Reimbursements overview 2015

Transcription

1 Healthcare insurance for university medical centres Reimbursements overview 2015 Clear communication is essential in my job. I expect the same from my health insurance company. Jaap Fogteloo, internist (acute medicine) Good care is your choice

2 2 Reimbursements overview 2015 Reader s guide This reimbursement overview provides an overview of reimbursements of the UMC Zorgverzekering (basic healthcare insurance) and the UMC Aanvullende Zorgpakketten (supplementary healthcare packages). All items listed in the overview of reimbursements marked with a are covered by your policy. Please note that, in the reimbursement conditions, the words per refer to the calendar and the abbreviation max. refers to maximum. Additional conditions Additional conditions, such as authorisation requirements, necessary referrals and authorised care providers, are specified in the 2015 policy conditions. If you require care, we recommend that you first consult the policy conditions. These are available at Non-contracted care UMC Zorgverzekering is a non-contracted care policy. Under this type of policy, you are entitled to reimbursement for the costs of care and you are entirely free to choose your own care provider. It does not matter if the care provider you choose has agreements with UMC Zorgverzekering or not. The only requirement is that the care provider satisfies the requirements set out in our policy conditions. You are entitled to reimbursement of the costs of care up to a maximum of the statutory rates current in the Netherlands. If no statutory rates apply, the costs will be reimbursed up to a maximum of the reasonable market price current in the Netherlands. If you obtain care from a contracted care provider, rates will have been agreed upon with the care provider in question that are in accordance with reasonable market prices current in the Netherlands. Compulsory and voluntary excess If you are aged 18 or older, a compulsory excess of 375 per calendar applies to your basic insurance. You can raise this excess voluntarily to 475, 575, 675, 775 or 875. If you do, you will be entitled to a discount on your premium. The excess does not apply to expenses incurred for visits to, for example, a general practitioner, obstetric care, maternity care, nursing and care, and preferred medications designated by us. If a particular type of care is subject to a personal contribution and/or maximum reimbursement, this will be indicated in the description. For more information, read the policy conditions. Reimbursements for supplementary insurance Your UMC supplementary healthcare package(s) entitle you to reimbursement of the costs of care up to a maximum of the statutory rates currently applicable in the Netherlands. If no statutory rates apply, the costs will be reimbursed up to a maximum of the reasonable market price current in the Netherlands. If you are using the services of one of our contracted care providers, the costs of care are reimbursed based on the rate agreed with the care provider concerned. Preferred, accredited or contracted care Please note: your supplementary insurance may refer to designated, accredited or contracted care. This is indicated in the overview. If you are using the services of non-contracted, non-accredited or non-designated care providers, note that you will be entitled to only partial reimbursement, or no reimbursement at all. For more information, read the policy conditions, which are available at Budgets If you opt for a supplementary healthcare package, UMC Zorgverzekering offers freedom and convenience in your reimbursements. This is because UMC Zorgverzekering has grouped the available treatments, allowing you to see at a glance which types of care are reimbursed. There is a maximum reimbursement for each treatment group. We refer to this as a budget. You decide which type of care and treatment you spend your budget on. This allows you to make the best possible use of your reimbursement amount. Budgets are available for movement-related care, alternative care, care aids, dental care, etc. You can find these budgets in the reimbursement overview. Good care is your choice

