Dutch health insurance gaps: what you pay yourself and how to check coverage
Use a four-part check before planned care: basic-package entitlement, deductible, statutory contribution and policy/provider limits. Covers the 2026 rules for dental care, physiotherapy, medicines, mental health, maternity care, devices, care abroad and supplementary insurance.
- Author
- By Inburgering.org team
- Reviewer
- Reviewed by Kirill Svavolia
- Last updated
What should I check before treatment?
For planned care, ask your insurer before treatment starts for a written answer that names the treatment or billing code, medical indication, required referral, provider contract, prior authorisation and your expected own cost. A referral does not guarantee full reimbursement. If care is urgent, seek help first through your huisarts (GP), the out-of-hours GP service or 112; do not delay urgent care over coverage uncertainty. If covered care cannot be provided on time, ask the insurer for zorgbemiddeling (care mediation).
The government sets the entitlement under the basisverzekering (basic health insurance), but “in the basic package” does not always mean “free” or “fully reimbursed by every provider.” Your bill can come from the eigen risico (compulsory deductible), an eigen bijdrage (statutory personal contribution), care outside the package, or a policy rule such as using a non-contracted provider.
Classify the cost before you compare insurance
| Question | Cost type | What you may pay in 2026 |
|---|---|---|
| Is the care outside the statutory basic package? | Uncovered care | The full bill, unless supplementary insurance applies |
| Is it covered care subject to eigen risico? | Compulsory deductible | Up to the unused part of €385, plus any voluntary deductible; none under age 18 |
| Does covered care have an eigen bijdrage? | Statutory contribution | The set amount or percentage first; the remaining covered amount may then count toward the deductible |
| Did you miss a referral, authorisation or provider rule? | Policy-related shortfall | Part or all of the bill, depending on your policy and the care |
Common covered care still has conditions
| Care | Basic-package rule | Typical own cost or limit |
|---|---|---|
| GP and out-of-hours GP service | The consultation is covered without a referral | No compulsory deductible for the GP care itself; ordered blood tests, medicines and other providers can count toward it |
| Hospital and medical specialist | Usually covered when the treatment qualifies; a referral is normally required, except for urgent specialist care | Deductible applies; provider network and prior-authorisation rules can affect reimbursement |
| Prescription medicines | Only medicines in the GVS reimbursement system, subject to indication rules and the insurer’s preference policy | Deductible; some medicines also have a statutory contribution capped at €250 per calendar year |
| Medical mental healthcare (GGZ) | GP/POH-GGZ care is GP care; insured GGZ normally needs a referral and a qualifying mental disorder | No deductible for GP/POH-GGZ; deductible for medical GGZ, with policy conditions for private or non-contracted clinics |
| Pregnancy and birth care | Midwife care and medically indicated birth care are covered | No deductible for maternity/midwife care itself; some tests, medicines and transport can have a deductible, and some maternity choices have a contribution |
| Medical devices | Covered only by device category, medical indication and policy conditions | Usually deductible from age 18; a contribution, contracted supplier, prescription, use period or prior permission may apply |
A GP visit is exempt from the deductible, but a laboratory, pharmacy or hospital used after that visit is a separate claim. For non-urgent specialist care, check which professionals your policy accepts as referrers and whether the provider is contracted. Acute specialist care does not require a referral.
Dental care and physiotherapy have age and diagnosis rules
| Care | What the basic package covers | What it usually leaves out |
|---|---|---|
| Dental care under 18 | Most preventive and treatment care, without deductible or statutory contribution | Braces and most crowns, bridges and implants, except narrow serious or accident-related indications |
| Dental care from 18 | Certain special dental care, full removable dentures and limited oral-surgery care | Routine check-ups, cleaning, fillings, crowns, root-canal care and routine dentist X-rays |
| Physiotherapy from 18 | Specific statutory indications; chronic-list care generally from session 21 | Ordinary complaints and the first 20 sessions per chronic-list condition |
| Physiotherapy under 18 | Usually 9 sessions, possibly 9 more; all sessions for qualifying chronic-list conditions | Care beyond the applicable limit when no other entitlement applies |
For adults, an X-ray is not generally covered merely because it is an X-ray: the covered category is imaging by or at the request of an oral surgeon for covered surgical dental care. Oral surgery that a regular dentist could perform can also be excluded. Full dentures have statutory contributions of 25%; implant-retained full dentures are 10% for the lower jaw or 8% for the upper jaw. Covered adult dental care also uses the deductible.
