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Health insurance decision

Original Language Title: Besluit zorgverzekering

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Decision of 28 June 2005 laying down a general measure of administration as referred to in Articles 11, 20, 22, 32, 34 and 89 of the Law on the Law of the Sea (Health Insurance Decision)

We Beatrix, at the grace of God, Queen of the Netherlands, Princess of Orange-Nassau, etc. etc. etc.

On the nomination of Our Minister of Health, Welfare and Sports of 22 April 2005, attribute Z/VV-2577868;

Having regard to the Articles 11, third and fourth members , 20 , 22, fifth paragraph , 32, second and third members , 34, third member , and 89, fifth paragraph, of the Zorginsurance Act ;

The Council of State heard (opinion of 20 June 2005, No W13.05.0153/III);

Having regard to the further report by Our Minister for Health, Welfare and Sport of 27 June 2005, attribute Z/VV-2596179;

Have found good and understand:

Chapter 1. Definitions and general provisions

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Article 1

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For the purposes of this Decision and the provisions based thereon, the following definitions shall apply:

  • a. Law: The Health insurance law ;

  • b. stay: stay at the dinner time;

  • c. Own contribution: an own contribution as referred to in the Article 11, third paragraph of the Act ;

  • ed. registered medicine: a medicinal product for which a marketing authorisation or a parallel marketing authorisation has been granted under the conditions of Pharmaceutical Act or under the Regulation, referred to in Article 1, first paragraph, point (fff) of that Act ;

  • e. In vitro fertilisation attempt: In accordance with the in vitro fertilisation method, taking into account:

    • 1 °. to promote the maturation of ova into the body of the woman by hormonal treatment;

    • 2 °. follicular puncture;

    • 3 °. the fertilisation of ova and the cultivation of embryos in the laboratory;

    • 4 °. Implanting one or more of the embryos in the uterine cavity in order to create pregnancy;

  • f. Contribution contribution: the contribution, intended to Section 4.2 of the Act ;

  • g. year of settlement: the calendar year to which an equaltation contribution relates;

  • h. cluster of performance: the cluster "variable care costs", the cluster "fixed care costs", the cluster "medical mental health service", the cluster " nursing and care ", or cluster" long-term mental health care ";

  • i. Variable care costs: the variable costs of residence, nursing and care provided under medical specialist care, with the exception of stay associated with care such as clinical psychologists and psychiatrists who commit, as well as the cost of medical care such as medical specialists who provide, with the exception of care such as clinical psychologists and psychiatrists who commit, all of this to the extent that these costs fall under the coverage of a health insurance policy and not to Ministerial arrangement provides that it will be considered as part of another cluster the expression and costs of benefits covered by the coverage of a health insurance which are not considered as part of another cluster;

  • j. Fixed care expenses: costs of care, designated by ministerial arrangement, which do not affect insurers or which are not normally non-normal in the context of the risk settlement, to the extent that they are covered by a health insurance scheme Falling;

  • k. costs of medical mental health services: the costs of medical care such as clinical psychologists and psychiatrists who provide and the associated stay for an uninterrupted period of not more than 365 days, to the extent that these costs are covered by the health insurance is covered and it is not established under any ministerial arrangement that these are considered to be part of another cluster;

  • l. [ Red: Expiring;]

  • m. macro-partial amount: one in the ministerial arrangement, referred to in Article 3.1, third paragraph , for a cluster of performance, amount that ex ante is distributed among health insurers;

  • n. part amount: an amount that a health insurer receives for a cluster of performance;

  • o. age and sex: Criteria for the settlement of insured persons according to their age, sex or age and sex;

  • P. FKG's: Pharmaceutical cost groups, an insurance criterion according to which insured persons are classed in classes of chronic disease based on the use of medicinal products in the past;

  • q. FKG's mental health disorders: "pharmaceutical cost groups" mental illness, an insurance criterion under which insured persons are classified into classes of chronic mental illness on the basis of past drug use;

  • r. DKG's: Diagnosis cost groups, an allocation criterion according to which insured persons are classified in cost homogeneous classes with different chronic conditions identified on the basis of the diagnosis treatment combinations;

  • s. nature of income: an insurance criterion under which insured persons are classified in classes on the basis of the nature of their income;

  • t. SES: socioeconomic status, an insurance criterion under which insured persons are classified in classes on the basis of the number of persons at an address, their age and the average income per address;

  • u. single address: 'residence at an address to which one person is registered' or in a class 'does not reside in an address to which one person is registered';

  • v. region: an entry criterion according to which the four digits of the postal code of their address for the residence are classified in classes, taking into account the differences in terms of care provided at the postal code level, socioeconomic conditions and health;

  • w. GGZ Region: an element of settlement under which insured persons are classified in classes based on the four digits of the postal code of their address of residence, taking into account the differences related to GGZ care provision at the post-code level, socioeconomic conditions and mental health;

  • x. [ Red: expired;]

  • y. [ Red: expired;]

  • z. multi-annual high costs: an interest rate criterion on the basis of which insured persons are classified according to the cost of the care they have received during the three years preceding the settlement year, in classes of predictable care costs;

  • aa. Nominal calculation premium: an amount to be taken into account in the calculation of the contribution contribution, at the level of the premium estimated by Our Minister, which provides an annual care insurer with an insured person insured for insured benefits;

  • Bb. estimated costs: the ministerial arrangement referred to in Article 3.1, third paragraph -certain macro-amounts, increased or reduced after the determination of these amounts but estimated for 1 January of the year of the settlement, to be determined by ministerial arrangement resulting from changes in the amount of the in the course of the year of the settlement of a health insurance scheme, any performance which could not be taken into account in the preparation of the ministerial arrangement referred to in Article 3.1, third paragraph;

  • cc. Nacalculation: adjustment of the partial amount on the basis of the difference between realised costs and the recalculated amount per health insurer, per distinguished cluster of performance;

  • dd. Bandwidth: an amount above which more or less costs may be reconstructed;

  • ed. HKG's: resource cost groups, an allocation criterion under which insured persons are classified into cost-homogeneous classes of chronic conditions based on past use of the auxiliary resource use;

  • Ff. DKG's mental health disorders: diagnostic cost groups, an allocation criterion on the basis of which insured persons are classified into cost homogeneous classes with different chronic mental illnesses identified on the basis of diagnosis of treatment combinations;

  • Gg. costs of nursing and care: costs of care as referred to in Article 2.10, first paragraph ;

  • hh. GSM: generic somatic morbidity, an enumeration criterion on the basis of which insured persons are classified in morbidity-based classes and age;

  • i. GGZ-MHK: multi-annual high costs in the GGZ, a settlement criterion on the basis of which insured persons are classified in classes of mental health care which they have enjoyed in the three years preceding the settlement year. costs in the GGZ;

  • jj. cost of long-term mental health care: the costs of medical care such as clinical psychologists and psychiatrists who provide, and the associated stay, for an uninterrupted period of more than 365 but not more than 1095 days, to the extent that such costs are covered by the the coverage of a health insurance policy is not determined by any ministerial arrangement, which is considered to be part of another cluster.

Chapter 2. The content of the health insurance

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§ 1. The performance to be insured

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Article 2.1

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  • 2 The content and extent of the forms of care or services shall be determined by the state of science and practice and, in the absence of such a measure, by what is relevant in the field in question as responsible and adequate care, and services.

  • 3 Without prejudice to the conditions laid down in the Articles 2.4 to 2.15 , the insured person, in a form of care or a service, is entitled only to the extent that he reasonably has been assigned to it according to the content and the extent of the service.

  • 5 By way of derogation from the second paragraph, the care and other services referred to in the Article 2.4 , 2.8 or 2.9 , also, the care and services designated by ministerial arrangement under the conditions laid down in that provision and for a period of up to seven years to be provided in this regard, to the extent that responsible care and services are involved.


Article 2.2

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  • 2 For the purpose of determining the fee, the following shall be deducted:

    • a. which should have been paid by the insured person as his own contribution if under the care insurance he would be entitled to benefits arising from care or other services;

    • (b) The costs which are higher than those in Dutch market conditions are reasonably considered to be appropriate.


Article 2.3

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  • 1 If the need for care or any other service is the result of one or more terrorist acts and the total damage resulting from such acts in a calendar year as a result of such acts in the event of damage, life or kind. Financial supervision Act is applicable, is declared, is expected to be higher than the maximum amount of the insured person's reinsurance per calendar year, is expected to be from the Dutch Herinsurance Corporation for Terrorism N.V. right to a performance to be determined by that society, for all insurance purposes equal percentage of the cost or value of care or other services.

  • 2 The first member shall apply only if the health insurer in which the insured person has his health insurance obligations is insured with the Dutch public health insurance scheme in the case of terrorist acts. Reinsurance society for terrorismeschaden N.V.

  • 3 If after a terrorist act on the basis of Article 33 of the Act or Article 3.23 of this Decision, an additional contribution is made available to the insured person, in addition to the benefits referred to in paragraph 1, to the benefits of a scheme provided for in the scheme, which is to be considered by the Commission. Article 33 of the Act or Article 3.23 of this Decision, to be determined in size.


Article 2.4

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  • 1 Medical care includes care such as general practitioners, medical specialists, clinical psychologists and midwives who provide services, sensory disability care, as intended. Article 2.5a , take care of stop-by-smoking program as intended Article 2.5b , geriatric rehabilitation as intended Article 2.5c and paramedical care as intended Article 2.6 , except that:

    • a. The care shall not include:

      • 1 °. Vaccination for influenza prevention;

      • 2 °. The combination test, non-invasive prenatal test and invasive diagnosis for pregnant women who do not have a medical indication to do so, except that:

        • -in the case of a non-invasive prenatal test under a medical indication, it is also defined as a combination test of a significant risk to a foetus with a chromosome abnormation;

        • -in case of invasive diagnosis under a medical indication, a combination test or non-invasive prenatal test of a foetus with a chromosome aberration shall be considered to be a test of that type;

      • 3 °. the fourth or next in vitro fertilisation attempt per pregnancy to be realized, after three attempts have ended between the moment a follicular puncture has been successful and the moment of a 10-week continuous pregnancy. count from the moment of follicular puncture and if the implantation of cryopreserved embryos has not resulted in a continuous pregnancy of nine weeks and three days from the implantation;

      • 4 °. the first and second in vitro fertilisation attempt in an insured person under 48 years of age, if more than one embryo is returned;

      • 5 °. fertility-related care where the insured woman is forty-three years of age or older, except in so far as it concerns an in vitro fertilisation attempt that has already been arrested before the insured woman has the age of forty-three years reached;

      • 6 °. Care as dental specialists to offer;

    • b. Treatment of a plastic surgical nature is only covered by the care provided that it is intended to correct:

      • 1 °. deviations in appearance that are associated with demonstrable physical impairment;

      • 2 °. mutilations resulting from an illness, accident or medical provision;

      • 3 °. paralysed or addictive upper eyelids resulting from a congenital disorder or a chronic condition present at birth;

      • 4 °. the following congenital malformations: lip-, jaw and palate plets, deformities of the bene face, benign anger of blood vessels, lymphatic or connective tissue, birth spots or deformities of urinary tract and genitals;

      • 5 °. primary sex characteristics at established transsexuality;

    • (c) transplants of tissues and organs are only to be taken care of if the transplantation has been carried out in a Member State of the European Union, in a State which is a party to the Agreement on the European Economic Area or in another state if the donor is resident in that state and the spouse, the registered partner or a blood relative is in the first, second or third degrees of the insured.

  • 2 In the case of ministerial arrangements, forms of care may be exempted.


Article 2.5

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  • 1 The medical care specified in Article 2.4, first paragraph, part c The following shall also include reimbursement of the costs of:

    • a. Specialist medical care in connection with the donor selection;

    • b. Specialist medical care in connection with the surgical removal of the transplantation material from the donor chosen;

    • c. the research, preservation, disposal and transport of post-mortem transplantation materials, in connection with the proposed transplantation;

    • d. the care to which the donor applies under this Chapter, for a period of not more than thirteen weeks, or half a year in the case of a liver transplant, after the date of dismissal from the institution in which the donor is selected for selection; or the removal of the transplantation material has been taken, to the extent that such care is related to such inclusion;

    • (e) the transport of the donor to the lowest class of a public transport service within the Netherlands or, if medically necessary, by car within the Netherlands, in connection with the selection, inclusion and dismissal from the hospital and with care, referred to in part d;

    • f. the transport to and from the Netherlands, from a donor resident abroad, in connection with transplantation of a kidney, bone marrow or liver to an insured person in the Netherlands and other costs involved in the transplant related to the living from the donor abroad, with the exception of the accommodation costs in the Netherlands and lost income.

  • 2 If the donor has completed a care insurance, the costs of the transport referred to in the first paragraph, parts e and f shall be borne by the health insurance of the donor.


Article 2.5a

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Sensory disability care includes multidisciplinary care related to visual impairment, an auditory limitation, or a communicative limitation due to a language development disorder, focused on learning how to handle, lift or reduce. To compensate for the limitation, with the aim of enabling the insured person to function as independently as possible.


Article 2.5b

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  • 1 Stop-by-smoking programme shall include medical and pharmacotherapeutic interventions in support of behavioural change with the aim of stopping smoking.

  • 2 The care referred to in paragraph 1 shall consist of following a programme one time per calendar year.


Article 2.5c

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  • 1 Geriatric rehabilitation includes integral and multidisciplinary rehabilitation care such as specialists in the age of medicine to offer in relation to vulnerability, complex multimorbidity and decreased learning and trainability, focused on the reduce the functional constraints of the insured person that a return to the home situation is possible.

  • 2 The geriatric rehabilitation shall only be covered by the care provided in paragraph 1 if:

    • a. The care within one week is connected to stay as intended in Article 2.12 in relation to medical care such as medical specialists who offer, where that stay has not preceded the stay in an institution as intended in Article 3.1.1, first paragraph, part a, of the Act on long-term care accompanied by treatment as referred to in Article 3.1.1, first paragraph, part c, of that law in the same institution; and

    • b. The care at inception is associated with stay as intended in Article 2.12 .

  • 3 The second paragraph, part (a), does not apply if acute mobility disorders or the reduction of self-reliance are caused by an acute condition and where there is prior medical specialist care for this condition; disease.

  • 4 The duration of the geriatric rehabilitation provided for in paragraph 1 shall not exceed six months. In special cases, the health insurer may allow for a longer period of time.


Article 2.6

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  • 1 Paramedical care includes physiotherapy, exercise therapy, speech therapy, ergotherapy and dietiology.

  • 2 Physiotherapy or exercise therapy shall include care such as physiotherapists and exercise therapists who provide for treatment of the Annex 1 conditions indicated, provided that the time limit specified in that procedure has not been exceeded. This concern for the insured of 18 years of age and older does not include the first twenty treatments.

  • Physiotherapy also includes pelvic physiotherapy related to urinary incontinence. This concern for insured persons of up to nine years of age shall be nine.

  • For insured persons under 18 years of age, physiotherapy and exercise therapy in cases other than the second member shall also be composed of up to nine treatments of the same condition per calendar year, if the result is insufficient to be extended by highest nine treatments.

  • Logopedicine includes care such as speech therapists, provided that the care has a medical purpose and that the treatment repair or improvement of speech function or speech ability can be expected.

  • 6 Ergotherapy includes care such as occupational therapists, provided that it is intended to promote and restore the self-sufficiency and self-reliance of the insured, up to a maximum of ten treatment hours per calendar year.

  • 7 Dietetics include care such as dietitians who offer to offer, provided that care has a medical purpose, up to a maximum of three treatment hours per calendar year.


Article 2.7

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  • 1 Mondcare includes care such as dentists who offer to offer, except that it concerns only dental care which is necessary:

    • a. if the insured has such a serious developmental disorder, growth failure, or acquired deviation from the dental jaw system that he cannot retain or acquire dental function equivalent to that which he is without that concern. would have had if the condition had not occurred;

    • b. if the insured person has a non-dental physical or mental condition and he cannot maintain or acquire any dental function equivalent to that which he would have had if the condition had not occurred either; or

    • c. if a medical treatment without that care will demonstrably have insufficient results and the insured person without that other care cannot maintain or acquire any dental function equivalent to that which he would have had as the the condition had not occurred.

  • 2 Under the care referred to in paragraph 1 (a), the application of a dental implant and the fixed part of the superstructure shall also be included, if there is a very severe tooth-toothless jaw and are to be used to confirm a removable prosthesis;

  • 3 Orthodontic aid is only under the care, referred to in the first member, understood in case of a very serious developmental or growth disorder of the tooth-jaw-mouth system, involving co-diagnosis or co-treatment of disciplines other than the dental is necessary.