3 3 UMC Zorgverzekering en UMC Extra Zorg Alternative care budget to spend on the care types specified below: - treatments and consultations (by a doctor or designated care provider) that fall within the following categories: a. acupuncture and other Eastern therapies; b. anthroposophic alternative treatments; c. homoeopathy; d. naturopathy; e. psycho-social care from age 18 - homoeopathic and/or anthroposophic medicines. Contraceptives Such as the contraceptive pill, birth control implant (Implanon rod), intrauterine contraceptive device (coil), ring or pessary Audiological care Examination of auditory function, hearing aid advice Delivery and maternity care Maternity package Maternity care at home via a maternity centre or a contracted birth centre for persons under age 21 (a personal contribution is payable for some contraceptives) alternative care budget, up to a max. of 300 per from age 21 (a personal contribution is payable for some contraceptives) contracted care via UMC Kraamzorg up to 10 days at most (a personal contribution of 4.15 per hour applies) alternative care budget, up to a max. of 300 per from age 21 (a personal contribution is payable for some contraceptives) contracted care via UMC Kraamzorg alternative care budget, up to a max. of 500 per from age 21 (a personal contribution is payable for some contraceptives) contracted care via UMC Kraamzorg 100% of the personal contribution alternative care budget, up to a max. of 750 per from age 21 (a personal contribution is payable for some contraceptives) contracted care via UMC Kraamzorg 100% of the personal contribution Maternity care not provided by a max. 296 per delivery max. 296 per delivery max. 296 per delivery max. 296 per delivery maternity centre, hospital or private nurse Maternity care at a hospital after a delivery with medical necessity Lactation consultation max. 50 per delivery max. 100 per delivery 100% per delivery Home delivery Delivery in a hospital or contracted birth centre (with medical necessity) - Delivery in a hospital, including maternity care during delivery (without medical necessity) - Delivery at one of our contracted birth centres (without medical necessity) UMC Zorgverzekering UMC Extra Zorg 1 UMC Extra Zorg 2 UMC Extra Zorg 3 UMC Extra Zorg per day (hospital accommodation charges) ( 235 minus 33 for the personal contribution for maternity care) Preconception care (this includes advice on a healthy diet, use of folic acid and other medicines) Extended maternity care/newborn after-care newborn max. 12 hours distributed across a max. of 4 days max. 12 hours distributed across a max. of 4 days max. 12 hours distributed across a max. of 4 days max. 12 hours distributed across a max. of 4 days GeboorteTENS (device to ease the pain of labour and delivery) max. 80 for the entire term of the insurance max. 150 for the entire term of the insurance Electrical breast pump max. 110 per delivery max. 150 per delivery Movement-related care A budget to spend on the care types specified below: For children under age 18: physiotherapy, remedial therapy, Cesar/ Mensendieck, oedema therapy and manual therapy (care for chronic complaints subject to prior permission 1) max. 18 sessions per complaint, per calendar. Additional sessions only for complaints listed in Appendix 1 to the Healthcare Insurance Decree (chronic complaints) movement-related care budget, max. 250 per movement-related care budget, max. 500 per movement-related care budget, max per movement-related care budget, max per working All items listed in the overview of reimbursements marked with a are covered by your policy.

