The changes to the health insurance in 2015 We are there for you
The changes to the basic insurance The basic insurance is an obligatory insurance policy for everyone in the Netherlands. The basic insurance policy reimbursements are set by the government. The reimbursements can be found at www.averoachmea. nl/ vergoedingen. The terms and conditions, regulations and other contributions can be found at www. averoachmea.nl/ voorwaardenzorg Select Zorg Plan and Keuze Zorg Plan basic insurance policies Valid for the Select Zorg Plan and Keuze Zorg Plan: Dealing with a complaint or reassessment The deadline for dealing with a complaint or reassessment is currently 20 working days (was 3 weeks). Non-registered allergens New: non-registered allergens are, in principle, not eligible for reimbursement unless treatment with a registered medication is impossible. The prescribing doctor can apply for a permit for the reimbursement of a non-registered allergen. Obligatory excess The obligatory excess in 2015 is 375 instead of 360 in 2014. Obligatory and voluntary excess The obligatory and voluntary excess does not apply to nursing and care in your own neighbourhood (district nursing), nor to travel expenses of a donor if these are reimbursed via the donor s own basic insurance policy. The following only apply to the Select Zorg Plan: Turnover ceiling In order to keep care affordable, turnover ceilings are agreed with care providers with which we have entered into a contract. If the ceiling is reached, we are allowed to remove parties (temporarily) from the list of contracted care providers (Zorgzoeker [Care Finder]). This means that the contracted care providers on 1 January 2015 may not be the same as the contracted care providers on (for example) 1 December 2015. Non-contracted care provider If you receive assistance from a non-contracted care provider, we reimburse up to a maximum of 75% of the average contracted price. This is a higher reimbursement than in 2014. Medical necessity The term medical necessity when prescribing medicines in the Reglement farmaceutische zorg VGZ [VGZ Pharmaceutical Care Regulations] has been defined more specifically so that the terms and conditions are clearer. Vakantieformulier Medicijnen [Medicines Holiday Form] The Medicines Holiday Form in relation to a longer stay abroad has been discontinued If you need medicines for a longer period of time, your pharmacist can make the necessary agreements with us. Frozen embryo If a frozen embryo is placed back into the uterus after a lasting pregnancy, this transfer is interpreted as a first attempt and not as part of the attempt at a pregnancy during which it was created. Reglement Hulpmiddelen [Nursing Articles Regulations] The Reglement Hulpmiddelen [Nursing Articles Regulations], which is part of the nursing articles entitlement contains a number of changes. We refer to two here: Article 4.7 Nursing Articles to be used in conjunction with skin function disorders. This is a new functional description. This covers dressings, allergen-free shoes and medical shoes. The maximum reimbursement for allergen-free shoes has been discontinued. The personal contribution for medical shoes no longer applies. 2
Article 4.13 External nursing articles to be used to check and regulate abnormal blood sugar levels. The article has been extended to include test strips for women with gestational diabetes. They are entitled to 400 test strips for the term of the pregnancy. Serious dyslexia care As of 1 January the serious dyslexia care is no longer going tobe reimbursed via the basic insurance but via the Jeugdwet [Youth Act]. GGZ [Mental healthcare] for children aged up to 18 As of 1 January the GGZ care for children aged up to 18 is no longer going to be reimbursed via the basic insurance policy, but via the Jeugdwet [Youth Act]. For insured parties aged 18 year and older, this care will continue to be part of the basic insurance. Long-term mental healthcare (GGZ) From 2015 onwards the costs of the first 3 years of admission for the purposes of treatment in the event of long-term mental healthcare (GGZ) will be covered by your basic insurance. This used to be just for the first year. Foot care for insured parties with diabetes mellitus We reimburse an annual examination within the framework of foot care for insured parties with diabetes mellitus if a care profile has been drawn up. During the annual examination the GP or specialist will determine whether there is a risk of foot problems due to the diabetes. A care profile will only be drawn up if that is the case. Whether an appointment with a chiropodist is reimbursed via the basic insurance depends on your care profile. Treatment of Obstructive Sleep Apnea Syndrome (OSAS) You will need prior permission from us for an osteotomy (jaw operation) for the treatment of Obstructive Sleep Apnea Syndrome (OSAS). Care for insured parties with an auditive, visual and/or communicative disability The care for insured parties with an auditive, visual and/or communicative disability who are aged up to 23 as a consequence of a primary language development disorder is included in the basic insurance. 3
Geriatric rehabilitation care Geriatric rehabilitation care is to be made more accessible. The care must be provided within 1 week after your admission to a hospital or after an acute medical problem which includes an acute mobility disorder. District nursing care The reimbursement for district nursing care has been transferred from the AWBZ to the basic insurance. The AWBZ A lot of changes are taking place as regards care covered by the General Exceptional Medical Expenses Act (AWBZ). In the brochure we explain what exactly the changes are. Kleur je leven [Colour Your Life] online self-help course In 2015 the costs of the Kleur je leven [Colour Your Life] online self-help course will fall under the obligatory and/or voluntary excess. Prenatal care The reimbursement for prenatal care has been extended to include the NIPT (Non-Invasive Prenatal Test). The combination test will now only be reimbursed if a GP, obstetrician or medical specialist has referred you. Statutory personal contributions and statutory maximum reimbursements The government indexes the statutory personal contributions and maximum statutory reimbursements every year. Repairing a removable complete prosthesis (dentures) Addition: We now reimburse the costs of repairing a removable complete prosthesis (dentures) if the work is carried out by a dental technician. Sports doctor New: your sports doctor is now allowed to refer you on to a medical specialist. General Avéro Achmea is entitled to change a product or withdraw it from the market. However, if it does so a suitable alternative must be offered. This applies to all products.
Changes to the supplementary insurance policies Start supplementary insurance policy Smarter Pregnancy [Slimmer Zwanger] New: we reimburse the subscription costs relating to the Slimmer Zwanger [Smarter Pregnancy] self-help programme once for the entire term of the insurance policy. Dental healthcare accident cover New: we reimburse the costs of incisor replacement for insured parties aged between in the event of damage before New: we reimburse the costs of an artificial nipple or breast prosthesis. Chiropodist care in the case of rheumatism or diabetes For chiropodist care in the case of rheumatism or diabetes we reimburse 25 per appointment instead of 23 to a maximum of 100. Royaal supplementary insurance policy Smarter Pregnancy [Slimmer Zwanger] New: we reimburse the subscription costs relating to the Slimmer Zwanger [Smarter Pregnancy] self-help programme once for the entire term of the insurance policy. Dental healthcare accident cover New: we reimburse the costs of an artificial nipple or breast prosthesis. Extra supplementary insurance Slimmer Zwanger [Smarter Pregnancy] New: we reimburse the subscription costs relating to the Slimmer Zwanger [Smarter Pregnancy] self-help programme once for the entire term of the insurance policy. Dental healthcare accident cover New: we reimburse the costs of incisor replacement for insured parties aged between in the event of damage before New: We reimburse the costs of incisor replacement for insured parties aged between in the event of damage before New: we reimburse the costs of an artificial nipple or breast prosthesis. Statutory personal contribution for hearing aids The reimbursement of the statutory personal contribution of a hearing aid is to change. The reimbursement amounts to a maximum of 200 per person per device (was: 250.00 per person per calendar year) Excellent supplementary insurance policy Smarter Pregnancy [Slimmer Zwanger] New: we reimburse the subscription costs relating to the Slimmer Zwanger [Smarter Pregnancy] self-help programme once for the entire term of the insurance policy. 5
Dental healthcare accident cover New: we reimburse the costs of incisor replacement for insured parties aged between in the event of damage before New: we reimburse the costs of an artificial nipple or breast prosthesis. Convalescent home The reimbursement scheme (was referred to in Article 40 convalescent homes ) has been changed. The reimbursement now also relates to a care hotel. The maximum reimbursement amounts to 100 per day to a maximum of 28 days per calendar year. (Was: to a maximum of 48 days per calendar year). Better for Now [Beter Voor Nu] supplementary insurance policy Dental healthcare accident cover New: we reimburse the costs of incisor replacement for insured parties aged between in the event of damage before Personal contribution (GVS upper limit price) Restriction: The costs of certain medicines will be paid partially by you and will also be partially reimbursed via the basic insurance policy. We refer to the part you have to pay yourself as the statutory personal contribution. In recent years there has been a very significant increase in the reimbursements connected to this personal contribution, particularly of ADHD medication. The 100% reimbursement is therefore going to be limited to a maximum of 500 per insured party per calendar year. This includes the statutory personal contribution towards the costs of contraception for insured parties aged 21 and over. Juist Voor Jou [Right For You] supplementary insurance policy Terminating the insurance On the grounds of the policy terms and conditions which apply up to and including 2014, your Juist Voor Jou insurance policy ends, in any event, as of 1 January following your 30th birthday. This provision will no longer apply as of 2015. This means that you will have Juist Voor Jou insurance after your 30th birthday as well. As a consequence of this change, an amended premium (table) will apply as of 1 January 2015 for insured parties aged 31 and over. From now on the premium will depend on your age. If your premium increases due to you exceeding an age limit, the premium will change on the first day of the month following the month in which you reached that age. We will publish details of the applicable premium as soon as possible. As a consequence, the following articles in your terms and conditions will change. Article: 5.3 Sometimes it is not possible to cancel after a change The sentence after the 2nd dash in the list is to be changed as follows: Your premium increases because you are no longer an insured student and/or have exceeded an age limit. Article 8 When do we terminate your supplementary insurance? The provision that Juist Voor Jou ends, in any event, as of 1 January following your 30th birthday included under e is to be deleted. New: we reimburse the costs of an artificial nipple or breast prosthesis. Statutory personal contribution for hearing aids The reimbursement of the statutory personal contribution of a hearing aid is to change. The reimbursement amounts to a maximum of 200 per person per device (was: 250 per person per calendar year) Article 10 Definition of terms The term insured young person is to be deleted. 6
Disclaimer Your privacy - why do we ask for your details? We ask for your personal details and other details if you apply to us for an insurance policy or a financial service. We use your details within the Achmea Group to conclude and execute agreements. We also provide you with information about products and services which may be important to you. What else do we use your details for? We also use your details: to manage our customer database; to prevent and combat fraud; to perform statistical analyses; to meet our legal requirements. Whenever we use your personal data, we observe the applicable rules, such as: the Wet Bescherming Persoonsgegevens [Personal Data Protection Act]; the Gedragscode Verwerking Persoonsgegevens Financiële Instellingen [Code of Conduct for the Processing of Personal Data by Financial Institutions]; the Gedragscode Verwerking Persoonsgegevens Zorgverzekeraars [Code of Conduct for the Processing of Personal Data by Health Insurers]. If you would prefer not to receive any information about our products and services, or do you not want us to use your e mail address, please send a letter or e-mail to: Avéro Achmea Postbus 101 7300 AC Apeldoorn www.averoachmea.nl Information about the Stichting Centraal Informatie Systeem [Central Information System Board] (CIS) We may request your details from, or have them included in, the files of the Stichting CIS in The Hague. This is the central information system used by insurance companies that operate in the Netherlands. We may do so if you have failed to submit important information and we want to terminate the insurance. It is a way for us to manage risks and prevent fraud. More information can be found at www.stichtingcis.nl. There, you can also read what the Board actually does with your details. Applicable law and complaints procedure The insurance policies are exclusively subject to Dutch law. It goes without saying that we do our very best to provide you with an optimal service at all times. Nevertheless, you may still be unhappy about some aspect of the services we provide. In such instances, you should first contact your adviser or contact person. If you still feel it is necessary to submit a complaint, you can do so by e-mail via our website www.averoachmea.nl (under the section klacht doorgeven [ submit complaint ]) or in writing to Avéro Achmea, Centrale Klachtencoördinatie, Antwoordnummer 2241, 8000 VB Zwolle. If, in your opinion, we do not manage to solve the problem satisfactorily and if you are a natural person that is not involved in running a business or engaged in a profession, you can submit your complaint to the authorised complaints board to which we are affiliated: Stichting Klachten and Geschillen Zorgverzekeringen (SKGZ), Postbus 291, 3700 AG Zeist, tel. +31 (0)30 698 83 60, www.skgz.nl What do we do and who are we? We offer insurance policies and other financial services. We do not sell our products and solutions to our clients ourselves. Instead we work together with advisers. Our advisers can give you independent advice. This means you will always have insurance that is appropriate. We are a brand of Achmea, Avéro Achmea Zorgverzekeringen N.V. in Leiden. Achmea is the largest insurer in the Netherlands. Avéro Achmea Zorgverzekeringen N.V is registered with the Chamber of Commerce under number 30208633 and with the AFM (Stichting Autoriteit Financiële Markten [Netherlands Authority for the Financial Markets]) under number 12001023. The office addresses of Avéro Achmea are: Dellaertweg 1 2316 WZ Leiden Lange Marktstraat 26 8911 AD Leeuwarden www.averoachmea.nl Avéro Achmea has acquired the Klantgericht Verzekeren [Customer-oriented Insurance] quality mark Confidence and certainty are essential for the quality of services provided in the insurance sector. The Klantgericht Verzekeren quality mark is issued by the independent Stichting toetsing verzekeraars [Insurers Assessment Foundation] (Stv). The quality mark is only awarded to insurers that provide honest information and dynamic services, are easy to contact, assess customer satisfaction and use the ensuing results to improve services, and pursue a consistent quality policy. 7
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