What is medical specialist care (general)?

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 as mentioned in our insurance conditions.

The following treatments do not fall under medical specialist care:

• The fourth or subsequent IVF attempt per ongoing pregnancy to be realised. An IVF attempt is regarded an attempt only when a follicle puncture is successful. Only attempts that are subsequently abandoned count towards the number of attempts. Within the meaning of this document, a viable pregnancy is:
  
  • a pregnancy lasting at least ten weeks, calculated from the moment that a follicle puncture succeeded;
  • in the event that frozen embryos are re-implanted, a pregnancy of at least nine weeks and three days, calculated from the moment that the frozen embryos are re-implanted;
  • a spontaneous pregnancy of twelve weeks after the date of the last menstruation
    An IVF attempt after a viable pregnancy is regarded as a new, first attempt, even if that pregnancy was
    terminated prematurely;
    
    
• 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. If the IVF treatment began before you turned 43, you are entitled to completion of that attempt;
• 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;
• Treatment of a plastic surgical nature to reconstruct the breast or replace a breast prosthesis, other than following full or partial mastectomy or in the case of agenesis or aplasia of the breast in women and a comparable situation in the event of established transsexuality;
• 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 other than medically necessary;
• 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).
• the medicines as defined in appendix 0 of the Healthcare Insurance Regulations, under the conditions as stated therein. The number of medicines and the conditions may be subject to interim changes. An up-to-date version can be found at www.hollandzorg.nl;
• the use of external devices during the treatment of diabetes to monitor and control blood sugar disorders, including the ketone test strips and insulin pumps;
• laboratory testing at the request of an alternative care provider.

Read our Conditions of Insurance for more information.

Referral required

For medical specialist care, you will require a referral from a general practitioner, clinical technologist, house officer, 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, clinical physiologic, audiologist, dental surgeon, optometrist, orthoptist or triage hearing specialist. 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.

Reimbursement under public healthcare insurance

The HollandZorg public healthcare insurance reimburses the cost of treatment and stay in a hospital or in an independent treatment centre. Read our insurance conditions for a full overview.

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.