Market prices

What are market prices?

The Dutch Health Insurance Act caps how much can be reimbursed under a basic health-care plan. How this works is different for an in-kind policy compared to a restitution-based policy.

• For contracted health care, an in-kind policy reimburses the price agreed on in the contract. Non-contracted health care is subject to a maximum reimbursement set by the health insurer.

• A restitution-based policy covers health care only if the price charged is in line with market prices. This means that the price charged for the health care cannot be unreasonably high in comparison with what other health-care providers charge for the same health care. If a health-care provider charges an ‘excessive price’ for the health care, the basic health-care plan is not allowed to reimburse the part of the price above the market price.

Market price-based reimbursements are not fixed in advance

Whether or not a price is in line with market prices in a certain situation depends on what other health-care providers charge for the same health care. Plus, the Dutch Health Insurance Act stipulates that it is up to the health insurer to demonstrate that a price claimed in an individual case is unreasonably high and not in line with market prices. This is not compatible with us fixing a maximum reimbursement in advance and rejecting all claims that exceed that amount, which is why we do not have a list of market prices.

What if a health-care provider charges a high price?

If the price charged by a health-care provider exceeds our market price-based cap, we will contact this health-care provider to ask them to explain why this is. We will then, for example, assess whether there are specific medical arguments for charging a high price. And we will look at whether there are any other market conditions that we need to take into account.

In such a situation, you can also contact us yourself to explain that there is a specific medical reason why, in your individual case, the health care you need merits a higher price. We are always willing to take a look at it and reassess your claim accordingly.

If after our reassessment we maintain that the price is not in line with market prices, and the health-care provider is unwilling to lower their price, we will set a reimbursement for the health care that is in line with current market prices. You will then have to pay the difference between the reimbursement and the price yourself.

Maximum reimbursement for non-contracted health care

In some cases, we have set a maximum reimbursement amount for non-contracted care. You can find this specified in the policy terms for that reimbursement.

Do you have the ONVZ Bewuste Keuze plan?

Then you have an ´in-kind´ policy. This means that for almost all non-contracted health care, our maximum ONVZ Bewuste Keuze reimbursements apply.

Do you have the ONVZ Vrije Keuze plan?

Then you have a combination insurance policy. For part of your insurance, our maximum ONVZ Vrije Keuze reimbursements apply to non-contracted care. For the other part, the market-based reimbursement applies.

What we do in case of specialist medical care up to and including 2024

For specialist medical care in 2024 and previous years, we have set a market price-based cap in our administrative systems. This cap was calculated based on all prices claimed from us for specialist medical care over the past calendar year, i.e. not the same year as when you receive your treatment. We therefore raise those market prices based on the price index for the current year.

In implementing the market price-based cap in our systems, we apply the ‘p95’ rule to the prices. This means that we determine for every treatment or DBC health-care product at what price 95% of contracted and non-contracted health-care providers provide the health care in question. This approach ensures that special prices that are not standard for the Dutch market do not unreasonably push up the market price-based cap.

For specialist medical care from 2025 onwards, our maximum reimbursements apply. These are determined based on our average contracted rates.

And what about health care abroad?

For health care received abroad, you will be reimbursed the same amount you would have received if the health care had been provided in the Netherlands.

Is it specialist medical care? In the Netherlands, hospitals charge for health care in the form of a DBC health-care product. DBC stands for ‘Diagnose Behandeling Combinatie’, which means ‘diagnosis treatment combination’. A DBC health-care product encompasses all health care you receive for a certain condition or disease. If you break a leg, for example, all examinations, treatments, and appointments related to your broken leg will be considered part of one single DBC health-care product, provided they all take place within a certain period. Obviously, health-care providers abroad do not use this same system, which is why we translate specialist medical care received outside the Netherlands to a DBC health-care product that best approximates the health care received. For that, we reimburse the market-based Dutch rate up to and including 2024.

From 2025 onwards, our maximum reimbursements for specialist medical care also apply abroad if you visit a non-contracted healthcare provider. The only exception is emergency care abroad - for that, the market-based reimbursement in 2025 will be determined in the same way as in 2024, as described above.