How does the health insurance law work?
Solidarity system
Source: Zorginstituut Nederland
The Dutch healthcare system is based on solidarity. Rich and poor, young and old, healthy and sick: we are all entitled to the same, affordable care from the basic health insurance package. Everyone contributes to this through premiums and taxes.
The Zvw at a glance
In the Netherlands, everyone is obliged to take out health insurance, with the right to care from the legally determined basic package. This is regulated by the Health Insurance Act (Zvw). Care includes treatments, services or products. Health insurers implement the Zvw, while health care providers are responsible for providing good care. Citizens can choose and change their health insurer or health care policy annually.
For whom is the Health Insurance Act?
Everyone who lives or works in the Netherlands is obliged to have health insurance. This gives everyone access to care in the basic package. The Zvw states what care is included in the basic package and what conditions apply. The insured person pays a monthly premium to the health insurer for his or her basic insurance. An insured person up to the age of 18 does not pay a premium and is insured free of charge for healthcare costs.
Reductible and co-payment
Most care in the basic package is subject to the mandatory deductible. The government determines the amount of the deductible. This applies per year and per person from the age of 18. For some types of care, a personal contribution may also apply. For example, maternity care and hearing aids. The government determines for which care the own contribution applies and how high that contribution is.
What care is reimbursed from the basic package?
Care is reimbursed from the basic package as soon as healthcare parties agree that this care is effective. This means that the care works and meets the "state of science and practice. The basic package is openly defined in law: it does not consist of a list of treatments, but a number of criteria that care must meet in order to be reimbursed. For a small part of the care, the Zorginstituut always does an assessment first. This applies to medicines available from pharmacies and expensive specialist medicines. We call this the closed part of the basic package.
What care is reimbursed from the Zvw?
The basic package covers many different forms of care and consists of many necessary medical care, medicines and aids. Some care is partially reimbursed, such as physiotherapy and oral care. Specific conditions, restrictions or exclusions apply to each type of care.
What role does the health insurer have?
Health insurers have several tasks. It is up to them to decide whether:
- The care that the insured person wants to receive (reimbursed) is covered by the health care policy.
- The insured person is eligible to receive the requested care.- The insured person has met the conditions of the health care policy.
In addition, health insurers have duties:
- Duty of care: every insured person must receive the care needed within a reasonable time and distance. When purchasing care, insurers must take into account the quality, affordability and accessibility of care.
- Duty of acceptance: health insurers must accept everyone. If someone wants to get insurance with a health insurer, the health insurer may not refuse the insured because of health, lifestyle or age.
Types of policies
Health insurers can offer different types of policies. In the health care policy, health insurers can:
- Determine who provides the care and where the care is provided.
- Set conditions. For example, the health insurer may require that certain care requires prior authorization. Or a referral, from the primary care physician, for example.
>- The insurer may set conditions.Free supplementary insurance
Not all care is included in the basic package. An insured can take out supplementary insurance for care that is not included in the basic package. For example, additional reimbursement for treatment at the dentist or physiotherapist. The pharmacist cannot see if you have supplementary insurance. You can submit the bill to your insurer yourself. The health insurer determines the content, conditions and reimbursements of supplementary insurance. For supplementary insurance, health insurers have no duty of acceptance.
Complaints?
Does an insured person disagree with a decision of the health insurer? Then the insured can ask the health insurer to reassess the decision. He can also then submit the complaint to the Stichting Klachten en Geschillen (SKGZ). Ultimately, the insured person can take their complaint to court.
Complaint about the quality of care?
The National Care Hotline provides information and advice if the insured has a question or complaint about the quality of care. It helps the insured further with options to resolve the complaint, answering questions and giving practical tips.
Compose basic package
Everyone living or working in the Netherlands is entitled to good care. The main task of the Care Institute is to compile the basic health insurance package for the Health Insurance Act (Zvw) and the Long-Term Care Act (Wlz).