Basic and supplementary insurance policy conditions

You are entitled to physiotherapy and/or remedial therapy (Cesar or Mensendieck). The following is a summary of the care involved and the conditions that apply for entitlement to these forms of care.

You are entitled to 10 hours of advice, tuition, training or treatment by an occupational therapist. This means 10 hours per calendar year. The occupational therapy must be intended to promote or improve your ability to cope better by yourself. The nature and extent of the care provided is limited to the care normally provided by occupational therapists.

What you are not entitled to under this article

We do not reimburse charges for:

1. appointments outside of regular working hours;
2. missed appointments;
3. reports.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to:

1. supply of functioning medical devices and bandages for personal use (not on loan). A statutory personal contribution or a statutory maximum reimbursement sometimes applies for a medical device;
2. alteration, replacement or repair of medical devices;
3. spare medical devices.

Conditions for entitlement to medical devices

More detailed conditions for reimbursement of medical devices are specified in the Medical Devices Regulations (Reglement Hulpmiddelen). These regulations form part of this policy and can be found on our website or obtained from us. You do not need prior permission for the supply, customisation, replacement or repair of a large number of medical devices. You can contact a contracted supplier directly. The medical devices to which this applies are listed in article 4 of the Medical Devices Regulations (Reglement Hulpmiddelen). You do need our prior permission for the supply, customisation, replacement or repair of a number of medical devices. We assess whether the medical device is necessary, appropriate and not needlessly expensive or complicated. You must always obtain our prior permission when non-contracted suppliers are involved, except in the case of ostomy equipment, catheters and accessories. In some cases medical devices are provided on loan. The devices to which this applies are listed in the Medical Devices Regulations (Reglement Hulpmiddelen). In this case, we depart from the provisions under (a) of this article and article A.2.1 Care entitlement.

What you are not entitled to under this article

Do you need a medical device that forms part of specialist medical care? In that case you are not entitled to medical devices under this article. These medical devices fall under article B.28.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Pharmaceutical care is defined as:

1. medicines and dietary preparations that are covered in your insurance agreement and with which you are provided by pharmacists;
2. advice and guidance normally provided by pharmacists in terms of doing a medication check and informing you of the responsible use of medicines and dietary preparations as designated in this insurance agreement.

More detailed conditions for pharmaceutical care are specified in the Pharmaceutical Care Regulations (Reglement Farmaceutische Zorg). These regulations form part of this policy and can be found on our website or obtained from us.

You are entitled to the dispensing of and the provision of advice and guidance on:

1. medicines designated for reimbursement by ministerial decree that are included in the GVS insofar these medicines are designated and included in the Pharmaceutical Care Regulations (Reglement Farmaceutische Zorg). GVS stands for Medicinal Products Reimbursement System (Geneesmiddelenvergoedingssysteem). The GVS states which medicines can be reimbursed under the basic insurance and what the maximum reimbursement is. The provision of medicines, advice and guidance must be carried out by a pharmacy that has entered into a contract with us or a pharmacy that does not have a contract with us; and
2. medicines other than registered medicines that may be supplied in the Netherlands according to the Dutch Medicines Act (Geneesmiddelenwet). These must be based on rational pharmacotherapy. We define rational pharmacotherapy as treatment with a medicine in a form suited to the patient, the efficacy and effectiveness of which has been established by scientific research and which is also most economic for your basic insurance. This definition of rational pharmacotherapy includes:
   
   • medicine prepared on a small scale by or on the orders of a pharmacy;
   • medicines that, according to article 40, third paragraph, under c, of the Dutch Medicines Act, in response to a request by a doctor as referred to in that provision, are prepared in the Netherlands by a manufacturer, as referred to in article 1, first paragraph, under mm, of the Medicines Act;
   • medicines that, according to article 40, third paragraph under c, of the Medicines Act, are marketed in a different member state or in a third country and, at the request of a doctor as referred to in that provision, are imported into the territory of the Netherlands. These medicines must be intended for one of that doctor's patients, who suffers from a disorder that is found in no more than 1 in every 150,000 residents in the Netherlands;
     medicines that, according to Article 40(3)(c) of the Medicines Act, are marketed in a different member state or in a third country and, at the request of a doctor as referred to in that provision, are imported into the territory of the Netherlands, where the medicine is a replacement for a registered medicine which is temporarily unavailable or cannot be supplied in sufficient quantities by the holder of the marketing license or parallel trade permit granted under the Medicines Act or the regulation referred to in Article 1(1)(fff) of that Act, or
   • medicines that, according to Article 52(1) of the Medicines Act, if the medicine serves to replace a registered medicine which temporarily cannot be supplied or cannot be supplied in sufficient quantities by the holder of the marketing license or parallel trade permit granted under to the Medicines Act or under to the regulation referred to in Article 1(1)(ffff) of that Act; and
3. polymer, oligomer, monomer and modular dietary preparations.

Statutory personal contribution

If a medicine is more expensive than the reimbursement limit included in the GVS, you are responsible for the additional costs. The statutory personal contribution for medicine is limited to € 250 per person per calendar year. If you have not been insured with us for a full calendar year, we calculate the maximum statutory personal contribution to medicines according to how many days you were insured with us in that calendar year.

Pharmaceutical care includes a number of (partial) provisions. A description of these (partial) provisions can be found in the Pharmaceutical Care Regulations (Reglement Farmaceutische Zorg). On our website you will also find a summary of the maximum reimbursements we have established for (partial) provisions relating to pharmacy, medicines and dietary preparations. You will also find the registered medicines that we have designated as 'preferred medicines'. You can of course also obtain this information from us.

Conditions for entitlement to medicines and dietary preparations

1. The medicines must be prescribed by a general practitioner, a medical specialist, a dentist, a geriatric specialist, a doctor who specialises in treating the mentally handicapped, an obstetrician or midwife or a suitably qualified nurse (once this has been regulated via the ministry).
2. The medicines must be dispensed by a pharmacy. We contract medical specialty stores to supply dietary preparations. Dietary preparations may also be provided by a pharmacy, but they will be reimbursed in accordance with the policy conditions for non-contracted care. For more information, see A.4 What is reimbursed? And which care providers, healthcare institutions and suppliers can you use?
3. Are there identical, interchangeable medicines based on active ingredient, strength and method of administration? Then you are only entitled to the medicines we have designated on the basis of the preference policy or the medicine designated by the pharmacy. You are only entitled to a non-designated medicine if there is a medical necessity. The prescriber (see under 1) must indicate on the prescription that there is a medical indication and must be able to substantiate this. You can read more about this in the Glossary of Terms in the Pharmaceutical Care Regulations.
4. You are only entitled to dietary preparations if:
   1. you have a condition that requires the use of these preparations as an essential part of adequate healthcare;
   2. your health problems cannot be managed with an regular adjusted diet and/or dietary products;
   3. the additional conditions for reimbursement listed in Annex 2 (Bijlage 2) of the Health Insurance Regulations (Regeling zorgverzekering) are met. Annex 2 (Bijlage 2) is amended on a regular basis. Also during the course of the current policy year. You can find the latest version of Annex 2 (Bijlage 2) (with the conditions for reimbursement) online at wetten.overheid.nl; type ‘Regeling zorgverzekering’ (Health Insurance Regulations) in the search box, click on ‘Zoeken’ (Search). Click on ‘Regeling zorgverzekering’. Click on Bijlage 2 (Annex 2) in the contents;
   4. if they have been prescribed by a doctor or dietitian. The pharmacist or medical specialty shop will determine whether the conditions have been met based on the 'Declaration of dietary preparations' filled in by your doctor or dietitian.

Additional provisions that apply for entitlement to specific medicines are listed in article 4.4 of the Pharmaceutical Care Regulations (Reglement Farmaceutische Zorg). You are only entitled to these medicines if you meet these additional provisions.

Conditions for entitlement to (partial) provisions

We stipulate additional requirements for a number of (partial) provisions relating to the quality of the care provided and/or preconditions regarding which pharmaceutical care you are allowed to declare. You are only entitled to these partial provisions if these additional requirements are met. The (partial) provisions to which these conditions apply are listed in the Pharmaceutical Care Regulations (Reglement Farmaceutische Zorg).

The mandatory excess applies to fitting of a coil for insured persons aged 18 to 21 years

What you are not entitled to under this article

You are not entitled to the following medicines and/or pharmaceutical (partial) provisions:

1. contraceptives for insured persons aged 21 or older, unless there is a medical indication. Within the framework of this article, our definition of a medical indication is endometriosis or menhorragia (severe blood loss);
2. medicines and/or advice on preventing an illness within the framework of travelling abroad;
3. pharmaceutical care listed in the Health Insurance Regulations (Regeling zorgverzekering) as care to which you are not entitled;
4. medicines that appear in article 40, third paragraph, under b of the Dutch Medicines Act (Geneesmiddelenwet);
5. medicines that appear in article 40, third paragraph, under f of the Dutch Medicines Act;
6. medicines that are—or are almost—the equivalent of any non-designated, registered medicine, unless otherwise stipulated by ministerial regulation.
7. non-prescription drugs not listed in the Regeling zorgverzekering (Health Insurance Regulations). Non-prescription drugs are medicines that you can purchase without a prescription;
8. all pharmaceutical (partial) provisions that are not regarded as insured care. All (partial) pharmaceutical provisions are described in the Pharmaceutical Care Regulations (Reglement Farmaceutische Zorg).
9. homeopathic, anthroposophic and/or other alternative medicines and remedies;
10. non-registered allergens, unless treatment with a registered allergen is not possible. You are only entitled to a non-registered allergen on the basis of authorisation issued by us on an individual basis.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Do you suffer from a serious development or growth disorder that affects the teeth, jaw or mouth or an acquired deformity of the teeth, jaw or mouth? And are you unable to retain or attain a dental function equivalent to the dental function you would have had without the disorder or deformity without orthodontic treatment? Then you are entitled to this treatment.

