The new rules approved for ADSE introduce relevant changes to the reimbursement of healthcare expenses, with a direct impact on beneficiaries who use glasses, complementary diagnostic tests and more complex medical procedures. The changes, already validated, represent an annual increase of 15.4 million euros for the public service sickness protection system and adjust limits, prices and forms of reimbursement.
At issue are updates to the price list and reimbursement conditions, with practical effects on the free regime and the agreed network. The measures range from expenses with optics to radiology, gastroenterology, surgeries and hospitalization, with the aim of adapting the system to the current use of healthcare.
What changes in glasses reimbursement
According to the newspaper Público, the reimbursement scheme for glasses maintains the rate of 80%, but there is now a maximum annual limit of 180 euros for the joint reimbursement of frames and lenses. The main change is the elimination of the quantitative restrictions that were in force until now.
According to the same source, previously beneficiaries were limited to two frames and eight lenses for each three-year period, with much lower maximum values per unit. With the new rules, these temporal and quantity limitations disappear, with control focusing solely on the annual reimbursement ceiling.
The changes do not stop at the optics. The newspaper writes that the prices of around 200 acts in the area of radiology were revised, at the same time that more than a hundred new codes were integrated, especially in exams such as CT scans and MRIs.
The publication adds that, in the area of gastroenterology, a harmonization of the distribution of expenses was introduced, which will allow an overall saving of around half a million euros for beneficiaries, without changing access to the necessary exams.
Surgeries and hospitalizations at no additional cost
The new rules also include surgical procedures and hospitalization episodes. The same source states that beneficiaries now have access to surgeries considered more advanced and effective, without this resulting in an increase in the individual costs borne by users.
These updates result from an extensive review of the ADSE tables and seek to align agreed prices with the technical evolution of medicine and the costs charged, maintaining the principle of financial protection for beneficiaries.
What is ADSE and how does it work
To understand the scope of the changes, it is important to understand how the system works. According to the portal that informs about all the benefits for the Portuguese, the ADSE Network is a model of access to healthcare based on collaboration with providers who have an agreement with ADSE, allowing more advantageous prices compared to the private sector without an agreement.
The network includes more than 1,600 providers distributed across around 3,800 locations across the country, ensuring broad and diversified coverage in consultations, exams, treatments and surgeries.
Who can benefit from the system
The website explains that ADSE beneficiaries are divided between holders and family members. Holders include workers with a public employment contract, private education teachers covered by an agreement, retirees not integrated into other systems and other cases provided for by law.
The same source adds that there are specific access conditions, such as the impossibility of accumulating with other public health subsystems and specific rules for retirees or spouses of beneficiaries of systems such as ADM or the SAD of the security forces.
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