio as a ready-made explanation for denials or late payment. We look at how each health plan behaves in the hospital's claims history: denials by reason, appeals upheld and time from receipt to payment, by plan and claim type. That is what shows where the pressure actually reaches the claim.
The same history helps in negotiation. When the loss ratio comes up as an argument in a rate adjustment, the hospital can answer with data from its own relationship with that health plan, alongside what the contract says about adjustments and what RN 503/2022 allows or prohibits. Revisiting a clause is the hospital's decision; our role is to show the clause and its effect on claims.
The same reading by health plan, plan and claim type underpins Receita Garantida: Accrua puts the value of eligible production into the hospital's cash on the timeline it needs and takes on the risk of eligible denials.
Where to start
- Build a profile of each health plan: type, size and published loss ratio, with source and period.
- Review the fee adjustment clauses in your contracts and flag any condition tied to the health plan's loss ratio or results.
- Cross the loss ratio with your own indicators: denial rate, collection period and adjustment obtained, by health plan.
- Prepare the negotiation with cost and quality data, not with the health plan's loss ratio.
- Follow the quarterly releases from ANS and the Anahp Observatory Report to update the figures.