Conditions for entitlement to orthodontic care in exceptional cases

1. The treatment must be carried out by an orthodontist or at a Centre for Exceptional Dentistry.
2. If you are being treated at a Centre for Exceptional Dentistry, you must have been referred by your dentist, general practitioner, a oral surgeon or medical specialist.
3. You have a permanent developmental or growth disorder resulting in a severe functional impairment comparable in severity to a lip, jaw or palate cleft (schisis).
4. This treatment requires a joint diagnosis or must involve other disciplines in addition to dental disciplines.
5. We must give you prior permission. When requesting permission, you must also submit a treatment plan, a cost estimate, photographs and available X-rays. The treatment plan and cost estimate will be drawn up by your care provider. We will then assess the appropriateness and legitimacy of your request.

What you are not entitled to under this article

You are not entitled to:

1. the repair or replacement of an existing orthodontic device if you lose or damage it through your own fault or negligence;
2. vacuum-formed orthodontics, aligners.

Are you under the age of 18? Then you are entitled to the following dental treatment:

1. a periodical preventive dental examination once a year (annual check-up), or several times a year, if you are reliant on more frequent check-ups to maintain dental health;
2. an occasional dental consultation;
3. the removal of scale;
4. up to 2 fluoride treatments a year, from the moment permanent teeth appear, unless you are reliant on several fluoride treatments a year to maintain dental health, in which case, we must give you permission in advance;
5. sealing of ridges in molars;
6. periodontal care (treatment of gums);
7. anaesthesia (local anaesthetic);
8. endodontic care (root canal therapy);
9. repairing of dental elements with plastic materials (fillings);
10. gnathological care (treatment of jaw problems);
11. removable dentures (metal frame dentures, partial (plate) dentures or full dentures);
12. surgical dental care. This care does not include the fitting of dental implants;
13. X-rays, with the exception of X-rays performed as part of orthodontic care.

Conditions for entitlement to dental care for insured persons up to the age of 18

1. The treatment must be carried out by a dentist, a oral surgeon, an oral hygienist or a clinical dental technician. This person must be competent and qualified to carry out the treatment involved.
2. Will you be undergoing treatment by a oral surgeon? In that case, you need a referral from your dentist, orthodontist, GP, doctor specialised in treating people with an intellectual disability, doctor specialised in juvenile health care or other medical specialist. You must obtain our advance consent for the following treatments: extraction (pulling of teeth or molars) under anaesthesia, jaw correction in combination with extraction, osteotomy (jaw surgery), genioplasty as a stand-alone operation, preimplantological and perimplantological surgery (bone remodeling) and the implantation of bone anchors for orthodontic treatment.
3. We only reimburse the costs of fitting bone anchors for orthodontic treatment as part of orthodontic care provided in exceptional cases (see Article B.5). We must give you prior permission.
4. If care as defined in article B.5, B.7, B.10, B.11 or B.12 is required, you must obtain our permission in advance. You can read more about this in the articles.
5. You must obtain prior permission:
   • for jaw overview imaging (X21);
   • for autotransplantation (diagnostics and moving one’s own tooth or molar to the site of a missing tooth or molar);
   • for dental sealants for baby teeth;
   • for dental sealants for more than 8 permanent teeth and/or molars per year (V30/V35);
   • if more than 1 hour per year of prevention education/evaluation is required (more than 12x (M01 and/or M02));
   • if more than 30 minutes of dental cleaning (more than 6x M03) is required per day;
   • if more than 1.5 hours of dental cleaning (more than 18x M03) is required per year;
   • if more than 6 fillings (V71 to 74, V81 to 84, V91 to 95) are needed per day or more than 10 fillings (V71 to 74, V81 to 84, V91 to 95) are needed per year.

Your care provider can request permission from us on your behalf. We will then assess the appropriateness and legitimacy of the request.

6. Diagnostics and autotransplants must be performed by a dental periodontist accredited by the Dutch Association for Periodontology (NVvP), a dental implantologist accredited by the Dutch Association for Oral Implantology (NVOI) or by an oral surgeon.

What you are not entitled to under this article

You are not entitled to:

1. non-restorative caries treatment in the deciduous teeth (M05) and treatment of white spots (M80 and M81);
2. orthodontic care. With the exception of the orthodontic care in exceptional cases as described in article B.5, this is not covered by the basic insurance. It may be reimbursed under an extra supplementary insurance;
3. implants. These may be covered under articles B.7, B.10, B.12 or D.14 Dental care for insured persons up to the age of 18 – crowns, bridges, inlays and implants. Dental care for insured persons up to the age of 18 - crowns, bridges, inlays and implants, or may be reimbursed under a supplemental dental insurance;
4. therapeutic botox injection (G44);
5. comprehensive examination for the purpose of formulating, recording, and providing a treatment plan to the patient (C012).

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Are you missing one or more permanent incisors or canine teeth that need to be replaced due to hypodontia or because the missing teeth are a direct result of an accident and is there a record of this diagnosis having been made before the age of 18? In that case you are entitled to non- plastic tooth replacement materials. Among other things these include a fixed bridge, an acid-etched or bonded bridge or an implant-retained crown and the fitting of dental implants in the front of the mouth.

Terms and conditions for entitlement for front tooth treatment.

1. The treatment must be carried out by a dentist, an orthodontist or a oral surgeon.
2. Will you be undergoing treatment by a oral surgeon? In that case you need a referral from your dentist.
3. We must give you permission for the treatment in advance. A treatment plan with a cost estimate and available X-rays must be submitted with your request for approval. The treatment plan must be prepared by your dentist, orthodontist or oral surgeon.

What you are not entitled to under this article

You are not entitled to autotransplantation (moving your own tooth or molar to the site of a missing tooth or molar).

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to specialist dental surgery and the X-rays this involves. This could be combined with a stay in hospital.

You are entitled to nursing and or hospital accommodation if these forms of care are necessary in connection with dental surgery. For more information, see article B.28.

Conditions for entitlement to dental surgery

1. The treatment must be carried out by a dental surgeon.
2. You must be referred by a general practitioner, dentist, orthodontist, dental prosthetist, dental hygienist, company doctor, geriatric specialist, doctor specialised in treating people with an intellectual disability or another medical specialist. A dental hygienist may only refer you if they suspect oral mucosal disease not caused by with teeth or gum problems. A clinical dental technician may only refer you if he or she suspects pathology in a toothless mouth.
3. We must give you permission in advance for the following treatments:
   
   • extraction (removal of teeth or molars) under anaesthesia;
   • jaw correction combined with an extraction;
   • osteotomy (jaw surgery);
   • chin plastic surgery as an independent operation;
   • preimplantological and perimplantological surgery (bone remodeling);
   • placing bone anchors for orthodontic treatment.
   • plastic surgery.
4. Have you requested permission for dental treatment? In that case we will assess the cost-effectiveness and legitimacy of your request.

What you are not entitled to under this article

You are not entitled to:

1. periodontal surgery;
2. the fitting of dental implants;
3. an uncomplicated extraction.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to the making and fitting of the following dentures or click dentures:

1. a full set of removable dentures for the upper and/or lower jaw (25% statutory personal contribution);
2. a full set of temporary removable dentures (25% statutory personal contribution);
3. a full set of removable overdentures on natural elements (25% statutory personal contribution);
4. a full set of snap-in dentures on implants for the upper and/or lower jaw and fastening materials, such as push buttons and pins (statutory personal contribution of 8% for the upper jaw and 10% for the lower jaw).

A personal contribution of 17% applies for the combination of implant-retained click denture for one jaw and non-implant-retained denture for the other jaw (code J080).

Are you having a full set of dentures (a–d) or click dentures repaired or rebased? Then a statutory personal contribution of 10% applies. We apply maximum amounts for the costs of dental technician services and materials. These amounts can be found on our website or obtained from us.

Conditions for entitlement to a full set of removable dentures and click dentures

1. The treatment must be performed by a dentist or clinical dental technician or at a Centre for Exceptional Dentistry.
2. Are you being treated at a Centre for Exceptional Dentistry? In that case, your dentist or oral surgeon must have referred you.
3. With a dental technician, you are only entitled to repairs (i.e. not rebasing) on removable full dentures for the upper and/or lower jaw. You are only entitled to this if no actions are required inside the mouth. This includes repairing a crack or a simple fracture in the dentures, which can be repaired outside the mouth, or attaching a tooth to the dentures outside the mouth.
4. If the dentures listed under a and c need to be replaced within 5 years, or if emergency dentures (P023) listed under (b) need to be replaced within 6 months, you must obtain our advance permission. We assess the appropriateness and legitimacy of your request.
5. Are you having a full set of upper or lower removable dentures made and fitted, and do the costs of dental technician services and materials exceed the maximum amounts we apply? In that case we must give you permission in advance.
6. Are you having a new full set of upper and/or lower implant-retained click dentures and attachment materials (such as press studs and rods) made? In that case we must give you permission in advance. When requesting our permission, you must also submit a treatment plan, a cost estimate and available X-rays. We will then assess the appropriateness and legitimacy of your request. This is not required for the repair and rebasing of removable complete click dentures on implants that are older than 5 years or for a simple repair of click dentures without rod disassembly and without impression (code J104) if performed after 4 months after placement of the click dentures.
7. The severely shrunken jaw supplement (P044) requires our permission in advance. You are only entitled to this if you are entitled to implants (see article B.10) but these are not placed.