4 4 UMC Zorgverzekering UMC Extra Zorg 1 UMC Extra Zorg 2 UMC Extra Zorg 3 UMC Extra Zorg 4 Movement-related care (cont.) For children from age 18: physiotherapy, remedial therapy, Cesar/ Mensendieck, oedema therapy and manual therapy (care for chronic complaints subject to prior permission 1) Occupational therapy Pelvic physiotherapy to prevent urine incontinence from age 18 Alternative movement-related therapy (by a designated care provider) Glasses and contact lenses A budget to spend on the care types specified below: - glasses and contact lenses from 0.25D; - laser eye treatments or lens implants. Care abroad only for complaints listed in Appendix 1 to the Healthcare Insurance Decree, except for the first 20 sessions max. 10 hours the first 9 treatment sessions Non-urgent care while abroad (in a number of cases subject to prior permission 2) based on NL rates full amount, based on NL rates based on NL rates Urgent care while on holiday or during a temporary stay abroad Repatriation (patient transport and transport of mortal remains from abroad) Genetic testing Tests to establish and determine the extent of genetic disorders Medical care Circumcision on medical grounds (subject to permission 1) In vitro fertilisation (IVF) up to age 43. Additional conditions apply. first, second and third attempts full amount for urgent care via the UMC Emergency Service (Alarmcentrale) full amount via the UMC Emergency Service (Alarmcentrale) contracted: full amount; non-contracted: up to a max. of 600 max. 100 every 3 s max. 200 every 3 s max. 250 every 3 s full amount, based on NL rates full amount for urgent care via the UMC Emergency Service (Alarmcentrale) full amount via the UMC Emergency Service (Alarmcentrale) contracted: full amount; non-contracted: up to a max. of 600 full amount, based on NL rates full amount for urgent care via the UMC Emergency Service (Alarmcentrale) full amount via the UMC Emergency Service (Alarmcentrale) contracted: full amount; non-contracted: up to a max. of 600 fourth attempt full amount, based on NL rates full amount for urgent care via the UMC Emergency Service (Alarmcentrale) full amount via the UMC Emergency Service (Alarmcentrale) contracted: full amount; non-contracted: up to a max. of 600 fourth and fifth attempts Other fertility treatments (women up to age 43) Reconstructive and cosmetic or aesthetic surgery Redression helmet treatment for children up to the age of 14 months for specific indications (by a contracted care provider) Sterilisation (male or female) and vasectomy reversal Medicines and vitamins Medicines listed in Appendix 1 to the Healthcare Insurance Regulations and the Pharmaceutical Care Regulations (subject to prior permission 2) Diet preparations (from specific suppliers and subject to permission 1) Vitamins to treat a serious vitamin deficiency Skin treatments Acne treatment (by designated care providers) Camouflage therapy (by designated care providers) Hair removal (epilation) (by designated care providers) for a number of indications up to the maximum statutory reimbursement amount (GVS) (a personal contribution is payable for some medicines) full amount for a number of indications not accepted by the healthcare insurer and 50% for cosmetic or aesthetic surgery due to specific medical circumstances full amount for a number of indications not accepted by the healthcare insurer and 50% for cosmetic or aesthetic surgery due to specific medical circumstances full amount full amount for a number of indications not accepted by the healthcare insurer and 50% for cosmetic or aesthetic surgery due to specific medical circumstances full amount full amount full amount full amount max. 300 a for the personal contribution full amount full amount full amount full amount max. 26 per treatment and up to 15 treatment sessions per max. 26 per treatment and up to 15 treatment sessions per max. 26 per treatment and up to 15 treatment sessions per max. 500 a for the personal contribution max. 26 per treatment and up to 15 treatment sessions per max. 165 every 3 s max. 165 every 3 s max. 165 every 3 s max. 165 every 3 s max. 445 per max. 445 per max. 445 per max. 445 per working All items listed in the overview of reimbursements marked with a are covered by your policy.

5 UMC Zorgverzekering UMC Extra Zorg 1 UMC Extra Zorg 2 UMC Extra Zorg 3 UMC Extra Zorg 4 5 care aids budget, max. 250 per care aids budget, max. 350 per care aids budget, max. 750 per Dental care (including implants and technician s costs, if applicable) and orthodontic care for specific indications (subject to prior permission1) Dental care for children under age 18 Dental care with the exception of crowns, bridges and orthodontic care Crowns, bridges and implants (including technician s costs) (subject to prior permission1) General practitioner care General practitioner care. This also includes counselling in relation to stopping smoking and foot care in the case of diabetes mellitus (annual foot check and advice and diabetic foot treatments from care profile 2 and higher) Care aids Care and bandaging aids in for some aids on loan accordance with the Healthcare (a personal contribution Insurance Regulations and the and/or partial reimbursement amount apply UMC Pharmaceutical Care Aids Regulations (subject to prior permission 2) to some aids) A budget for care aids that you can spend on: 1. a reimbursement of the statutory personal contributions/personal payments for the care aids specified below; or 2. the purchase of extras associated with the care aids specified below that are not listed in the Healthcare Insurance Regulations: - arch supports and therapeutic soles; - support pessary; - support stockings and compression stockings (compression category 1); - alarm device (once-only, from contracted care provider); - hearing aids; - wigs; - breast prosthesis; - simple crutches; - hand or finger splint for temporary use (by a contracted care provider). Multi-disciplinary care Multi-disciplinary care for diabetes mellitus type 2, COPD and cardiovascular risk management ( care programmes ) Speech therapy Treatment or improvement of on medical grounds speech or ability to speak Specialist medical care This also includes care provided by a thrombosis service, a second opinion and dialysis (subject to prior permission 2) Oral care/dental care Dental and orthodontic care in special cases (a personal contribution may apply) Dental care from age 18 Crowns (with implants, if medically necessary) and bridges required as the direct consequence of an accident (subject to prior permission 1) Dental surgery from age 18 Dental surgery by a dental surgeon with the exclusion of fitting implants, treatment of gums and simple extractions if to replace one or more permanent incisors or canines that have not developed or are missing due to an accident from age 18 to 27 from age 18 to 27 from age 18 to 27 from age 18 to 27 working All items listed in the overview of reimbursements marked with a are covered by your policy.

