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Medical specialist care

Reimbursement medical specialist care 2019

  1. What is medical specialist care (general)?
  2. Referral required
  3. Reimbursement under public healthcare insurance in 2019
  4. Maximum reimbursement for non-contracted care providers
  5. Reimbursement under supplementary insurance in 2019
  6. No statutory personal contribution
  7. Policy excess
  8. Who may provide this type of care?
  9. Request permission

Please note: the information provided on this page is a summary of the reimbursement applicable. You will only be able to derive rights from the HollandZorg Conditions of Insurance (pdf).

1. What is medical specialist care (general)?

Medical specialist care is the care that medical specialists generally provide. A medical specialist could be an internist, a dermatologist or a plastic surgeon.

 

Under the public health insurance, the following treatments fall under medical specialist care too:

  • medical aids which you receive as part of an admission or medical specialist treatment, provided they form (or are supposed to form) part of that admission or treatment.
  • medicines you receive within the framework of an admission or medical specialist treatment, provided they form (or are supposed to form) part of that admission or treatment.
  • Conditional medical specialised care included in the list of Conditional care.

Plastic surgery (treatment of a plastic surgical nature) is only included under medical specialist care if it is carried out in order to correct:

  • defects in your appearance related to demonstrable physical functional disorders;
  • mutilation resulting from a disease, accident or medical operation;
  • paralysis or weakening of the upper eyelids, if the paralysis or weakening seriously restricts the range of vision or is caused by a congenital defect or a chronic disorder present at birth;
  • the following congenital malformations: cleft lip, jaw and palate, malformation of the facial bone structure, benign morbid growth of blood vessels, lymphatic vessels or connecting tissue, birth marks or malformation of the urinary organs and genitals;
  • primary sexual characteristics in the event of established transsexuality.

The following treatments do not fall under medical specialist care:

  • The fourth or subsequent IVF attempt per ongoing pregnancy to be realised.
  • The first and second IVF attempt, provided you are younger than 38 and one or more embryos are re-placed;
  • Fertility-related care if you are a woman aged 43 or older;
  • Treatment of paralysis or weakening of the upper eyelids, other than when the paralysis or weakening seriously restricts the range of vision or is caused by a congenital defect or a chronic disorder present at birth;
  • Liposuction of the stomach;
  • The operative placement and operative replacement of a breast prosthesis other than after a full or partial breast amputation;
  • The operative removal of a breast prosthesis without medical grounds;
  • Treatment for snoring with uvuloplasty;
  • Treatments aimed at the sterilisation or reversal of the sterilisation of the insured party (either a man or a woman);
  • Treatments aimed at the circumcision of a male insured party;
  • An abdominal wall correction (abdominal plastic surgery), except in the case of mutilation or serious function limitation.
  • Treatment of an asymmetrical distortion of the back of the head (plagiocephaly) and central flattening of the back of the head (brachycephaly) in young children using a  cranial remodelling helmet where there is no premature fusing of the cranial sutures (craniosynostosis).
  • With effect from 1 January 2020: nivolumab, where provided in relation to the treatment of lung cancer;
  • ibrutinib: provided in the context of primary treatment of chronic lymphocytic leukemia, except for primary treatment of chronic lymphatic leukemia in the presence of 17p deletion or TP53 mutation in patients who are not suitable for chemoimmunotherapy and, until 01 January 2020, with the exception of primary treatment of chronic lymphatic leukemia without the presence of 17p deletion or TP53 mutation in
    non-fit patients for whom use of anti-CD20 is not suitable;
  • with effect from 0 January 2020: pembrolizumab, insofar as provided within the framework of treatment of lung cancer and Hodgkin-lymphoma;
  • daratumumab, insofar as provided for the treatment of multiple myeloma, with the exception of the use as monotherapy for the treatment of multiple-year insured with recidified and refractory multiple myeloma, whose previous treatment consisted of a protease inhibitor and an immunomodulatory agent and who showed disease progression during the last treatment;
  • nusinersen, insofar as provided within the framework of treatment of 5q spinal muscular atrophy;
  • ribociclib, insofar as provided within the framework of treatment of hormone receptor positive, human epidermal growth factor receptor 2 negative, locally advanced or metastatic breast cancer;
  • atezolizumab, insofar as provided within the framework of treatment of lung cancer or within the framework of treatment of urothelial carcinoma;
  • pembrolizumab, where provided in relation to the treatment of lung cancer;
  • palbociclib, where provided in relation to the treatment of hormone receptor positive, HER2-negative, locally advanced breast cancer or of hormone receptor positive or HER2-negative metastatic breast cancer;
  • laboratory testing at the request of an alternative care provider.