What you are not entitled to under this article

You are not entitled to materials that serve to attach the full set of removable overdentures to natural elements (your own tooth roots).

Do you suffer from a serious development or growth disorder that affects the teeth, jaw or mouth or an acquired deformity of the teeth, jaw or mouth? And are you unable to retain or attain a dental function equivalent to the dental function you would have had without the disorder or deformity without the fitting of implants? And do you have a severely shrunken, toothless jaw? In that case you are entitled to dental implants that serve to retain a full set of removable click-tight dentures.

We apply maximum amounts for the costs of dental technician services and materials. These amounts can be found on our website or obtained from us.

Conditions for entitlement to implants

1. The treatment must be carried out by a dentist, a oral surgeon, or a Centre for Exceptional Dentistry.
2. Are you attending a Centre for Exceptional Dentistry for treatment? In that case you must be referred by your dentist. A clinical dental technician may only refer you to a dentist.
3. Are you being treated by a oral surgeon? In that case you must be referred by your dentist, a Centre for Exceptional Dentistry or medical specialist.
4. You must obtain our advance permission for the treatment. When requesting our permission, you must also submit a treatment plan, a cost estimate and available X-rays. We will then assess the appropriateness and legitimacy of your request.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Do you have a non-dental physical and/or intellectual disability? And are you unable, without dental care, to retain or attain a dental function that is equivalent to the dental function you would have had without the physical and/or intellectual disability? In that case you are entitled to dental care.

Conditions for entitlement to dental care for insured persons with a disability

1. The treatment must be carried out by a dentist, an oral hygienist, a clinical dental technician, an orthodontist, a oral surgeon, or a Centre for Exceptional Dentistry.
2. Are you attending a Centre for Exceptional Dentistry for the care? In that case you must be referred by your dentist, general practitioner, a oral surgeon or medical specialist.
3. Are you being treated by a oral surgeon? In that case you must be referred by your dentist, general practitioner, a Centre for Exceptional Dentistry or medical specialist.
4. You are only entitled to this care if you are not entitled to dental care under the Dutch Long-term Care Act (Wet langdurige zorg (Wlz)).
5. We must give you permission for the care in advance. When requesting our permission, you must also submit a treatment plan, a cost estimate and available X-rays. The treatment plan and cost estimate will be drawn up by your care provider. We will then assess the appropriateness and legitimacy of your request.
6. Treatment of jaw complaints (such as pain in joints and chewing muscles) will only be reimbursed if performed by a dentist-gnathologist or centre for special dentistry recognised by the NVGPT.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to dental treatment in the following exceptional cases:

1. If you suffer from a serious development or growth disorder that affects the teeth, jaw or mouth, or an acquired deformity of the teeth, jaw or mouth and are unable to retain or attain a dental function equivalent to the dental function you would have had without the condition without dental care.
2. If, without the dental care, medical treatment would have demonstrably insufficient results. And if, without the dental care, you are unable to attain or retain a dental function equivalent to the dental function you would have had without the medical condition.
3. if you suffer from extreme anxiety about dental treatment, according to the validated anxiety scales as described in the guidelines of the Centres for Exceptional Dentistry.

In so far as care is involved that is not directly linked to the indication for exceptional dental care, insured persons aged 18 years or older pay a contribution equal to the sum that would be charged to the insured person concerned if this article did not apply. For instance, do you go to a dentist who specialises in anxiety? In that case you usually pay a higher tariff than for a normal dentist. You are only entitled to the additional costs. You must pay the standard tariff for a normal dentist yourself.

Conditions for entitlement to dental care in exceptional cases

1. The treatment must be carried out by a dentist, an oral hygienist, an orthodontist, a oral surgeon, or a Centre for Exceptional Dentistry.
2. Are you attending a Centre for Exceptional Dentistry for the care? In that case you must be referred by your dentist, general practitioner, a oral surgeon or medical specialist.
3. Are you being treated by a oral surgeon? In that case you must be referred by your dentist, general practitioner, a Centre for Exceptional Dentistry or medical specialist.
4. We must give you prior permission When requesting our permission, you must also submit a treatment plan, a cost estimate and available X-rays. The treatment plan and cost estimate will be drawn up by your care provider. We will then assess the appropriateness and legitimacy of your request.
5. Treatments performed under anaesthesia or nitrous oxide are only reimbursed as a last resort in an anxiety management process. The treatment performed under anaesthetic or nitrous oxide must be carried out at a Centre for Exceptional Dentistry or by a dentist who meets our expertise, organisational and safety requirements for treatments performed under anaesthetic and/or nitrous oxide.
6. Treatment of jaw complaints (such as pain in joints and chewing muscles) will only be reimbursed if performed by a dentist-gnathologist or centre for special dentistry recognised by the NVGPT.
7. Diagnostics and autotransplants must be performed by a dental periodontist accredited by the Dutch Association for Periodontology (NVvP), a dental implantologist accredited by the Dutch Association for Oral Implantology (NVOI), or by an oral surgeon.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to sensory impairment care. This is multidisciplinary care that focuses on learning to cope with, overcoming or compensating for the limitation. This care is designed to enable you to function as independently as possible.

You are eligible for this care if you:

1. have a hearing impairment (you are deaf or hearing impaired) and/or
2. have a visual impairment (you are blind or visually impaired);
3. have a communication impairment (you have significant difficulties with speech and/or language) caused by a primary language development disorder and are under the age of 23. A disorder is considered a communicative disability as a result of a language development disorder if it can be traced back to neurobiological and/or neuropsychological factors. The language development disorder must also be primary. This means that other problems (psychiatric, physiological, neurological) are secondary to the language development disorder.

The multidisciplinary care consists of:

1. diagnostic examination;
2. interventions aimed at teaching mental strategies to help cope with the disability;
3. interventions that alleviate or compensate for the disability and therefore increase self-reliance (the ability to cope independently).

In the case of auditory and communication impairments, the health psychologist is ultimately responsible for the multidisciplinary care and the care plan. This task may also be performed by remedial educationalists or developmental psychologists. In the case of visual impairments the ophthalmologist or a medical physicist who specialises in the visual system is ultimately responsible for the multidisciplinary care when it comes to coordination of the treatment of the 'vision problem'. The healthcare psychologist or a similar behavioural specialist is ultimately responsible for the multidisciplinary care when it comes to coordination of the treatment of mental and/or behavioural problems and learning to cope with the disability. This task may also be performed by practitioners trained in other disciplines.

Conditions for entitlement to sensory impairment care

1. For auditory and communicative impairments, you must be referred by a medical physicist audiologist who works at an audiology centre or a medical specialist who has diagnosed an auditory and/or communicative impairment under the applicable FENAC guidelines.
2. For of visual impairments, you must be referred by an ophthalmologist or another medical specialist who has diagnosed a visual impairment according to the evidence-based NOG Visual Impairment, Rehabilitation and Referral Directive. Was your sensory impairment disorder previously diagnosed by a medical physicist audiologist, ophthalmologist or medical specialist? And has a sensory impairment-related care need arisen without there being any change in the sensory impairment disorder? In that case you can also be referred by a general practitioner or a doctor who specialises in juvenile health care.

You do not need a new referral for simple rehabilitation care (that falls within Care Programme 11*) if: the referral is a repeat referral;

• there has been no change in the sensory impairment disorder; there has been a change in your medical or personal situation that
• necessitates further treatment under your basic insurance;
• the sensory impairment care provider has established that the care needs can be met within Care Programme 11;
• the sensory impairment care provider notifies the general practitioner in writing of the process followed. The general practitioner adds the information to the patient's medical file.

* Care Programme 11 enables fast-track admission for people who have received treatment and/or training in the past and require further treatment. It is also for adults confronted (for the first time) with visual impairment (caused by conditions such as retinitis pigmentosa) whose care needs usually involve being able to make optimal use of their remaining vision, and older people (55+) with an acquired visual impairment who are specifically seeking to retain their independence. The condition is known, the person's vision has been assessed, and the person has one or two specific care needs. These care needs involve learning to compensate for their visual impairment and/or make optimal use of their remaining vision in order to retain their independence. In most cases, these care needs can be met within 10 hours.

What you are not entitled to under this article

You are not entitled to:

1. elements of care designed to support social functioning;
2. complex, long-term and lifewide support for deaf and blind adults and prelingually deaf adults (who became deaf or hard of hearing before the age of 3).

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

If you suffer from a psychological disorder, you are entitled to mental healthcare (GGZ).

If you require hospitalisation for treatment of your psychological disorder, you are also entitled to:

1. stay with nursing and care;
2. paramedical care, medicines, medical devices and dressings that are part of your treatment during your stay.

The nature and extent of the care provided is limited to the care normally provided by psychiatrists and clinical psychologists.