6 6 Dental prostheses (dentures) from age 18 Removable full dentures (including technician s costs) (subject to prior permission 2) Removable dentures on implants (including technician s costs) for seriously shrunken, toothless jaws (subject to prior permission 1) Orthodontics Orthodontic treatment for children under age 18 Orthodontics from age 18 Paramedical care Group swimming for patients with severe forms of rheumatism Podotherapy and pedicure (including foot treatments for insured persons with rheumatoid arthritis and diabetes mellitus with Simm s classification 1 in care profile 1. The provision of advice and information about diet and eating habits for a medical purpose Preventative care Menopause care UMC Zorgverzekering UMC Extra Zorg 1 UMC Extra Zorg 2 UMC Extra Zorg 3 UMC Extra Zorg 4 (a personal contribution of 25% applies) (a personal contribution of 125 per jaw applies) for a limited number of indications, a personal contribution may apply (subject to permission 1) for a limited number of indications, a personal contribution may apply (subject to permission 1) max. 3 hours of treatment of indications of indications 100% for a limited number of indications; other orthodontic treatment up to a max. of 1,250 for the entire term of the insurance of indications of indications; other orthodontic treatment up to a max. of 2,500 for the entire term of the insurance of indications 100% full amount full amount full amount full amount 100% for a limited number of indications; other orthodontic treatment up to a max. of 300 for the entire term of the insurance max. 115 per max. 115 per max. 115 per max. 4 hours of treatment max. 4 hours of treatment max. 4 hours of treatment max. 4 hours of treatment max. 50 per consultation max. 4 consultations per max. 50 per consultation max. 4 consultations per max. 50 per consultation max. 4 consultations per full amount per Substitute informal care (by a contracted max. 4 days a max. 8 days a max. 12 days a max. 24 days a care provider): Sports medicine max. 55 per max. 55 per max. 125 per max. 500 per Medical check-up (excluding preventative scans) Training courses (incl. pregnancy, coping with illnesses or disorders and reanimation) Vaccinations in connection with foreign travel Psychological care Specialist mental healthcare (GGZ) from age 18 - generalist basic mental healthcare - specialist mental healthcare Psychosocial care for oncology patients Sexological care Mindfulness (MBCT and MBSR) following symptoms of burnout, 8-week group therapy Rehabilitation Rehabilitation (this also includes a quick scan and oncological rehabilitation) Geriatric rehabilitation (for a max. of 6 months) Stopping smoking Stop-smoking programme (medical care and support medications Once a aimed at effecting behavioural change) Home care Domestic help via Care Advice and Mediation (Zorgadvies & Bemiddeling) (for specific indications, by a contracted organisation) Child care via Care Advice and Mediation (Zorgadvies & Bemiddeling) (for specific indications, by a contracted organisation) max. 75 every 2 consecutive s max. 75 every 2 consecutive s max. 75 every 2 consecutive s full amount every 2 consecutive s max. 50 per max. 100 per max. 150 per max. 500 per 80%, up to a max. of 125 per 80%, up to a max. of 175 per 100% per max. 445 per max. 445 per max. 445 per max. 445 per max. 60 per session max. 4 sessions per max. 60 per session max. 4 sessions per max. 60 per session max. 4 sessions per 350 per 350 per 350 per 350 per max. 10 hours per max. 24 hours per max. 20 hours per max. 50 hours per working All items listed in the overview of reimbursements marked with a are covered by your policy.

