Eigen risico in 2026: what the €385 deductible covers and what it does not

Before planned care, check the care type, the provider or supplier contract, any referral or prior-authorisation rule, and your remaining deductible with your insurer. The insurer decides the reimbursement under your policy. This guide explains general 2026 rules, not whether a treatment is medically appropriate or what one person will owe. For the insurance obligation and enrolment deadline, use the Dutch health-insurance guide.

Five charges are often confused. Only the compulsory eigen risico reduces the standard €385 balance.

The compulsory amount belongs to one person and one calendar year. It is lower when basic insurance applies for only part of that year, including the year someone turns 18. The insurer calculates the exact reduced amount. Using the full compulsory amount does not remove a voluntary excess, co-payment, uncovered cost or contract-related shortfall.

Usually the provider sends the claim to the insurer. The insurer pays the covered part and later invoices the amount you owe. If you submit a bill yourself, the insurer can subtract the deductible from the reimbursement. The treatment date, or the start date of a hospital billing package, determines the year—not the date the invoice arrives.

Only care reimbursed from the basisverzekering (basic health-insurance package) can use the eigen risico. Care outside that package does not use it: you pay the uncovered amount yourself or claim it from supplementary insurance. Covered care can still carry other charges and policy conditions. The coverage-gaps guide explains common uninsured costs.

A huisarts (general practitioner, GP) consultation and the huisartsenpost (out-of-hours GP service) are exempt. The cause of many surprise bills is that the GP only ordered the next service. A laboratory, pharmacy or specialist then supplied and billed that separate care. Ask what will be ordered and check the likely reimbursement with the insurer; do not assume the GP exemption follows the referral.

• Basic-package care for children under 18
• GP and out-of-hours GP care
• Midwifery, specified prenatal screening and maternity care
• District nursing at home
• Coordinated chronic-care programmes (ketenzorg)
• Combined lifestyle intervention
• Stop-smoking programme
• The first exploratory conversation in medical mental healthcare
• Follow-up checks and travel costs for organ donors

An insurer may also exclude selected providers, care programmes, medicines or devices from the compulsory deductible. That is a policy-specific waiver, not a national exemption for every insured person. Check the current policy conditions and the insurer's care finder before relying on it.

A prescribed medicine is not automatically free. A medicine in the basic package and the pharmacy's service costs normally use the deductible. The insurer may cover only a preferred equivalent medicine. A medicine above its reimbursement limit can also have an eigen bijdrage; medicine co-payments are capped at €250 per person in 2026. The co-payment is applied first and the remaining covered cost then uses the compulsory and any voluntary deductible. Over-the-counter or non-covered medicines are paid outside the deductible.

Covered medical devices normally use the deductible too. The policy can require a prescription, prior permission or a contracted supplier, and can say whether the device is owned or loaned. Some devices also have a statutory co-payment or maximum reimbursement. Ordinary products, replacement batteries or maintenance may be uncovered. Check the device page and policy before ordering, because an uncovered supplier or product does not become deductible spending.

Having a chronic condition does not exempt every related cost. The organised ketenzorg programme can be exempt, including programmes for conditions such as type 2 diabetes, COPD and cardiovascular risk management. Medicines, laboratory work and a specialist outside the care group can still use the deductible. Ask whether each provider and activity is billed inside the care programme.

Children under 18 have no compulsory deductible for basic-package care, but co-payments and uncovered products can still exist. Midwifery, prenatal screening and maternity care are exempt from the compulsory deductible. Related medicines, transport and some blood tests can still count, while home maternity care and a hospital birth without medical indication can have an eigen bijdrage. Check the exact service rather than treating all pregnancy-related costs as one category.

The insurer applies the policy's referral, authorisation, provider and supplier conditions. A provider without a contract may be reimbursed only partly. That unpaid difference is not eigen risico and does not reduce the €385 balance. Providers must tell you before treatment whether they have a contract and whether you may have to pay, but the insurer confirms the exact reimbursement and remaining deductible.

A hospital (ziekenhuis) may bill a diagnose-behandelcombinatie (diagnosis-treatment combination, dbc): one package for consultations, tests and treatment for a diagnosis. A dbc can run for up to 120 days and is billed after it closes, so the insurer's invoice can arrive months after the first visit. A longer treatment can create a follow-up dbc and another bill. Check the claim overview before assuming a late invoice is a duplicate.

The start date of the dbc decides which calendar year's deductible applies. If a first dbc starts in December 2025, it can use the 2025 balance even when care and billing continue in 2026. A follow-up dbc that starts in 2026 can then use the new 2026 balance. Compare the start date, provider and diagnosis on the claim with your appointments, and ask the insurer to explain any mismatch.

An adult can add a vrijwillig eigen risico (voluntary excess) of €100, €200, €300, €400 or €500 for a lower monthly premium. It is used after the compulsory €385, so the maximum total is €885. Compare the full yearly premium discount with the extra amount you could owe, including expected medicines or hospital care and your available cash buffer. Exempt care usually remains exempt from the voluntary excess, but check the policy. The choice applies for a policy year and is normally changed during the annual insurance-selection period.

After an invoice arrives, ask the insurer for a betalingsregeling (payment plan); the Zorginstituut says instalments carry no extra cost. Insurers can also offer advance or monthly spread payment of the compulsory deductible, often collected with the premium, with unused money returned later. Conditions and enrolment dates differ, so contact the insurer early. Zorgtoeslag can help eligible households with insurance costs but does not cancel the deductible. See the toeslagen overview.

Open the insurer's claim overview and identify the provider, care date or dbc start date, covered amount, remaining compulsory and voluntary balances, eigen bijdrage and any non-contracted shortfall. Ask the insurer for an itemised explanation if one line is unclear. If the care was not yours, the year is wrong or the policy was applied incorrectly, use the insurer's correction or complaint process. If the complaint remains unresolved, SKGZ handles health-insurance disputes.