- A condition on the official chronic list: adults pay at least the first 20 treatments per condition; basic-package cover starts at treatment 21 and may have an indication-specific time limit.
- Hip or knee osteoarthritis: supervised exercise therapy from the first treatment, up to 12 treatments.
- Claudicatio intermittens: supervised exercise therapy from the first treatment, up to 37 treatments.
- Urinary incontinence: pelvic physiotherapy from the first treatment, up to 9 treatments.
- COPD phase 2 or higher: supervised exercise therapy from the first treatment without a statutory session maximum, but only care that is clinically needed qualifies.
- Severe functional limitations from rheumatoid arthritis or axial spondyloarthritis: personalised supervised exercise therapy from the first treatment, without a statutory session maximum when the strict criteria are met.
These entitlements are not interchangeable. The diagnosis, severity, provider and any referral requirements must match the relevant rule. A supplementary package may cover a fixed number of ordinary sessions or the first 20 chronic-list sessions, but check its annual limit and provider conditions.
Medicines and mental healthcare are not blanket promises
| Area | Coverage test | Action before care |
|---|---|---|
| Medicine | Check the GVS listing, any indication restriction and the insurer’s preferred brand. Pharmacy service costs are part of the medicine claim. | Ask doctor, pharmacist or insurer for a covered equivalent if a product or brand is not reimbursed; medical necessity can matter under preference policy. |
| Mental healthcare | GP and POH-GGZ support differs from insured medical GGZ. Medical GGZ needs the right referral and a qualifying disorder; municipal social support is a different system. | Check referral wording, diagnosis route, provider contract and any prior authorisation before a private or independent clinic starts. |
Pregnancy, devices, glasses and contraception need separate checks
| Care or product | 2026 basic-package position | Own cost |
|---|---|---|
| Midwife care, home birth or medically indicated hospital birth | Covered | No deductible or statutory contribution for the birth care itself |
| Hospital or birth-centre birth without medical indication | Covered only up to the statutory reimbursement | At least €22.50 per day for the mother and €22.50 per baby; any provider charge above the reimbursement limit can add more |
| Kraamzorg (maternity home care) | Covered | €5.70 per hour at home; institution-based care has its own daily contribution and possible excess charge |
| Ordinary glasses | Lenses and frame are outside the basic package | Full cost; narrow medical exceptions exist for some children and specialised visual aids |
| Medically indicated contact lenses | Covered when the statutory indication is met | €66 per lens under the 2026 rules, then the remaining covered cost can use the deductible |
| Other medical devices | Only listed categories and indications; simple walking aids such as rollators are excluded | Device-specific deductible/contribution; for example, adults pay 25% for hearing aids |
Contraceptives are covered under the basic package before age 21, subject to product rules; from age 18 the deductible applies and hormonal products can also have a contribution. From age 21, contraception is generally self-paid, although narrow medical indications can qualify. Check the exact product and indication rather than relying on age alone.
Care abroad can leave a large balance
During a temporary trip, the Dutch basic policy can cover suddenly needed care, generally no more than the Dutch tariff. The deductible still applies. An EHIC helps with medically necessary public care in the EU/EEA, Switzerland and the United Kingdom, but it does not cover planned treatment, private clinics, cruise-ship care or repatriation. Call the assistance number on your health or travel policy as soon as practical; higher foreign tariffs and transport home may need travel or supplementary insurance.
The benefit is national; the route and reimbursement are policy-specific
A naturapolis (in-kind policy) or restrictive policy can reimburse less at a non-contracted provider. A combinatiepolis (combination policy) can apply different rules by care type. Policies can also require a named supplier, referral, prescription or prior authorisation. Check the insurer’s provider finder and the 2026 policy terms for the exact care—not only whether the provider “works with insurers.” Get permission before treatment when the policy requires it.
Supplementary insurance is a separate contract
| Expected need | What to compare | Common trap |
|---|---|---|
| Dental care | Annual premium, reimbursement percentage, annual maximum and excluded treatment codes | A high headline maximum can still reimburse only part of each bill |
| Physiotherapy | Number of sessions, contracted-provider rules and whether the first 20 chronic-list sessions count | Cover stops when the annual session budget is used |
| Glasses, lenses or statutory contributions | Amount, frequency, approved supplier and whether the contribution is included | An allowance every 2 or 3 years may be worth less than one year of premiums |
| Already planned treatment | Acceptance, medical questions, start date, waiting period and existing-treatment exclusion | Buying a policy does not prove that this treatment is payable |
There is no statutory acceptance duty for supplementary insurance. Refusal is uncommon in practice, but an insurer may assess health for some packages or apply a waiting period. These rules are not universal: for example, one 2026 insurer’s terms use medical assessment for some dental packages and a one-year waiting period for orthodontics. Read the terms for the exact product and obtain acceptance before cancelling existing supplementary cover.
Decide with expected reimbursement, not the package name
- List the care you realistically expect next calendar year and the exact codes or number of sessions.
- Estimate what the basic package pays, then subtract deductible, statutory contribution and any non-contracted shortfall.
- For each supplementary package, calculate annual premium and the maximum it would actually reimburse under its percentage and frequency limits.
- Check acceptance, waiting period, provider network and start date before relying on the package.
- Choose supplementary cover only when its usable protection and risk value justify the premium; otherwise keep funds for self-payment.
Use the complaint route that matches the problem
| Problem | First route | If unresolved |
|---|---|---|
| Insurer refuses or underpays reimbursement | Ask the insurer for the decision, policy clause and internal reconsideration in writing | After its written response, use free SKGZ mediation or the paid binding disputes committee; court remains a separate option |
| Care provider’s quality, conduct or bill | Raise it with the provider and its independent complaints officer | Use the provider’s recognised disputes body; the national healthcare reporting centre can advise on quality complaints |
| Suspected incorrect billing, misleading information or unresolved access problem | First contact provider or insurer and keep the documents | Report the signal to the NZa; it supervises but does not replace your individual SKGZ dispute |
Make the next call with the policy open
For current planned care, contact the insurer now and request the six-point written coverage answer. For urgent symptoms, use the appropriate urgent-care route first. Keep the separate basic health-insurance guide and eigen risico guide beside your 2026 policy terms.
Official Sources
Official source checked: August 2026.
- Rijksoverheid: Basic package in 2026 - National entitlement, 2026 deductible and major conditions.
- Rijksoverheid: Compulsory deductible - The €385 amount and care exempt from the deductible.
- Rijksoverheid: Statutory contributions - 2026 contributions and the order before the deductible.
- Rijksoverheid: GP costs - GP exemption and separate laboratory and medicine claims.
- Zorginstituut Nederland: Medical specialist care - Referral exception for urgency, deductible and provider conditions.
- Rijksoverheid: Policy types and contracted care - Network-policy differences and lower non-contracted reimbursement.
- Zorginstituut Nederland: Dental and oral care - Age limits, adult exceptions, dentures and oral surgery.
- Zorginstituut Nederland: Physiotherapy and exercise therapy - Diagnosis-specific entitlements and first-treatment exceptions.
- Zorginstituut Nederland: Chronic-condition list - First 20 adult treatments and condition-specific time limits.
- Zorginstituut Nederland: Prescription medicines - GVS, indication limits, preferred medicines and €250 cap.
- Zorginstituut Nederland: Medical mental healthcare - GP/POH-GGZ distinction, referral and deductible.
- Zorginstituut Nederland: Maternity and birth care - Medical indication, non-medical birth contribution and deductible exceptions.
- Zorginstituut Nederland: Visual aids - Glasses exclusions, medical lenses and 2026 contributions.
- Zorginstituut Nederland: Medical devices - Indications, supplier rules, permission and use periods.
- Zorginstituut Nederland: Contraception - Age rule, product contributions and medical exceptions.
- Rijksoverheid: Care while abroad - Dutch-tariff limit, EHIC limits and repatriation exclusion.
- CAK: CAK EHIC reimbursement - Different rules for people insured through the CAK foreign scheme.
- Rijksoverheid: Supplementary insurance - Voluntary cover, acceptance, premium and possible waiting periods.
- Zilveren Kruis: 2026 policy conditions - A current insurer example of medical assessment and orthodontic waiting time.
- Zorginstituut Nederland: Reimbursement complaints - Insurer reconsideration, SKGZ mediation and disputes committee.
- Rijksoverheid: Provider complaints - Provider, complaints officer and recognised disputes body.
- Nederlandse Zorgautoriteit: NZa reporting point - Signals about billing, information and access after first contacting the responsible party.
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