7 UMC Zorgverzekering UMC Extra Zorg 1 UMC Extra Zorg 2 UMC Extra Zorg 3 UMC Extra Zorg 4 7 Tissue and organ transplants If the transplant is carried out in an EU or EEA Member State Inpatient care Treatment at a (designated) health resort Convalescent home/care hotel (at a contracted care provider) or multiple-day holiday trip Accommodation expenses for a guest house affiliated with a hospital located in the Netherlands Hospice (via an accredited care provider) Hospital (psychiatric or otherwise), mental healthcare or rehabilitation facility (subject to prior permission 2) Nursing and care Nursing and care without inpatient care (possibly in the form of a personal budget) Transport Ambulance transport Seated patient transport for specific indications by patient s own car (subject to prior permission 1) Seated patient transport for specific indications by public transport or a taxi (subject to prior permission 1) Hospital care Outpatient care (subject to permission 2) Hospital admittance (medical specialist care and inpatient care) (subject to prior permission 2) Care and waiting list mediation Care for persons with a sensory disability Care for persons with a sensory disability max per km for a limited number of indications (a personal contribution of 97 per applies) a personal contribution of 97 per applies to a limited number of indications with the exception of a number of indications max. 885 per max. 885 per max. 885 per max. 885 per 50% for a max. of 6 weeks 50% for a max. of 6 weeks 50% for a max. of 6 weeks 50% for a max. of 6 weeks max. 18 per day max. 18 per day max. 18 per day max. 18 per day max. 130 per day max. 130 per day max. 130 per day max. 130 per day working All items listed in the overview of reimbursements marked with a are covered by your policy. UMC Extra Tand UMC Extra Tand 1 UMC Extra Tand 2 UMC Extra Tand 3 Dental care from age 18 Dental care, with the exception of orthodontic care and general anaesthesia (including material costs and the cost of a dental technician)* full amount for consultations (C codes), preventive oral care (M codes), specific gum treatments by an oral hygienist (T22, T52, T54 and T56) and 80% for other treatments up to a maximum of 250 per full amount for consultations (C codes), preventive oral care (M codes), specific gum treatments by an oral hygienist (T22, T52, T54 and T56) and 80% for other treatments up to a maximum of 750 per full amount for consultations (C codes), preventive oral care (M codes), specific gum treatments by an oral hygienist (T22, T52, T54 and T56) and 80% for other treatments up to a maximum of 1,250 per * A number of treatments are precluded from reimbursement in all packages, such as the costs for appointments missed, examinations and study models for a treatment plan, physical examination reports and statements of good health, bleaching of teeth, sealing and polishing, indirect pulp caps, mouth protectors, general anaesthesia, a number of gnathologic treatments and restoration treatments such as composite inlays. A comprehensive overview of entitlements is included in the insurance terms and conditions (see

8 Submitting claims Submitting your claims online is easy using www. umczorgverzekering.nl. If you would rather submit your claims by post, you can complete a claim form and send it to us, together with the invoice. We will process your claim within ten working days. For more information, we refer to the policy conditions and our website. More information If you have any questions after reading this brochure or if you would like additional information, please visit Finding a good care provider easily Vergelijk en Kies clearly illustrates the differences in the quality of care available to you and indicates the care providers with whom we have concluded a contract. A very handy tool! Find a good care provider easily via UMC Zorgverzekering Healthcare insurance for university medical centres D No rights may be derived from of this brochure. N.V. Zorgverzekeraar UMC (Zorgverzekeraar UMC), established in Arnhem, CoC number: , DNB licence number: