Is the rate adjustment mandatory?
Yes. Since Law 13,003/2014 added article 17-A to Law 9,656/1998 (Lei dos Planos de Saúde, Brazil's Health Plans Act), the relationship between a health plan (operadora, the company that runs the plan) and a provider requires a written contract. Mandatory clauses include prices, adjustment criteria, form and frequency, and billing and payment terms (§ 2, II) [1]. Paragraph 3 makes the adjustment annual, within a non-extendable 90 days from the start of each calendar year; § 4 says that after that period the Agência Nacional de Saúde Suplementar (ANS, Brazil's private health insurance regulator) sets the index “where applicable” [1].
Two ANS rules regulate this. RN 503/2022 (Resolução Normativa, normative resolution) covers written contracts; RN 512/2022 defines the index used when negotiation fails [2][3]. Market context is in the guide Brazilian private healthcare, and mandatory contract clauses are in the guide RN 503/2022: what the payer contract must say. This guide covers only the adjustment.
What RN 503/2022 says about adjustments
Article 12 of RN 503/2022 sets the rules [2]:
- Quality and performance. Pricing and adjustment criteria must consider care quality and performance attributes previously discussed and accepted by both parties (§ 1).
- Contract anniversary. The adjustment applies annually on the anniversary of the written contract (§ 2).
- Free negotiation with a deadline. The contract may provide for free negotiation; the negotiation period is 90 calendar days, non-extendable, from January 1 each year (§ 3).
The rule also bans adjustments conditioned on the health plan's loss ratio (sinistralidade) and adjustments that keep or reduce the nominal price of the contracted service [2][4].
When does the ANS index apply?
RN 512/2022 sets the ANS index as the IPCA (Índice Nacional de Preços ao Consumidor Amplo) (art. 3) and applies it only when both conditions are met (art. 4) [3]:
- the written contract provides free negotiation as the only adjustment method; and
- the parties did not reach agreement by the end of the 90-day period.
If the contract has any other method besides free negotiation (a fallback index, a percentage, a formula), the contract prevails, even without agreement [4]. Without a written contract, the ANS index does not apply (art. 6) [3].
When it applies, the index is the IPCA accumulated over the 12 months before the contract anniversary, using the latest month released by IBGE (Brazil's statistics bureau), applied on the anniversary (art. 4, §§ 1–2) [3]. For non-hospital providers it applies to services, excluding separately billed orthotics, prosthetics, supplies and drugs; for hospitals, it applies as the contract defines (art. 5, sole paragraph) [3][4].
| Adjustment clause | Without agreement in 90 days | Watch out for |
|---|---|---|
| Free negotiation only | IPCA × Quality Factor, on the anniversary [3] | For hospitals, the base follows the contract |
| Free negotiation with fallback index | The contract's index [4][6] | The fallback becomes the real floor |
| Fixed index or percentage | The contract's index, no yearly negotiation [6] | Revisit at renewal |
| Formula with quality indicators | The contract's formula [2] | Indicators must be defined and measurable |
| No written contract | No ANS index [3] | Formalize the contract first |
The Quality Factor raises the index
RN 512/2022 applies a Quality Factor (arts. 7–8): 115% of IPCA for level A, 110% for level B, 105% for level C and 100% for all others [3]. ANS criteria for hospitals [5]:
| Level | % of IPCA | Hospital criterion |
|---|---|---|
| A | 115% | Top-level accreditation, plus the common requirements |
| B | 110% | Certification covering the full scope of care, plus the common requirements |
| C | 105% | Common requirements, or participation in an ANS quality-induction project, when available |
| Others | 100% | — |
Common requirements: a patient safety unit registered with Anvisa (Brazil's health surveillance agency) with at least one Notivisa report per quarter in the base year, and at least 75% of claims forms sent to health plans in the current versions of the TISS standard (Brazil's mandatory health data exchange standard) [5]. The health plan checks the criteria at any time in the base year (art. 9) [3].
Do not confuse it with member premium increases
Every year the ANS publishes the cap for individual and family plan premiums, and the press reports average increases for group plans. Those numbers concern what members pay the health plan. They do not apply to the hospital–health plan contract, which follows Law 9,656/1998, RN 503/2022 and RN 512/2022 [1][2][3]. They can be used as context, since they show how health plan revenue grows.
What does the negotiation calendar look like?
The legal rule counts 90 days from January 1, through the end of March [1][2]. The contracting manual of Anahp (Associação Nacional de Hospitais Privados, Brazil's national association of private hospitals) notes that, in practice, hospitals and health plans often agree to negotiate in the 90 days before the contract anniversary, and recommends starting talks before that window [6]. It also advises that, on the anniversary without agreement under a free-negotiation-only contract, the hospital apply the ANS index [6].
| When | What to do |
|---|---|
| 120+ days before the window | Read each adjustment clause; map anniversaries; build the data file |
| Window opens (January 1 or 90 days before the anniversary, per contract) | Send a formal written proposal with numbers and calculation |
| During the window | Log every counteroffer; address denials and payment terms in parallel |
| Window closes without agreement | Check whether the ANS index (free negotiation only) or the contract's fallback applies |
| Contract anniversary | Apply the agreed or applicable adjustment to the price table and billing |
The data behind the request
| Argument | Data | Source |
|---|---|---|
| Reference inflation | IPCA of 4.26% in 2025 | IBGE [10] |
| Payroll weight | 39.03% of total expenses at Anahp hospitals in 2024 (36.71% in 2023) | [9] |
| Thin margins | Total expenses at 93% of net revenue in 2025; EBITDA margin of 11.05% in 2025 and 9.45% in Q1 2026 | [7][8] |
| Collection period | 77.35 days in 2025, from invoice to payment | [7] |
| Denial | Initial denial of 15.93% of receivables and accepted denial of 1.72% of gross health plan revenue in 2025 | [7] |
| Health plan results | BRL 23.43 billion in net income in 2025 (6.96% of revenue); loss ratio of 81.5% | [7] |
Hospitals get paid after more than two months on average, lose part of billing to denials and run on thin margins, while health plan results improved. Anahp also notes that, beyond accepted denials, hospitals accept discounts in settlements to collect invoices [7]. That is why the adjustment should not be negotiated alone: payment terms, denial and audit rules, all covered by RN 503/2022, belong in the same package [2]. Formulas are in the guide Revenue cycle KPIs; loss ratio logic is in the guide Health plan loss ratio. More sector figures are in Industry data.
What may change in 2026
The ANS opened public consultation CP 170/2026 on a draft that consolidates RN 503/2022 and RN 512/2022, with input accepted through July 3, 2026. If the new rule is published, the index, Quality Factor and negotiation-period rules described in this guide may change.
What we see in operations
At Accrua, each health plan's contract is loaded into Accrua OS, with its adjustment clause, current price table, authorization rules and denial history. That lets us see, contract by contract, whether the adjustment is by free negotiation only, whether there is a fallback index or a fixed index, and when the anniversary date falls.
For the negotiation, we bring the hospital what its claim history shows about that health plan: initial and accepted denials, recurring reasons, observed payment time against the contract deadline, and appeals upheld but not paid. Those figures go on the table next to the index, because what the hospital receives depends on the price table, on what gets denied and on how long payment takes.
Changing a contract is always a decision for a person at the hospital. Our role is to deliver the figures consolidated, each with its source, and after the agreement, to update the contract and price table in the system so the next claims go out under the new rule.
Where to start
- Read the adjustment clause of each contract and classify it.
- Build the calendar with anniversaries and the negotiation window per health plan.
- Check your Quality Factor level: accreditation, certification, patient safety unit, reports and TISS compliance.
- Prepare the data file with industry numbers and your own (payroll, collection period, denial by health plan).
- Negotiate payment terms, denials and the adjustment together, in writing.