The health insurance system in the Netherlands, which we have already considered in our reviews (часть 1 и Part 2), implies the mandatory availability of basic insurance for each resident. At the same time, in addition to the monthly premium (premie in Dutch), the insured person, in order to start using a health insurance policy, must pay a deductible (as it is commonly called in Dutch) - the so-called own risk (eigen risico).
Own risk (eigen risico, franchise) is the threshold amount that an insured person over the age of 18 must pay before receiving a refund from their insurance company after applying for medical care. Two points are important here:
- the franchise is valid for one calendar year (from January 1 to December 31) - if a person does not seek medical help for a year, then he does not pay the franchise;
- the deductible is not established for all types of medical care - for example, when contacting a family doctor (therapist), you do not need to pay a deductible (see table).
When does the franchise apply?
Eigen risico must be paid for most medical expenses covered by basic insurance, including:
- treatment in a hospital (in a hospital), examinations and visits to a specialist;
- medical care of specialized specialists (consultations, examinations, operations and treatment): cardiologist, pulmonologist, otolaryngologist, etc.;
- medicines prescribed by a family doctor or specialist;
- blood tests and other laboratory tests (as prescribed by a doctor);
- urgent transportation of the patient by ambulance or ambulance helicopter;
- psychological and psychiatric assistance - both consultations and treatment in a specialized institution;
- paramedical care from the basic insurance (if it is included there), for example, physiotherapy, speech therapy, consultations with a nutritionist;
- certain medical aids: hearing aids, dentures, or crutches.
When does the franchise not apply?
You will not have to pay eigen risico for certain types of medical care, including:
- consultations and treatment with a family doctor or nurse;
- a visit to the duty post of a family doctor outside working hours;
- home care/personal assistance provided by a community nurse;
- midwifery and maternity care (or a personal contribution is applied if desired);
- medical care for children under 18;
- medical assistance to categories of persons who fall under the Wlz Law or the Wmo Law;
- certain types of examinations and vaccinations of a nationwide nature;
- all types of medical care under additional insurance.
How does a franchise work?
You pay your deductible as soon as you use the services from the basic package of your health insurance policy, except when the deductible does not apply (for example, medical care for a child under 18).
Step by step it looks like this:
- You go to a doctor, hospital or pharmacy for treatment or medicine.
- A health care provider (practice, hospital) or pharmacy reports the costs to your insurance company.
- The insurance company reimburses the health care provider and, if you have not yet paid the full amount of the deductible for the current calendar year, sends you an invoice for the deductible.
- The deductible amount is either automatically deducted from your bank account, or you pay it yourself before the date indicated on the invoice.
What size is eigen risico?
The government announces the amount of the franchise every year on Prince's Day (Prinsjesdag). It was decided not to tie it to changes in the income of the inhabitants of the Netherlands, so the amount has not changed for several years (since 2016) and is 385 euro per person per year. It is assumed that in 2023 it will remain the same. However, eigen risico is not deductible in the individual's annual income tax return (inkomstenbelasting).
How to calculate the franchise?
Example 1.
- You go to see your family doctor (huisarts) for a consultation.
- The family doctor will refer you to a surgeon in the hospital for a simple operation (cost 340 euros).
- After the operation, the surgeon prescribes medicines that you get at the pharmacy (cost 65 euros).
- The total cost of this operation and prescribed medicines was 405 euros, of which you pay 385 euros for deductibles, and 20 euros are covered by the insurance company.
- After a few months, you will need to return to the surgeon for an examination (cost 190 euros).
- Now the entire amount (190 euros) is covered by your insurance company, since the deductible has already been paid.
- In total, your medical expenses for this example amounted to 595 euros. You have paid 385 euros of the deductible, the remaining 210 euros are covered by the insurance company.
- If in the same calendar year you need to contact the surgeon again for examination or consultation on this problem, the entire amount will be fully paid by your insurance company.
Example 2.
- After an accident, you go to the emergency room at a hospital.
- The wound is sutured and bandaged (cost 295 euros).
- The hospital sends the bill to the insurance company.
- The insurance company collects this amount from you as a deductible.
- You are no longer incurring medical expenses this year, so you pay nothing more. Next year, the franchise calculations are conducted from scratch.
Example 3.
- At the beginning of the year, you complain to your family doctor, who sends you to the hospital for an examination. You are also prescribed medication as a precaution.
- The cost of a hospital examination and medicines is 220 and 60 euros respectively, together - 280 euros.
- The cost of a family doctor's consultation is fully reimbursed by the insurance company, since the deductible does not apply to this type of expense. Therefore, you will have to pay 280 euros as a deductible.
- Later that year, you are admitted to the hospital for a minor procedure (cost €170).
- The calculations will be as follows. 385 – 280 = 105 euros is the amount you have to pay. The remaining 65 euros will be compensated by the insurance company.
Who and why voluntarily increases the franchise?
The €385 deductible is the minimum statutory amount that every insured person will have to deal with. However, most Dutch health insurance policies allow you to voluntarily increase your deductible in increments of 100 euros up to a maximum amount of 885 euros per year.
What is the benefit? If you choose this option, you will receive a discount on the insurance premium (premie). We remind you: minimum monthly fee at the time of writing (September 2022) is 108,25 euros. The amount of such a discount depends on the insurance company, but can be up to 25 euros per month, or up to 300 euros per year.
Who benefits? The option to increase the deductible is beneficial for those people who will not seek medical care for a year, and, accordingly, will not pay the deductible. That is, we are talking about young and healthy people. For them, this is a chance to save on health insurance.
How is a franchise different from a personal contribution?
If a deductible is a mandatory fixed amount, then a personal contribution is a certain co-payment for certain medical expenses. For example, for dentures, hearing aids, or for delivery in a hospital without a medical indication.
How does a franchise compare to dbc?
Hospitals and clinics in the Netherlands use dbc (de diagnose-behandelcombinatie) - a scheme for collecting information on all patient expenses related to hospital visits, treatment and examinations over a certain period.
The launch date of the dbc schema could be a consultation or a brief examination by a specialist. As soon as dbc starts, an account is opened to which all subsequent procedures are bound. The dbc start date defines the first medical bill in the calendar year and therefore the deductible. This means that if dbc opens in 2022, the 2022 deductible will be used anyway.
What is an insurance company escrow account?
Hospitals send the bill to insurance companies only after the entire treatment process is completed. This can be confusing for patients, as insurers sometimes pay deductibles only after the end of the calendar year or even later. At the same time, the insurance company bills the patient so that he knows in advance what his deductible is.
Why does the franchise even exist?
Eigen risico in health care (franchise) was introduced in the Netherlands in 2011. Its goal is to raise awareness of the population regarding medical care under insurance. In other words, so that a person does not immediately go to the doctor with every pain. In addition, due to the franchise, health care costs in the Netherlands have become more manageable.
The bottom line:
To use health insurance in the Netherlands, you should invest a lot of money from your own wallet. For people with low and middle incomes, the purchase of a compulsory health insurance policy is quite a large, and in some places even unaffordable expense.
For such categories of the population, the state has provided a support mechanism, namely a subsidy that reimburses part of the health insurance - Zorgtoeslag. You can find out more about this in our article, а request Zorgtoeslag you can, using the services of Nalog.nl specialists.
Publication Date: 15.09.2022