Conditions for entitlement to mental healthcare

1. You must be 18 or older.
2. You must be referred by a general practitioner, a company doctor, a medical specialist (psychiatrist, specialist hospital, a geriatric specialist, a doctor specialised in treating people with an intellectual disability, or a doctor specialised in emergency medicine), a street doctor, an A&E doctor, or the specialist in charge (in case of referral). A referral is not required for acute care.
3. The referral must comply with the “Mental Health Referral Agreements” as published by the Dutch Ministry of Health, Welfare and Sport (VWS).
4. A referral is valid for up to 9 months. This means that you must be registered with the care provider within 9 months of the date the referral is issued. What if it is more than 9 months since the referral was issued? Then you must ask for another referral.
5. Your healthcare provider must have an approved quality statute. Check your care provider's website or ask about the quality charter.
6. Your GGZ treatment requires there to be a specialist in charge. The mental healthcare practitioners allowed to be specialists in charge are described in the applicable sector agreement. You can find this on our website.

What you are not entitled to under this article

Among other things you are not entitled to:

1. treatment of adjustment disorders;
2. assistance with work-related and relationship problems;
3. assistance with psychiatric complaints that do not involve a mental disorder;
4. medical GGZ for insured persons up to the age of 18, with or without stay. This falls under the Dutch Youth Act (Jeugdwet). You can contact your municipality about this.

How many days stay with treatment are you entitled to?

In the case of a stay at a psychiatric hospital with treatment you are entitled to an uninterrupted stay at a GGZ institution for a period of up to 1,095 days. The following forms of stay also count towards the calculation of the 1,095 days:

1. stay at a rehabilitation centre or a hospital for the purpose of rehabilitation;
2. a stay in a non-psychiatric hospital;
3. primary care stay.

An interruption of up to 30 days is not treated as an interruption and these days are not counted when calculating the 1,095 days. What if your stay is interrupted for a weekend break or a holiday? In that case we count these days in our calculation.

Long-term medical stay

If you require a long-term medical stay at a GGZ institution (longer than 365 days), then you need prior permission. Your care provider will request this permission from us in the 9th and/or 21st month of treatment by submitting the completed Long-term Medical Necessity Stay GGZ Checklist via the zk.nl/machtigingggz webpage. The authorisation is valid for a maximum of 12 months.

If your treatment requires you to stay hospitalised for longer than 1,095 days, you can apply for an indication for the Long-Term Care Act in consultation with your healthcare provider.

Additional terms and conditions which apply when the care is provided by a non-contracted care provider

Do you want to use a non-contracted care provider? You need prior approval from us for:

1. psychiatric residency. Your care provider must complete the following application form to apply for approval before your stay: zk.nl/machtigingggz. We will then assess the appropriateness and legitimacy of the request. We will notify your care provider when we authorise or reject your application.
2. for treatment with the medicine Spravato (esketamine) in the case of hard-to-treat depression by a non-contracted care provider. Your care provider must complete the following application form to apply for approval: zk.nl/machtigingggz. We will then assess the appropriateness and legitimacy of the request. We will notify your care provider when we authorise or reject your application.
3. for treatment abroad by a care provider without a Dutch AGB code. Your care provider must complete the following application form to apply for approval: zilverenkruis.nl/consumenten/service/buitenland/formulieren/machtiging-buitenland-ggz. We will then assess the appropriateness and legitimacy of the request. We will notify your care provider when we authorise or reject your application.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to treatment sessions with a speech therapist insofar as this care has a medical purpose. Speech therapists treat disorders related to personal communication, voice, language, speech, hearing and swallowing. The nature and extent of the care provided are limited to the care normally provided by speech therapists. This also applies to stutter therapy given by a speech therapist.

What you are not entitled to under this article

You are not entitled to:

1. treatments that we do not define as speech therapy, which include the treatment of dyslexia and of language developmental disorders relating to dialect or speaking a different language;
2. surcharges for:
   • appointments outside of regular working hours;
   • missed appointments;
   • reports.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

If you have an increased risk of foot ulcers because of diabetes mellitus or another condition or medical treatment, In that case, you are entitled to foot care. The nature of the foot care you receive will depend on your care profile (care profile 1, 2, 3 or 4). Your care profile is determined by the GP, company doctor, paediatrician, medical specialist, geriatrician, doctor specialised in treating people with an intellectual disability, nursing specialist or physician assistant. To assess this, the physician relies on the siMS score or risk classification.

Once your care profile has been established, a personal treatment plan will be prepared for you. This will be done by a suitably qualified and competent podiatrist. The number of foot inspections and the use of diagnostics will partly depend on the care profile. You are entitled to the care components as included in the applicable care module concerning prevention of foot ulcers by the Nederlandse Vereniging van Podotherapeuten (NVvP), insofar as these have been designated by Zorginstituut Nederland as medical care covered by the basic insurance. The care module can be found on our website or obtained from us.

The foot care to which you are entitled under this policy is arranged as part of integrated care or through care providers outside the healthcare chain. For foot care arranged as part of integrated care, please see article B.38.

Conditions for entitlement to preventive foot care

1. The podiatrist must meet the following conditions:
   
   • The podiatrist must be registered as such in the Kwaliteitsregister Paramedici;
     The podiatrist may delegate the provision of preventive foot care to a chiropodist. The chiropodist works as a subcontractor for the podiatrist.
     A chiropodist is, when concerning:
     
     • a diabetic foot:
       
       • a paramedical chiropodist, medical chiropodist or chiropodist+ with the entry 'foot care for diabetics' (DV), registered in the paramedical foot care register (RPV) of the Stipezo trade association, category 1 (A+B);
       • a medical chiropodist or a chiropodist with the entry 'foot care for diabetics' (DV) registered in the ProCERT KwaliteitsRegister voor Pedicures (KRP);
       • the Kwaliteitsregister Medisch Voetzorgverleners (KMV) maintained by Kwaliteitsregistratie en Accreditatie Beroepsbeoefenaren in de Zorg (KABIZ) in partnership with Nederlandse Maatschappij van/voor Medisch Voetzorgverleners (NMMV).
     • a rheumatic foot:
       
       • a paramedical chiropodist, medical chiropodist or chiropodist+ with the entry 'foot care for diabetics' (RV) registered in the Register Paramedische Voetzorg (RPV) maintained by the Stipezo trade association, category 1 (A+B);
       • a medical chiropodist (MP) or a chiropodist with the entry 'rheumatoid foot' (RV) registered in the ProCERT KwaliteitsRegister voor Pedicures (KRP);
       • the Kwaliteitsregister Medisch Voetzorgverleners (KMV) maintained by Kwaliteitsregistratie en Accreditatie Beroepsbeoefenaren in de Zorg (KABIZ) in partnership with Nederlandse Maatschappij van/voor Medisch Voetzorgverleners (NMMV).
     • another indication that leads to an increased risk of foot ulcers:
       
       • a paramedical chiropodist or medical chiropodist , registered in the Register Paramedische Voetzorg (RPV) maintained by the Stipezo trade association;
       • a medical chiropodist registered in the ProCERT KwaliteitsRegister voor Pedicures (KRP).
2. The podiatrist is the specialist in charge. The podiatrist will claim the costs directly from us quarterly. This also applies if the treatments are provided by a chiropodist
3. You need a statement from the GP, company doctor, paediatrician, medical specialist, geriatrician, doctor specialised in treating people with an intellectual disability, nursing specialist or physician assistant. The statement must specify your care profile. We use the statement to determine if and to what extent you are entitled to preventive foot care under this article.
4. The podiatrist must note the care profile and details of the services provided on the invoice.

What you are not entitled to under this article

You are not entitled to:

1. foot care and treatment by a podiatrist or chiropodist if you have an increased risk of foot ulcers and are entitled to the corresponding integrated care, which includes foot care. These foot care treatments fall under integrated care (see article B.38);
2. medical devices for foot care treatment, such as podiatric insoles and orthoses. More information about this can be found in the Medical Devices Regulations (Reglement Hulpmiddelen). This can be found on our website or obtained from us.
3. foot care services provided by a chiropodist if you have no care profile or Care profile 1 (Zorgprofiel 1). If you have Care Profile 1 (Zorgprofiel 1), you may be entitled to reimbursement under your supplementary insurance;
4. foot screening by a general practitioner. This foot screening falls under GP care (see article B.37).

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Do you want to have genetic research carried out? Or do you want advice? In that case you are entitled to obtain it in a centre for genetic research. This care comprises:

1. research into and on hereditary disorders by means of genealogical analysis;
2. chromosomal research;
3. biochemical diagnostics;
4. ultrasound scanning and DNA research;
5. genetic advice and psychosocial counselling provided as part of this care.

If it is necessary to be able to advise you, the centre will also examine persons other than yourself. The centre can also advise these persons.

Condition for entitlement to genetic research and advice

You must have a referral from your doctor, obstetrician or midwife.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to necessary mechanical respiration and the specialist medical care this involves. The care can take place in a treatment centre or at home.

Mechanical respiration at home

Mechanical respiration can be provided at home, under the responsibility of a respiratory centre. In that case:

1. the respiratory centre provides the necessary apparatus – ready-to-use – for every treatment;
2. the respiratory centre provides specialist medical care and the appropriate pharmaceutical care involved in mechanical respiration;
3. electricity costs are reimbursed. You can find the current daily rate on our website.

Condition for entitlement to mechanical respiration

You must be referred by a pulmonologist.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Are you receiving dialysis treatment at home? In that case, you are entitled to reimbursement of the associated costs. These are:

1. any modifications necessary in and around the home and for subsequently returning things back to their original state. We only reimburse the costs of modifications we consider reasonable. Furthermore, we only reimburse these modification costs if they are not already covered by other statutory regulations;
2. other reasonable costs directly related to your dialysis at home (such as the costs of water and electricity). These too will only be reimbursed if they are not covered by other statutory regulations.