Read our Conditions of Insurance for more information.

2. Referral required

For medical specialist care, you will require a referral from a general practitioner, medical specialist, obstetrician, youth healthcare doctor, doctor for the mentally disabled, specialist geriatrics doctor, infectious disease and tuberculosis prevention doctor, A&E doctor, physician assistant, nursing specialist, sports doctor, company doctor or dentist. This condition will not apply to urgent care. The referral will remain valid for a period of twelve months, commencing on the day the referral was issued.

 

You will require our prior written permission for reimbursements under the public health insurance that feature in the List of Procedures to be Requested in Advance (pdf). You will know if you will receive a reimbursement for the care and what this reimbursement will be in advance.

3. Reimbursement under public healthcare insurance in 2019

The HollandZorg public healthcare insurance reimburses the cost of treatment and stay in a hospital or in an independent treatment centre. 

4. Maximum rates for non-contracted care providers

A maximum reimbursement applies to medical specialist care that is provided by a non-contracted care provider. If you decide to use a care provider with whom we have not made any agreements, we will reimburse up to a maximum of the rates in the Rate List for Non-contracted Care.

5. Reimbursement under supplementary insurance 2019

Not all treatments fall under the cover provided by the public healthcare insurance. Under the HollandZorg supplementary insurances we offer a reimbursement for the following treatments:

  • Eye laser

  • Lens implants

  • Ear correction (for children under 18 years)

  • MammaPrint

  • Treatment for varicose veins

  • Sterilisation

Read our Conditions of Insurance for more information about reimbursement under our supplementary insurances.

6. No statutory personal contribution

There is no statutory personal contribution for medical specialist care.

7. Policy excess

Are you 18 or older? The costs incurred for medical specialist care under the public healthcare insurance will count towards your compulsory policy excess and any voluntary policy excess.

8. Who may provide this type of care?

You may obtain medical specialist care from a hospital, a medical specialist that works outside a hospital and from an independent treatment centre (ZBC). For medical specialist care, you will require a referral from a general practitioner, a medical specialist, a midwife, a youth healthcare doctor, a sports doctor, a doctor for the mentally disabled, a specialist in geriatric medicine, a company doctor or dentist. This condition will not apply to urgent care.

 

For medical care under the public healthcare insurance you can receive treatment in hospitals. Would you like to receive treatment in a specific independent treatment centre or from an independent medical specialist? If so, please contact us before receiving treatment. This will ensure that you know whether we have a contract with your preferred independent treatment centre or specialist.

 

See our Care Guide to find a (contracted) care provider near you. If you have any questions or would like more information, contact customer services on +31(0)570 687 123. We will be happy to answer your questions.

9. Request permission

You will require prior written permission for the reimbursement of treatments that feature in the List of Procedures to be Requested in Advance (pdf). With the request for care, include a report from the doctor in attendance that includes the medical diagnosis/diagnoses, a description of the current problem, the treatment plan proposed (care activity) and, if applicable, appropriate photographs.

 

If we give our permission, it will be valid for one year, calculated from the date on which the written permission was granted. This permission may be valid for a shorter or longer period of time if we explicitly mentioned this fact when we granted the permission.

 

Please send requests for permission to:

HollandZorg
Medical Advisor
Antwoordnummer 30
7400 VB Deventer

 

No stamp is necessary.

 

If your care provider submits the request on your behalf, we will want to know if you agree to this request. You can do this by signing the request.
 

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