How does the Health Insurance Act work?
Solidarity-based system
Source: Dutch Healthcare Institute
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 covered by the basic health insurance package. Everyone contributes to this through premiums and taxes.
The Zvw at a Glance
In the Netherlands, everyone is required to have health insurance, which entitles them to care covered by the statutory basic package. This is regulated by the Health Insurance Act (Zvw). Health care includes treatments, services, or products. Health insurers administer the Zvw, while health care providers are responsible for delivering quality care. Citizens can choose and change their health insurer or health insurance policy annually.
Who is the Zvw for?
Everyone who lives or works in the Netherlands is required to have health insurance. This ensures that everyone has access to the care included in the basic coverage package. The Zvw specifies which healthcare services are included in the basic coverage package and the conditions that apply to them. The insured person pays a monthly premium to the health insurer for their basic coverage. Insured persons under the age of 18 do not pay a premium and are covered for healthcare costs free of charge.
Deductible and Copayment
The mandatory deductible applies to most healthcare services covered by the basic health insurance plan. The government sets the amount of the deductible. This applies annually and per person aged 18 and older. A copayment may also apply to certain types of care, such as postpartum care and hearing aids. The government determines which types of care are subject to a copayment and how much that copayment is.
What types of care are covered under the basic health insurance package?
Care is covered under the basic health insurance package once healthcare providers agree that it is effective. This means that the care is effective and meets the “current state of science and practice.” The basic coverage package is defined broadly by law: it does not consist of a list of treatments, but rather a set of criteria that care must meet in order to be covered. For a small portion of healthcare, the Dutch Healthcare Institute (Zorginstituut) always conducts an assessment first. This applies to medications available at pharmacies and expensive specialty medications. We refer to this as the “closed portion” of the basic health insurance package.
What types of care are covered under the Zvw?
The basic coverage package covers many different types of care and includes a wide range of essential medical care, medications, and medical devices. Some types of care are partially covered, such as physical therapy and dental care. Specific conditions, limitations, or exclusions apply to each type of care.
What is the role of the health insurer?
Health insurers have various responsibilities. It is up to them to decide whether:
• The care that the insured person wishes to receive (with reimbursement) is covered under the health insurance policy.
• The insured person is eligible to receive the requested care.
• The insured person has met the conditions of the health insurance policy.
In addition, health insurers have certain obligations:
• Duty of care: Every insured person must receive the necessary care within a reasonable time and distance. When purchasing care, the insurer must take into account the quality, affordability, and accessibility of the care.
• Duty to accept: Health insurers must accept everyone. If someone wishes to obtain insurance from a health insurer, the insurer may not refuse the insured person on the basis of health, lifestyle, or age.
Types of Policies
Health insurers may offer different types of policies. In a health insurance policy, health insurers can:
• Determine who provides the care and where it is provided.
• Set conditions. For example, the health insurer may require prior authorization for certain types of care, or a referral from a primary care physician.
Voluntary supplemental insurance
Not all healthcare services are covered by the basic plan. An insured person can purchase supplemental insurance to cover care not included in the basic plan. For example, additional reimbursement for treatment at the dentist or physical therapist. The pharmacist cannot tell if you have supplemental insurance. You can submit the bill to your insurer yourself. The health insurer determines the coverage, terms, and reimbursement rates for supplemental insurance. Health insurers are not required to accept applicants for supplemental insurance.
Complaints?
If an insured person disagrees with a decision made by the health insurer, they may ask the health insurer to reconsider the decision. They can also subsequently submit the complaint to the Complaints and Disputes Foundation (SKGZ). Ultimately, the insured person can take their complaint to court.
Do you have a complaint about the quality of care?
The National Healthcare Hotline provides information and advice if an insured person has a question or complaint about the quality of care. It assists insured individuals by exploring options to resolve the complaint, answering questions, and providing practical tips.
Compiling the Basic Health Insurance Package
Everyone who lives or works in the Netherlands is entitled to quality health care. The primary task of the Dutch Healthcare Institute is to determine the scope of the basic health insurance package under the Health Insurance Act (Zvw) and the Long-Term Care Act (Wlz).