Condition for entitlement to reimbursement of these costs

You must obtain our written permission in advance. You must have submitted an estimate of the costs.

In the case of organ transplants you are entitled to the following treatments:

1. transplantation of tissues and organs in a hospital. The transplant procedure must be performed in:
   • a member state of the European Union;
   • a state that is party to the Agreement on the European Economic Area;
   • another state. In that case, the donor must live in that state and must be your spouse, registered partner or a first, second or third degree blood relative;
2. transplantation of tissues and organs in an independent treatment centre legally qualified and competent to perform these procedures.

In the case of proposed transplantation of an organ you are entitled to reimbursement of the costs of specialist medical care associated with:

1. the choosing of the donor;
2. the surgical removal of the transplant material from the chosen donor;
3. examination, preservation, removal and transportation of postmortem transplant tissue.

You are entitled to reimbursement of the costs of:

1. care to which the donor is entitled in under this policy. The donor is entitled to reimbursement for up to 13 weeks, or 6 months in the case of a liver transplant, from the date of discharge from the hospital. This must be the hospital in which the donor stayed for the selection or removal of the transplant material. Furthermore, you are only entitled to reimbursement of the costs of the care provided if it relates to that hospital stay;
2. transport of the donor by the lowest class of public transport, or, if medically necessary, by car. The transport must be related to the selection process, the stay in hospital, discharge from hospital or the care referred to in point a;
3. Transport of a donor who lives abroad to and from the Netherlands. The donor is only entitled to transport if you are undergoing a kidney, bone marrow or liver transplant in the Netherlands. You are also entitled to other transplant-related costs incurred as a result of the donor residing abroad.

In the case of b and c, if the donor has basic insurance, entitlement to reimbursement of the costs of transport applies under the donor's basic insurance. If the donor does not have basic insurance, these costs will be covered by the recipient's basic insurance.

Conditions for entitlement to this care

1. Are you having the transplant done in a hospital? And is this hospital not contracted by us? You must request our permission in writing before the transplant. Do you want to know with which hospitals we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker.
2. You must obtain advance permission for donor transport from our Transport Telephone Line (Vervoerslijn, +31 71 365 41 54).

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to plastic surgery procedures performed by a medical specialist at a hospital or independent treatment centre (ZBC) if these procedures help to correct:

• 1. abnormalities in personal appearance associated with demonstrable physical dysfunction;
  2. mutilations that are the result of an illness, an accident or a medical intervention (this includes beard epilation for trans women);
  3. the following congenital deformities:
     • cleft lip, jaw and palate;
     • deformities of the facial bones;
     • benign proliferations of blood vessels, lymphatic vessels or connective tissue;
     • birthmarks or
     • deformities of the urinary tract and genital organs;
  4. paralysed or weakened upper eyelids if the paralysis or weakening seriously impairs the field of vision (if the lower edge of the upper eyelid, or overhanging skinfold, is within 1 mm of the centre of the pupil), or if the paralysis or weakening is a consequence of a congenital defect or a chronic disorder present at birth;
  5. the abdominal wall (abdominoplasty), in the following cases:
     • mutilations whose severity is comparable to third degree burns;
     • untreatable inflammation (intertrigo) in skin folds;
     • an extremely severe limitation in the freedom to move (if your belly covers at least a quarter of your upper legs);
  6. primary sexual characteristics in cases of confirmed transsexuality (including epilation of the pubic region as part of vaginoplasty and penile construction);
  7. female breast agenesis/aplasia and a similar situation in trans women (also referred to as male-to-female transgender persons).

If a stay is medically necessary, you are entitled to this care in accordance with article B.28.

Conditions for entitlement to plastic surgery

1. You must have been referred by a GP or medical specialist. For plastic surgery for transgender people, a referral is needed from a medical specialist from the multidisciplinary gender team. The multidisciplinary gender team specialises in protocolised treatment of gender incongruence and works together on a structural basis. Within this team, a relevant expert must be in charge throughout the treatment process.
2. We must give you written permission in advance. We reimburse plastic surgery only if the examinations and treatments are carried out in accordance with the ‘VAV werkwijzer beoordeling behandelingen van plastisch chirurgische aard’ assessment of plastic surgery treatments.

What you are not entitled to under this article

1. Some plastic surgery procedures are not covered by your insurance. You are not entitled to the following procedures:
   1. surgical placement or replacement of breast implants, unless the surgery is performed following a (partial) mastectomy or in the case of female breast agenesis/aplasia;
   2. surgical removal of a breast prosthesis without a medical necessity;
   3. liposuction of the stomach;
   4. treatment to correct paralysed or weakened upper eyelids, unless the paralysis or weakening seriously impairs the field of vision (if the lower edge of the upper eyelid, or overhanging skinfold, is within 1 mm of the centre of the pupil), or if the paralysis or weakening is a consequence of a congenital defect or a chronic disorder present at birth.
2. You are not entitled to: treatments at a private clinic.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Selective contracting for Basis Budget

Do you want to know which hospitals have been contracted especially for Basis Budget insurance? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us. A list of the reimbursement tariffs that apply to care provided by non-contracted hospitals can also be found on our website or obtained from us.

You are entitled to specialist medical rehabilitation (24.1) and geriatric rehabilitation (24.2).

Do you want a second opinion? In that case, you are entitled to one. Getting a second opinion means having the diagnosis made by your doctor or treatment proposed by your doctor reassessed. Your doctor can also request a second opinion. The reassessment is performed by a second, independent doctor. The second doctor must possess the same area of expertise and must practice the same profession as the first doctor.

Conditions for entitlement to a second opinion

1. The second opinion must relate to diagnostics or treatment that is covered by the basic insurance.
2. You must be referred by a general practitioner, medical specialist, clinical psychologist or psychotherapist.
3. The second opinion must relate to medical care that is intended for you and which you have discussed with your first doctor.
4. When obtaining a second opinion you give a copy of your first doctor's medical file to the second doctor.
5. You must return to the first doctor with the second opinion. This doctor remains in charge of your treatment.

What you are not entitled to under this article

Insured care does not cover a second opinion if the purpose of the second opinion is to obtain treatment that is not included in the basic insurance.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Selective contracting for Basis Budget

Do you want to know which hospitals have been contracted especially for Basis Budget insurance? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us. A list of the reimbursement tariffs that apply to care provided by non-contracted hospitals can also be found on our website or obtained from us.

Articles B.15, B.27 and B.28 list the conditions for nursing at an inpatient facility (e.g., a hospital). However, you are also entitled to nursing and care in your own surroundings. The nature and extent of the care provided is limited to the care normally provided by nurses and carers, which is specified in the occupational profiles and national quality framework defined by Verpleegkundigen & Verzorgenden Nederland (V&VN) (Netherlands Nurses and Carers Association).

You are entitled to nursing and care related to the need or a high risk of the need for medical care.

For children under the age of 18, nursing and care can also be provided at a medical childcare facility or children's hospice.

Conditions for entitlement to nursing and care in your own surroundings

1. a. For adults aged 18 or older, a care needs assessment conducted in your presence by a professionally (at least BA level) qualified, BIG-registered nurse, in accordance with the applicable standards for the assessment of care needs and the organisation of nursing and care in one's own surroundings.
   b. For children under the age of 18, a care needs assessment conducted by a paediatric nurse with a degree from a university of applied sciences or a nurse with specialist training in paediatric nursing. The paediatrician or medical specialist remains ultimately responsible for the treatment. If it becomes apparent that intensive child care is required, the nurse must work for a care provider affiliated with the Intensive Child Care Branch Organisation (BIKZ). If there are capacity problems due to a shortage on the labour market, you can contact us to find a suitable solution with the care provider in question. The care need must be defined in the home environment with you (the child) and your parent(s) or legal guardian(s) present, in accordance with the Guideline for Care Needs Assessment in Childcare and the standards for care needs assessment and organisation of nursing and care in your own surroundings.
2. A professionally qualified (at least BA level), BIG-registered nurse (as stated in 1a and 1b) must conduct a care needs assessment before commencing care. This means that the district nurse will discuss with you what care you need in your particular situation, and the intended results and duration of the care. As part of the care needs assessment, the agreements that have been made are put in a care plan and the need for care is translated into the number of hours of nursing and care required. In the care plan the professionally (HBO) qualified BIG-registered nurse notes the care need and the care that is to be provided. The care plan specifies the number of hours of nursing and the number of hours of care. The care needs must be defined in accordance with the 6 standards listed in the document 'Standards for needs assessment and organisation of nursing and care in one's own surroundings' (‘Normen voor indiceren en organiseren van verpleging en verzorging in de eigen omgeving’).
3. Nursing and care must be provided by a level 3 nurse or caregiver or higher.
4. In palliative terminal care, the nurse has noted in the medical file that the attending physician (name, specialty, BIG number and date) has determined that the palliative terminal stage has begun. The nature, content and extent of the care must be detailed in the care plan. Provision of care must comply with the quality framework for palliative care.
5. When nursing involves restricted or high-risk procedures, it must be demonstrated that said procedures are performed on the instructions of a physician. The health care provider must also be demonstrably competent and qualified to perform these procedures. In the case of a high-risk procedure, the nature, extent and content of the care must be elaborated in the care plan. In the case of a restricted procedure, a request for execution from a doctor must be present, and work must be carried out in accordance with the 'Manual for restricted procedures in district nursing & care' (ActiZ, 2019).

What you are not entitled to under this article

1. You are not entitled to maternity care under this article. This is reimbursed under article B.32;
2. You are not entitled to personal care under this basic insurance if you are entitled to personal care under the Dutch Social Support Act (Wet maatschappelijke ondersteuning (Wmo)).
3. You are not entitled to care through your own network (formerly "usual care"). When making a care needs assessment, the district nurse must assess what you and your network can solve yourself, according to the V&VN Normative Framework for Assessing and Organising Nursing and Care in One's Own Environment. This means that they will identify your network and consider what care may or may not be expected of your network, based on workload and capacity. The care that can be provided by your network may not be included in an indication for district nursing. The indication must include the consideration that the district nurse makes in this regard. The V&VN defines network as: "Next of kin and family caregivers" such as partners, children, roommates, family and friends of the insured. At the time of indication, the district nurse considers how the request for help can be solved or how the intervention can be carried out, taking into account the full context of the insured (care seeker). Self-sufficiency (together with the insured’s network) is the starting point of the Standards Framework.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Additional conditions if care is provided by a non-contracted care provider

1. Are you using a non-contracted care provider? In that case, you must request permission from us in advance. To request permission, you must use the 'Authorisation to use non-contracted district nursing care' (‘Aanvraag machtiging niet-gecontracteerde wijkverpleegkundige zorg’) application form, which can be found on our website. When requesting permission, you need to supply the following:
   
   • the care needs assessment and the care plan (these must meet the conditions listed above);
   • the nursing diploma held by the professionally (at least BA level) qualified BIG- registered nurse who conducted the care needs assessment;
   • in palliative terminal care, evidence that the nurse has noted in the medical file that the attending physician (name, specialty, BIG number and date) has determined that the palliative terminal stage has begun.

We will then assess the appropriateness and legitimacy of your request. We assess the efficacy by, among other things, comparing your indication with similar indications, and determine whether it is suitable for your care needs. We can also ask the nurse who drew up your indication for further explanation. We will notify you whether your request has been approved or fully or partially denied.

2. You must submit the invoices you receive from your non-contracted care provider to us for reimbursement. Invoices will only be reimbursed if authorisation to use a non-contracted care provider has been requested and approved.

You are entitled to primary care stay. The stay must be necessary for medical care and may involve nursing and (paramedical) care. Your general practitioner must consider that recovery is to be expected in the short term. The purpose of the stay is generally to enable you to return to your home situation. Has your doctor indicated that your estimated life expectancy is less than 3 months? In that case you are entitled to palliative terminal care at an institution where patients can stay for primary care.

Primary care stay consists of:

• medically necessary stay in connection with medical care;
• 24-hour availability and provision of nursing and/or care;
• medical care provided by a general practitioner, a geriatric specialist and/or a doctor specialised in treating people with an intellectual disability;
• paramedical care (physiotherapy, Cesar or Mensendieck remedial therapy, speech therapy, dietetic therapy and/or occupational therapy) required in connection with the need for the stay.

The nature and extent of the medical care provided are limited to the care normally provided by general practitioners.

Conditions for entitlement to primary care stay

1. You must be referred by a general practitioner, a medical specialist, a doctor specialised in emergency medicine, a geriatric specialist or a doctor specialised in treating people with an intellectual disability.
2. If your stay will be longer than 3 months, you or your care provider must request permission from us to extend the stay beyond the first 3 months, before the 60th day of your stay. This does not apply for palliative care.
3. You must obtain our advance permission if you wish to stay with a non-contracted primary care provider. For more information about the application, see the bottom of this article.
4. For palliative care, the provision of care must be aligned with the palliative care module or the quality framework for palliative care.
5. The primary nurse must be a level 4 nurse at minimum.

What you are not entitled to under this article

You are not entitled to a primary care stay:

1. if you have been allocated a complete or modular home care package or a personal care allowance (PGB) to pay for care in your own home under the Dutch Long-term Care Act (Wet langdurige zorg (Wlz)), or if you receive care through a form of clustered housing. In that case the cost of the stay is covered under the Long-term Care Act (Wlz);
2. in the case of respite care. Respite care is the temporary assumption of full responsibility for the provision of care to provide relief for the usual informal carer. This is paid for by the Social Support Act (Wmo);
3. if you are under the age of 18 and need mental healthcare. This falls under the Dutch Youth Act (Jeugdwet). You can contact your municipality about this.

How many days of clinical stay are you entitled to?

Days of primary care stay count towards the calculation of the maximum of 1,095 days of stay. The following forms of stay also count towards the calculation of the 1,095 days:

1. (psychiatric) hospital stay;
2. stay in a rehabilitation centre or a hospital for the purpose of rehabilitation.

An interruption of up to 30 days is not treated as an interruption and these days are not counted when calculating the 1,095 days. What if your stay is interrupted for a weekend break or a holiday? In that case we count these days in our calculation.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Additional conditions if primary care stay is provided by a non-contracted care provider

1. Do you want to use a non-contracted care provider? Then you need prior approval from us. To apply for approval, you or your healthcare provider must use the Request for Primary Care Stay with Non-Contracted Healthcare Providers application form (Machtigingsformulier ELV niet-gecontrracteerde zorgaanbieders), which can be found on our website.
2. The application must include the referral from the general practitioner, geriatric specialist or medical specialist. The referral must state the care need and the relevant comorbidity. It must be clear from the explanation whether the request concerns a low, high or palliative primary care stay. The referral must also explain that you are expected to be able to return to your home situation after treatment. The latter does not apply to palliative terminal care. Upon receiving your application, we will assess its efficacy and legitimacy. We will notify you and your care provider whether your request is approved or denied.
3. You must submit the invoices you receive from your non-contracted care provider to us for reimbursement. Invoices will only be reimbursed if authorisation to use a non-contracted care provider has been requested and approved.

You are entitled to specialist medical care and stay. This care can be provided at:

1. a hospital;
2. an independent treatment centre; or
3. the home practice of a medical specialist (extramural specialist), if they have an AGB code. You can check this on agbcode.nl. If an extramural specialist is not contracted by us, reimbursement takes place in the same way as for non-contracted independent treatment centres.

The care consists of:

1. specialist medical care;
2. your treatment and possible stay (based on the lowest class accommodation and care) in a hospital or independent treatment centre, including nursing and care, paramedical care, medicines, medical devices and dressings that are part of the treatment.

The nature and extent of the care provided are limited to the care normally provided by medical specialists.

Conditions for entitlement to specialist medical care

1. You must be referred by a general practitioner, a company doctor, geriatric specialist, a doctor specialised in treating people with an intellectual disability, a paediatrician, a physician assistant, a nurse specialist, an emergency department doctor, a doctor assistent, clinical technologist, obstetrician (if it concerns obstetric care or a referral to a paediatrician within the first 10 days after delivery), optometrist (only if it concerns eye care), oral surgeon, dentist (only if it concerns dermatology, neurology, anesthesiology or ENT), GGD doctor (for TBC or an STI) or another medical specialist.
2. A hearing-aid specialist or medical physicist audiologist can also refer you to an ENT specialist.
3. You may also be referred to a paediatrician by the RIVM after a positive/abnormal heel prick screening for a newborn.
4. If you live in a nursing home and do not have your own general practitioner, you may also be referred by a junior doctor working in your nursing home.
5. The referring doctor (see under 1) informs our medical advisor of the reason for your stay. You must authorise the referring doctor to provide this information.
6. Are you being admitted for plastic surgery? In that case you are only entitled to this care if you have requested our permission. This must be done at least 3 weeks before the stay. As proof of our permission, we issue the hospital or independent treatment centre with a guarantee statement.
7. The stay must be medically necessary for specialist medical care.
8. If you are undergoing polysomnography (a comprehensive sleep registration test that measures the quality of your breathing and sleep) with a non-contracted care provider, then you need prior approval from us. To apply for approval, your care provider must submit the authorisation form for non-contracted clinical mental healthcare services (“Aanvraag machtiging niet-gecontracteerde klinische GGZ”), which can be found on our website.

What you are not entitled to under this article

You are not entitled to:

1. Specialist medical care and/or stay, as described in this article, if you are treated at a private clinic;
2. treatments for snoring (uvulopalatoplasty);
3. treatment with a corrective helmet for plagiocephaly and brachycephaly without craniostenosis;
4. treatments designed to result in sterilisation;
5. treatments designed to reverse sterilisation;
6. treatments for circumcision without medical necessity.

Mental healthcare (GGZ) does not fall under this article. To find out what mental healthcare you are entitled to, read article B.15.

How many days stay are you entitled to?

Have you been admitted to a hospital or independent treatment centre? In that case you are entitled to an uninterrupted stay in a hospital or independent treatment centre for a period of up to 1,095 days. The following forms of stay also count towards the calculation of the 1,095 days:

1. stay in a rehabilitation centre or a hospital for the purpose of rehabilitation;
2. stay in a psychiatric hospital;
3. primary care stay.

An interruption of up to 30 days is not treated as an interruption and these days are not counted when calculating the 1,095 days. What if your stay is interrupted for a weekend break or a holiday? In that case we count these days in our calculation.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

The lists of the reimbursement rates that apply to care provided by non-contracted hospitals and independent treatment centres can also be found on our website or obtained from us.

Selective contracting for Basis Budget

Do you want to know which hospitals have been contracted especially for Basis Budget insurance? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

If you are undergoing CAR T-cell therapy and cannot get to the hospital where you are being treated within 60 minutes, you are entitled to reimbursement of the costs of overnight accommodation near the hospital. You will be reimbursed up to € 89 per night.

Condition for reimbursement

If you are undergoing CAR T-cell therapy and cannot get to the hospital where you are being treated within 60 minutes, you are entitled to reimbursement of the costs of overnight accommodation near the hospital during the third and fourth week of treatment. You will stay at the hospital during the first and second week after treatment.

How do I claim my transport costs?

You must submit the invoices for your accommodation costs to us using the claim form on our website.

When assessing your entitlement to obstetric or midwifery care and care during delivery, we distinguish between 'with medical indication' (30.1) and 'without medical indication' (30.2).

You are entitled to IVF or ICSI (31.1), other forms of fertility-enhancing treatments (31.2), sperm cryopreservation (31.3) and oocyte vitrification (31.4).

Female insured persons are entitled to maternity care. The nature and extent of care provided is limited to the care normally provided by maternity carers.

Maternity care can be provided:

1. at home
   A statutory personal contribution of € 5.10 per hour applies for maternity care provided at home. Maternity care at home is also reimbursed to the newborn’s guardian after adoption or if the mother died during or shortly after childbirth.
2. at a birth or maternity centre
   A maximum of 8 hours of maternity care is charged per bed-day in a birth or a maternity centre. The statutory personal contribution of € 5.10 per hour also applies in this case. You are entitled to up to 4 bed-days. You are entitled to receive the remainder of the indicated maternity care at home.
3. at hospital
   Are you staying at a hospital without a medical indication? In that case, a statutory personal contribution of € 40 applies for each day of your stay (€ 20 for the mother and € 20 for the child). If the hospital charges more than € 286 per day (€ 143 for the mother and € 143 for the child), you will also have to pay the amount above € 286 per day in addition to the personal contribution of € 40.
   You are entitled to the number of hours of maternity care determined in the manner indicated below under the heading 'How much maternity care will you receive?', divided over a maximum of 6 weeks, counting from the day of delivery. If the maternity care has already partly taken place at the hospital, a number of hours of maternity care will be deducted from the aforementioned number of determined hours. For the remaining number of hours you are entitled to maternity care at home.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

How much maternity care are you entitled to?

The number of hours of maternity care to which you are entitled is limited to at least 24 hours to a maximum of 80 hours, spread over a maximum of six weeks, counting from the day of delivery. The birth centre or maternity centre will determine the number of hours you receive. This will be done in accordance with the National Maternity Care Indication Protocol (Landelijk Indicatieprotocol Kraamzorg) or the indication protocol.method that replaces it. The protocol and explanatory notes can be found on our website or contact us.

You are entitled to care provided by the Dutch Child Oncology Group (Stichting Kinderoncologie Nederland (SKION)). SKION coordinates and registers tissue material it receives and establishes the diagnosis.

As a female insured person you are entitled to:

1. counselling that explains the procedures involved in prenatal screening;
2. Non-Invasive Prenatal Testing (NIPT). You are only entitled to reimbursement of this test if you have a medical indication;
3. invasive diagnostic test (for example a chorionic villus test or an amniocentesis). You are only entitled to reimbursement of this diagnistic if you have a medical indication or if the result of the NIPT is positive. Your care provider will determine this.

Condition for entitlement to prenatal screening

The care provider who carries out the prenatal screening must have a permit as defined in the Population Screening Act (WBO-vergunning) or work in collaboration with a regional centre that has such a permit.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to 3 hours of dietetic therapy by a dietitian. This means 3 hours per calendar year. Dietetic therapy includes information and advice on nutrition and eating habits. Dietetic therapy must have a medical objective. The nature and extent of the care provided is limited to the care normally provided by dietitians.

What you are not entitled to under this article

You are not entitled to:

1. appointments outside of regular working hours;
2. missed appointments;
3. reports.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

If you have a moderate, high or extreme weight-related health risk profile (GGR) under the Obesity Care Standard (Zorgstandaard Obesitas) by Partnership Overweight Netherlands (Partnerschap Overgewicht Nederland (PON)), you are entitled to a Combined Lifestyle Intervention (Gecombineerde Leefstijl Interventie (GLI)).

The GLI is a programme aimed at modifying your behaviour. You will receive guidance in improving your eating habits, increasing your exercise activity and maintaining these habits as a sustainable behavioural change. This is a 2-year programme.

Conditions for entitlement to GLI

1. You must be 18 or older. If you are 16 or 17 years old, you are entitled to a Combined Lifestyle Intervention (Gecombineerde Leefstijl Interventie (GLI)) if your general practitioner deems it appropriate.
2. You must be referred by a general practitioner, medical specialist or company doctor.
3. A moderately, strongly or extremely elevated Weight-related Health Risk (Gewichtsgerelateerd GezondheidsRisico (GGR)) must be established by the general practitioner, medical specialist or company doctor. These risks are detailed in PON’s Obesity Care Standard.
4. The care provider works with an effective GLI programme registered as such with the Healthy Living Bureau register and designated as insured care.
5. The care provider must at least have the competencies of a lifestyle coach with a degree from a university of applied sciences and be registered with a GLI endorsement in one of the following registries:
   1. the Lifestyle Coaches Registry of the professional association for lifestyle coaches in the Netherlands (Beroepsvereniging Leefstijlcoaches Nederland (BLCN));
   2. the Central Quality Registry (Centraal Kwaliteitsregister (CKR)) or the partial registry of the Physical Therapy Certification Foundation;
   3. or, in the case of dietitians or remedial therapists, the quality registry for paramedics (het kwaliteitsregister Paramedici).

What you are not entitled to under this article

You are not entitled to GLI if your Weight-related Health Risk has been assessed by your general practitioner, medical specialist or company doctor, as slightly elevated according to the Healthcare Standard for Obesity.

Lower reimbursement for treatment provided by a non-contracted care provider

We have contracted GLI care groups that work with care providers who offer the effective GLI. Does your care provider work on behalf of the care group? Then you will receive full reimbursement. The care group invoices the costs directly to us on a quarterly basis; the care provider invoices his or her costs to the care group.

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Additional terms and conditions which apply when the care is provided by a non-contracted care provider

Do you want to use a non-contracted care provider? Then you need prior approval from us. To apply for approval, your healthcare provider must use the Request for Non-Contracted Combined Lifestyle Interventions application form (aanvraagformulier niet-gecontracteerde Gecombineerde Leefstijlinterventies) on our website. The following must be sent with the application:

• the name of and referral letter from the general practitioner, medical specialist or company doctor, stating that you have a moderately, severely or extremely elevated GGR;
• the name and AGB code of the health care provider supervising the GLI program;
• the name of the GLI programme.

We will then assess the appropriateness and legitimacy of the request. You and/or your care provider will receive a notification from us whether your request has been approved or denied.

You are entitled to medical care provided by a general practitioner. The care can also be provided by a care provider under the supervision of the general practitioner. If requested by a general practitioner, you are also entitled to Xrays and laboratory tests. The nature and extent of the care provided is limited to the care normally provided by general practitioners.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to integrated care for diabetes mellitus type 2 (for insured persons aged 18 or older), COPD, asthma or vascular risk management (VRM) if we have made agreements with a care group. In the provision of integrated care the patient with a chronic condition is the primary concern. Care providers from various disciplines play a role in the care programme. We currently purchase integrated care for diabetes mellitus type 2, COPD, asthma and VRM. The content of these programmes is aligned with the current care standards for diabetes mellitus, COPD, asthma and VRM.

Entitlement to integrated care provided by a non-contracted care group

Do you have diabetes mellitus type 2 and are you under the age of 18? Or is your care provider not affiliated with a care group? In that case you are only entitled to care normally provided by medical specialists, dietitians and general practitioners. This is the care as defined in articles B.28, B.35 and B.37. In the case of diabetes mellitus type 2, you are also entitled to foot care as defined in article B.18.

To find out with which care providers we have a contract, use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

If you are younger than 18 and have a moderately elevated weight-related health risk or higher according to the Addendum voor kinderen op de Zorgstandaard Overgewicht en Obesitas by Partnerschap Overgewicht Nederland (PON), you are entitled to care and support within the framework of an integrated approach for obese children that covers two domains (the social domain and the domain of the Health Insurance Act/basic insurance), insofar as such care and support have been designated as basic insurance care by the Dutch National Healthcare Institute (ZINL). Upon determination of a moderately elevated weight-related health risk or higher, you will be referred to a central care provider who will perform a broad history (or comprehensive intake and analysis of the problem) and prepare a plan of action. If the plan of action indicates a combined lifestyle intervention (GLI), you are entitled to the GLI and further supervision and coordination by the central care provider. The central care provider guides and coordinates within the chain to ensure the right support and care for the child and family at the right time by the right professional, and ensures consistency in the integrated approach. The GLI is an intervention aimed at reducing energy intake, increasing physical activity and potentially adding custom psychological interventions to support behavioural change.

Conditions for entitlement to the Integrated approach for obese children

1. Children up to 18 are entitled to a GLI under this article. If you are 16 or 17 years old, you are also entitled to the GLI for adults from B.36 if your GP considers this care appropriate for you. Care under this section and B.36 cannot take place at the same time.
2. You must have been referred by a GP, paediatrician, or paediatric nurse, although a paediatric nurse may not refer patients to themselves, given point 8 below.
3. A moderately, severely, or extremely elevated weight-related health risk must be determined by a GP, paediatrician, or paediatric nurse according to the Addendum voor Kinderen to PON's Zorgstandaard Overgewicht en Obesitas.
4. You are entitled to a GLI and further support and coordination by a central care provider if you have a moderately elevated weight-related health risk or higher and a GLI programme is indicated and substantiated in the care plan.
5. The GLI programme has a maximum duration of 24 consecutive months.
6. The deployment of the central care provider within this integrated approach can last up to 3.5 years in its entirety.
7. The phase between taking the history and starting the GLI (intermediate phase) must be no more than 6 months. The intermediate phase can only be extended if there are clear arguments for it and we have given our prior consent. To that end, the central care provider must submit an application with the reasoning via our website.
8. The central care provider must be a paediatric nurse with an HBO+ education supplemented by specific training to become a central care provider with a focus on knowledge of the social and care domains, specifically aimed at youth and family. The central care provider must have proof of successful completion of their training and education.
9. The GLI must be conducted by an HBO-trained paediatric lifestyle coach. The required competencies for the paediatric lifestyle coach are still being elaborated by Beroepsvereniging Leefstijlcoaches Nederland (BLCN). BLCN must clarify what additional requirements apply to paediatric lifestyle coach training compared to adult lifestyle coach training (e.g., the ‘systemic’ approach), accredit training for this purpose and establish a register for paediatric lifestyle coaches. Once the BLCN has established such a register, paediatric lifestyle coaches must be registered in it.
10. Paediatric lifestyle coaches must work with paediatric GLI programmes whose effectiveness has been established and proven at a sufficient level by the RIVM and which have been designated as insured care by Zorgverzekeraars Nederland/Zorginstituut Nederland and us.

What you are not entitled to under this article

You are not entitled to:

1. an anamnesis and plan of action when your GP or paediatrician has determined your weight-related health risk to be slightly elevated according to the Addendum voor Kinderen to the Zorgstandaard Overgewicht en Obesitas by Partnerschap Overgewicht Nederland (PON).
2. a GLI and further support and coordination by the central care provider if the GLI—despite having a moderately elevated weight-related health risk or higher—is not indicated by the central care provider in the plan of action.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

You are entitled to up to 1 stop smoking programme designed to help you give up smoking per calendar year. The stop smoking programme must consist of medical and possibly pharmacotherapeutic interventions that support behavioural change, the objective of which is to stop smoking. This involves support such as that normally provided by general practitioners, medical specialists and clinical psychologists.

Conditions for entitlement to a stop smoking programme

1. You must be referred by a general practitioner, a company doctor, a geriatric specialist, a doctor who specialises in treating the mentally handicapped, an obstetrician or midwife or a medical specialist.
2. Pharmacotherapy with nicotine-replacement medicines, nortriptyline, bupropion and varenicline is only reimbursed in combination with support that focuses on behaviour.
3. The programme must have been drawn up in accordance with the description and frameworks set out in the 'Stoppen met Roken' (Stop smoking) care module and comply with the CBO Tobacco Addiction (Tabaksverslaving) guideline.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Do you suffer from thrombosis? In that case you are entitled to care from a thrombosis service. The care provided by this service includes:

1. taking regular blood samples;
2. carrying out the necessary laboratory tests in order to determine the coagulation time of your blood. The thrombosis service may also arrange for a third party to carry out these tests. The thrombosis service remains accountable;
3. providing you with apparatus and equipment so you can measure the coagulation time of your blood yourself;
4. training you to use this equipment and supervising you when you carry out measurements;
5. advising you on the use of medicines to influence the coagulation time of your blood.

Condition for entitlement to care from a thrombosis service

You must be referred by a general practitioner, an obstetrician or midwife (in case of pregnancy or delivery), a geriatric specialist, a doctor for the mentally handicapped or a medical specialist.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

Medical care for specific patient groups (GZSP) is a collection of forms of care for vulnerable people who still live at home. Care needs are multifaceted and may be somatic, psychological and/or behavioural. This concerns:

• elderly people with complex disorders (somatic and/or psychological);
• people with chronic, progressive, degenerative disorders such as Parkinson's, Huntington's and multiple sclerosis;
• people with non-congenital brain injuries;
• people with intellectual disabilities.

The care consists of:

• generalist medical care aimed at vulnerable patients such as the elderly and people with an intellectual disability. The treatment focuses on teaching the patient skills or behaviour to help them deal with the implications of their condition, disorder or disability.
• care which is no longer focused on recovery, but on dealing with the problems and limitations arising from the condition.

The care you receive is determined by the care needs and professional considerations that apply to the specific interventions offered. The care may be provided by a doctor specialised in treating people with an intellectual disability or a geriatric specialist (monodisciplinary care). The treatment may also be provided by a multidisciplinary team led by the GZSP director. In both cases, the treatment will be laid out in a treatment plan. The care may be provided individually or in groups. The provided care must comply with the GZSP "Group Care" basic principles (Uitgangspunten ‘Zorg in een groep’ Geneeskundige Zorg voor Specifieke Patiëntgroepen (GZSP)) and the GZSP "Individual Performance" basic principles (Uitgangspunten ‘Individuele prestaties’ Geneeskundige Zorg voor Specifieke Patiëntgroepen (GZSP)). These basic principles have been jointly drawn up by various care providers, professional associations and Zorgverzekeraars Nederland. You can view the basic principles at zn.nl/publicaties.

The nature and extent of the care provided is limited to the care normally provided by general practitioners, clinical psychologists and paramedics.

Conditions for entitlement to medical care for specific patient groups

You must be referred by a general practitioner or a medical specialist.

What you are not entitled to under this article

1. You are not entitled to care if the treatment goals have been met or if there are no more treatment goals.
2. You are not entitled to care if an indication for the Long-term Care Act (Wlz) has been issued.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

We reimburse the costs of consultations and treatments provided by alternative healers or therapists. To find out which treatments we reimburse, see the overview of professional associations and treatments. The list of professional associations and treatments can be found on our website or obtained from us.

In addition, we reimburse the costs of homeopathic and anthroposophic medicines.

Conditions for reimbursement

1. Your alternative healer or therapist must be a member of a professional association that satisfies the requirements of our alternative medicine policy. The alternative medicine policy and the list of professional associations that meet our criteria are part of this policy. We only reimburse consultations and treatments included in the overview of reimbursable treatments. The list of professional associations and treatments can be found on our website or obtained from us.
2. The invoice must state the alternative healer's valid AGB code issued for the care being provided, as well as which professional association the alternative healer or therapist is affiliated with.
3. The consultation must be conducted within the context of medical treatment.
4. The consultation must be provided on an individual basis. In other words, it must be only for you.
5. The homeopathic and anthroposophic medicines must be listed as homeopathic or anthroposophic medicines in the Netherlands and in the G-standaard of the Z-Index. The G-standaard is a database which lists all of the medicines available from pharmacies. The G-standaard is a dynamic list that can be amended throughout the year. The reimbursement may also change throughout the year if the registration is amended.
6. The homeopathic and/or anthroposophic medicines must be supplied by a pharmacy. We reimburse these products up to the limit published in the G-Standaard (Z-index) and known to your pharmacy.
7. We only reimburse the costs of homeopathic and anthroposophic medicines if they have been prescribed by a doctor.

What we do not reimburse under this article

We do not reimburse the costs of:

1. care if your alternative healer or therapist is also your general practitioner;
2. (laboratory) tests;
3. manual therapy provided by a physiotherapist;
4. treatments, examinations and courses of a social nature or designed to promote well-being (the extent to which a person feels good physically, mentally and socially) and/or prevention;
5. work or school-related coaching;
6. care reimbursed under another article, e.g. the Mindfulness article;
7. psychosocial care for insured persons up to the age of 18.

We reimburse the costs of:

1. medically necessary patient transport by ambulance or aircraft from abroad to a healthcare institution in the Netherlands;
2. transport of mortal remains (body or remains of the body) from the place of death to the insured person’s home in the Netherlands.

Conditions for reimbursement

1. Patient transport must be required in connection with urgent medical treatment abroad.
2. Zilveren Kruis Emergency Services by Eurocross must give you permission in advance and must also arrange the transport.

Are you travelling abroad? In that case, we reimburse the costs of consultations, necessary vaccinations and/or preventive medication required for a stay abroad. By ‘necessary vaccinations and/or preventive medication’ we mean vaccinations and/or preventive medication identified as necessary by the Landelijk Coördinatiecentrum Reizigersadvisering (LCR) (National Coordination Centre for Travel Advice). The vaccinations recommended by the LCR for each country are listed on their website, lcr.nl/landen

Conditions for reimbursement

1. We only reimburse consultations, medication and vaccinations required to prevent rabies if you will be staying in a country where rabies is endemic (permanently present as a disease in certain areas) for a prolonged period and where adequate medical aid is not easily accessible. You must also meet at least one of the following conditions:
   • you will be spending several days walking or cycling outside of tourist areas;
   • you will be spending more than 3 months (staying) with the local population;
   • you will be staying outside of a resort or protected environment;
   • you are under the age of 12.
2. Preventive medication (such as malaria tablets) must be prescribed by a doctor affiliated with LCR.
3. Preventive medication must be supplied by a contracted pharmacy. What if you choose a non-contracted pharmacy? Then you will receive no reimbursement.

Lower reimbursement for treatment provided by a non-contracted care provider

Do you want to know with which care providers we have a contract? Use the Zorgzoeker on zk.nl/zorgzoeker or contact us.

What we do not reimburse under this article

We do not reimburse the costs of non-prescription drugs not listed in the Regeling zorgverzekering (Health Insurance Regulations). Non-prescription drugs are drugs that can be purchased over the counter in the Netherlands.

We reimburse the costs of medical treatment abroad. The conditions for reimbursement are listed below.