  • For insured persons less than 18 years of age, in cases other than the first paragraph, parts a to c shall be:

    • a. periodic preventive dental examinations, once a year, unless the insured species is more likely to be designated by that aid per year;

    • b. incidental dental consultation;

    • c. The removal of sproced stones;

    • d. Fluid application, up to twice a year, unless the insured species is designated by that aid more times per year;

    • e. sealing;

    • f. Parodontal assistance;

    • g. anaesthesia;

    • h. Endodontic help;

    • Restoration of dental elements with plastic materials;

    • j. gnathological assistance;

    • k. Detachable Prosthetic Devices;

    • l. Dental substitutes with non-plastic materials and the application of dental implants, if they are the replacement of one or more of the missing, permanent cutting or cornering teeth which have not been constructed, or because the absence of such use is not being done. of that tooth or teeth is the direct result of an accident;

    • m. surgical dental aid, with the exception of the application of dental implants;

    • n. X-ray examination, with the exception of X-ray examination for orthodontic assistance.

  • For insured persons of 18 years of age and above, in cases other than the first paragraph, parts a to c shall be:

    • a. Surgical dental assistance of a specialist nature and associated X-ray examinations, with the exception of parodontal surgery, the application of a dental implant and uncomplicated extractions;

    • b. Detachable full prosthetic devices for the upper or lower jaw.


Article 2.8

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  • 3 The designation by the health insurer shall be such that of all active substances which are included in the medicinal products designated by the Ministerial Scheme, at least one medicinal product is available to the insured person.

  • 4 Pharmaceutical concerns also include another medicine designated by ministerial arrangement than the drug designated by the health care insurer, to the extent that treatment with the drug designated by the care insurer for the insured person is is not justified.

  • 5 In the case of the ministerial arrangement referred to in paragraph 1 (a), the designated medicinal products shall as far as possible be divided into groups of substitutes for medicinal products.

    That ministerial order also regulates the procedure for the designation, lays down rules on the classification of the classification into groups of substitutes, and lays down rules on the system of classification of medicinal products. establishing a limit for the reimbursement of each group of medicinal products which are substitutes for each other.

  • 6 By way of derogation from paragraph 5, a ministerial arrangement may provide that the groups of substitutes for renewable medicinal products designated by that scheme may be recalculated or put out of the service.


Article 2.9

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  • 1 Aid resources shall include designated, functioning resources and resources designated by Ministerial Regulations, which may be governed by:

    • a. in which cases the insured person is entitled to such care;

    • (b) reimbursement of costs designated under that scheme in connection with home dialysis.

  • 2 The costs of normal use of resources shall be borne by the insured person, unless otherwise provided for in the case of a ministerial arrangement.


Article 2.10

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  • 1 Nursing and care includes care such as nurses who offer them, where that care:

    • a. relates to the need for the medical care provided in Article 2.4 , or a high risk of that,

    • b. is not accompanied by a stay as referred to in Article 2.12 , and

    • c. no maternity care as intended in Article 2.11 is.

  • 2 The care referred to in paragraph 1 shall not cover insured persons until 18 years of age, unless there is a provision of care because of complex somatic problems or because of a physical disability, where:

    • a. there is a need for permanent supervision; or

    • b. 24 hours per day care must be available in the vicinity and that care is associated with one or more specific nursing operations.


Article 2.11

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Maternity care covers such care as maternity care to give birth to mother and child for a period of up to ten days from the day of confinement.


Article 2.12

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  • 1 Stay included during an uninterrupted period of up to 1,095 days, which is medically necessary in connection with the medical care provided by Article 2.4 , or in connection with surgical dental assistance of specialist nature as intended in Article 2.7 , whether accompanied or not with nursing, care or paramedical care.

  • 2 A break of up to 30 days is not considered to be an interruption, but these days do not count for the calculation of the 1,095 days.

  • 3 In derogation from the second paragraph, interruptions due to weekend and holiday leave shall be interrupted for the calculation of the 1,095 days.


Article 2.13

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  • 1 Transport includes transport services by motor vehicle as referred to in Article 1, first paragraph, part b, of the Temporary Act ambulance care , of the insured over a distance of not more than 200 kilometres:

    • a. to a person in whom or an institution in which he will receive care whose expenses are wholly or partly charged to the care insurance;

    • b. to an institution in which it is wholly or partly dependant on the insurance policy as referred to in the Long-term care law will go to stay;

    • c. to a person or institution in which an insured person under eighteen years of age will receive mental health care whose expenses are wholly or partly dependant on the person under the Juvenile law Responsible College of Mayor and Aldermen;

    • d. From an institution referred to in subparagraph (b) to:

      • 1. a person with whom or an institution in which he wholly or partly depended on the insurance as referred to in the Long-term care law an examination or treatment;

      • 2 °. a person or institution for the measurement and fitting of a prosthetic which is wholly or partly charged to the insurance as intended in the Long-term care law shall be provided;

    • e. to his residence or any other dwelling, if he cannot reasonably receive the necessary care in his residence if he comes from any of the persons or institutions referred to in parts (a) to (d).

  • 2 If the health insurer gives an insured person permission to apply to a particular person or institution, the limitation of 200 kilometers does not apply.


Article 2.14

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  • 1 The transport also includes transport services by car, other than by motor vehicle as specified in the Annex. Article 1, first paragraph, part b, of the Temporary Act ambulance care , or from transport in the lowest class of a public means of transport to and from a person or institution as referred to in Article 2.13, first paragraph, parts a, b or d , or a dwelling as referred to in Article 2.13, first paragraph, part e, on a single travel distance of not more than 200 kilometres provided that:

    • a. The insured kidney dialysis treatment must be given;

    • b. has to undergo the insured oncological treatments with chemotherapy or radiotherapy;

    • c. The insured person can only move with a wheelchair;

    • d. The insured person's vision is limited in such a way as to be unable to move without guidance;

    • e. The insured person is less than eighteen years of age and is dependent on care because of complex somatic problems or because of a physical disability, as intended in Article 2.10 .

  • 2 Where the carriage of goods referred to in the first paragraph is private car, the amount to be paid shall be a sum to be determined by ministerial order per kilometre.

  • 3 By way of derogation from the first paragraph, points (a) to (e), transport shall include transport in other cases where the insured person is dependent on transport for a long period due to the treatment of a long-term illness or condition and failure to do so the provision or reimbursement of that transport for the insured person will lead to a lack of fairness in nature.

  • 4 If the health insurer has an assured consent to apply to a particular person or institution, the limitation of 200 kilometers does not apply.


Article 2.15

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  • 2 The transport of ambulances shall also include the carriage of an accompanying person, where counselling is necessary, or if it is accompanied by children under the age of 16. In special cases, the health insurer may allow the transport of two escorts.


§ 1a. Own contributions

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Article 2.16 [ Expat per 01-01-2014]

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Article 2.16a

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The insured person of 18 years of age or older shall pay their own contribution for oral care, Article 2.7, first and fifth paragraph, part b .


Article 2.16b

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  • 1 The insured person pays his own contribution for a medicine as referred to in Article 2.8, first paragraph , which is classified in a group of substitutable medicinal products, if the purchase price is higher than the fee limit. An own contribution shall also be paid to the extent that a medicinal product is prepared from a medicinal product for which its own contribution is due.

  • 2 In the case of a ministerial arrangement, the calculation of own contribution shall be governed.


Article 2.16c

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The insured person shall pay for an aid to be indicated by a ministerial arrangement as referred to in Article 2.9 , own contribution to the size of:

  • a. An amount mentioned in that statement for savings of costs;

  • (b) the difference between the purchase cost and the amount specified in that aid, which may vary according to the group of insured persons to which the insured person belongs; or

  • (c) a percentage of the cost of the device to be determined by that scheme, which may be different for insured persons of up to 18 years old and insured for 18 years or older.


Article 2.16d

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  • 1 The insured person pays for care as referred to in Article 2.11 , own contribution per hour, where it concerns care at the shiver's level.

  • 2 The insured person and her child pay each for care as intended Article 2.11 , which shall be granted in an institution without any medical stay in the institution, an own contribution per day, plus an amount to be determined by ministerial arrangement to exceed the rate of the institution per day.


Article 2.16th

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  • 2 In the case of a ministerial arrangement, the situations in which the own contribution may not be applied may be determined.


Article 2.16f

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In the case of a ministerial arrangement, the level of own contributions is to be set out in the Articles 2.16a and 2.16c to 2.16th That's fixed.


§ 2. Own risk

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Article 2.17

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  • 2 The health insurance provider may determine that costs of using care and other services as referred to in Article 11 of the Act In whole or in part, outside the required own risk, if:

    • a. The insured person turns to a care provider designated by the care insurer; or

    • b. the insured person identified a program designated by the health care insurer with regard to diabetes, depression, heart disease, chronic obstructive pulmonary suffering, overweight or smoking cessation and the cost relates to the condition for which the insured person has followed that programme; or

    • c. The insured person makes use of a medicine or tool designated by the health insurer.

  • 4 By way of derogation from the third paragraph, the health insurer is entitled to charge its own risk if it is due to the insured that the account has not been submitted for the day mentioned in the third paragraph.


Article 2.18

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  • 1 The costs of registration of a general practitioner or of an institution providing household health care shall be excluded from the voluntary own risk.

  • 2 Under the costs of registration:

    • a. An amount corresponding to the registration as a patient, up to a maximum of the rate applicable on the basis of the Health Organisation Act has been established as an availability rate;

    • b. fees associated with the manner in which medical care is provided in the practice of the general practitioner or in the institution, with the characteristics of the patient file or with the location of the practice or the institution, to the extent that this fees between the health insurer of the insured person and his general practitioner or institution have been agreed upon and the general practitioner or institution may charge these fees in accordance with the contract referred to in the aforementioned agreement.


Article 2.19

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The percentage, intended in Article 21, first paragraph, of the Act -100.

Chapter 3. Health insurers

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§ 1. The settlement contribution

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§ 1.1. The breakdown of the macro-performance amount in macro-amounts, the total estimated yield of the nominal calculation premium and the total estimated revenue from the required own risk

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Article 3.1

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  • 1 The macro performance amount is the sum of the following macro-amounts:

    • a. The macro-amount variable care costs;

    • b. The macro-amount fixed care costs;

    • c. the macro-amount cost of medical mental health care;

    • d. the macro-amount cost of nursing and care;

    • e. the macro-part amount cost of long-term mental health care.

  • 2 To the macro-performance amount or macro-amounts do not include the cost of care or other insured services that have become necessary as a result of a terrorist act.

  • 3 The level of the macro-performance and the macro-amounts for a year of settlement shall be determined annually before 1 October of the year preceding the year of the ministerial arrangement.


Article 3.2

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  • 1 The amount of the total yield from the nominal calculation premium for a year of interest shall be estimated annually before 1 October of the year preceding that of the ministerial order.

  • 2 The amount of the total revenue from the compulsory own risk for a year of interest shall be estimated annually before 1 October of the year preceding the year of the previous year under ministerial arrangement.


§ 1.2. The distribution of the macro-amounts and the calculation of the normative amount for the purpose of granting the contribution (ex ante) to a health insurer

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Article 3.3

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The Zorginstitute divides the Article 3.1 mentioned macro-amounts on the update and under the Articles 3.4 to 3.8 certain means in part amounts.


Article 3.4

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  • 1 The Institute of Care divides the macro-amount variable cost of care on the basis of the number of insured persons per health insurer, divided by age and sex, HKGs, FKG's, DKG's, nature of income, SES, multiyear high cost, region and GSM.

  • 2 Our Minister grants weights to all classes of the listed criteria.

  • 3 The classes referred to in paragraph 1 and the weights referred to in paragraph 2 shall be determined annually by ministerial arrangement.


Article 3.5

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The Care Institute distributes the macro-part amount of fixed care costs to the health insurers on the basis of the estimated insurance numbers for the relevant year of the settlement.


Article 3.6

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  • 1 The Institute of care divides the macro-amount cost of medical mental health care on the basis of the numbers of insured persons per health insurer, divided by age and sex, DKG's mental health disorders, FKG's mental health disorders, nature of income, SES, single address, GGZ region, and GGZ-MHK.

  • 2 Our Minister grants weights to all classes of the listed criteria.

  • 3 The classes referred to in paragraph 1 and the weights referred to in paragraph 2 shall be determined annually by ministerial arrangement.


Article 3.7

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  • 1 The Health Institute distributes the macro-amount cost of nursing and care based on the numbers of insured persons per health insurer, divided by age and sex, HKGs, FKG's, DKG's, nature of income, SES, multiyear high costs, region and GSM.

  • 2 Our Minister grants weights to all classes of the listed criteria.

  • 3 The classes referred to in paragraph 1 and the weights referred to in paragraph 2 shall be determined annually by ministerial arrangement.


Article 3.7a

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  • 1 The Institute of Care divides the macro-amount cost of long-term mental health care on the basis of insurance numbers per health insurer, divided by age and sex, DKG's mental illness, FKG's mental health disorders, nature of income, SES, single address, GGZ region, and GGZ-MHK.

  • 2 Our Minister grants weights to all classes of the listed criteria.

  • 3 The classes referred to in paragraph 1 and the weights referred to in paragraph 2 shall be determined annually by ministerial arrangement.


Article 3.8

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By way of derogation from the Articles 3.4 , 3.6 , 3.7 and 3.7a "No FKG", "No FKG mental illness", "No HKG", "DKG" 0 "and" DKG "psychiatric disorders" 0 " and the weights of these classes are to be considered to be insured abroad. insured persons under a ministerial arrangement laid down by the Zorginstitute.


Article 3.9

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The Care Institute sommeert the following Articles 3.3 to 3.8 amounts allocated to a health insurance provider up to a single normative amount per health insurer.


Article 3.10

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  • 1 The Institute of Care then brings on the normative amount, which is intended to be Article 3.9 , by deduction, the income from the nominal calculation premium estimated for the health insurer and the estimated revenue from the obligation of the care insurer from the obligation of own risk.

  • 2 The estimate of the yield from the nominal calculation premium and the own risk of own risk shall be based on a method to be determined by ministerial order.

  • 3 The Care Institute grants an equation contribution to the health insurer as to the outcome of the calculation referred to in the first paragraph.

  • 4 The Care Institute shares to the health insurer the calculated normative amount, intended in Article 3.9 , and the amount of the contribution granted, as referred to in paragraph 3, and shall indicate the amounts referred to in paragraph 1 in the allocation of the contribution.


§ 1.3. The recalculation of the normative amount for the purposes of determining the contribution (ex post) contribution to a health insurer

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Article 3.11

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  • 2 Having regard to the provisions of and pursuant to the Articles 3.13 , 3.14 and 3.15, 1st Member , the Zorginstitute shall determine the cost of the settlement year per cluster of performance for all health insurance companies together.

  • 3 To the realised cost do not include costs for which contributions as referred to in Article 3.23 have been provided.

  • 4 The Care Institute corrects the estimated cost per cluster of performance for the actual number of insured persons in the settlement year and their actual insurance features.

  • 5 [ Red: Expated.]

  • 6 The extent to which an insured person who is not insured for the whole of the settlement year with a health insurer or who is insured for several health insurance companies during the course of the settlement for the same period is determined by ministerial arrangement. the determination of the contribution to be taken into account.


Article 3.12

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  • 1 For the purpose of recalculation, Article 3.11, first paragraph , the ZorgInstitute shall first multiply the subamounts specified in the Articles 3.4 , 3.6 , 3.7 and 3.7a On the basis of the actual numbers and their actual insurance characteristics per health insurer, by a factor equal to the quotient of the realised costs referred to in Article 3.11, second paragraph, and the estimated estimated costs, The fourth paragraph of Article 3.11 of the performance cluster belonging to the partial amount.

  • 2 The Care Institute reduces each amount of the amount calculated on the basis of the first member for a health insurer, by an amount that it calculates as follows:

    • a. The Zorginstitute shall calculate the difference between the realized costs, as referred to in Article 3.11, second paragraph , and the adjusted estimated cost referred to in Article 3.11, fourth paragraph, for the performance cluster corresponding to the partial amount;

    • (b) The Zorginstitute shall share the result obtained under (a) by the total number of insured persons registered in the year of interest of 18 years of age and over which Article 24 of the Act does not apply;

    • c. The Zorginstitute shall multiply for each health insurer the result obtained under (b) by the number of insured persons who are registered in the year of the settlement of that insurer from 18 years of age and over which Article 24 of the Act does not apply.

  • 3 If in other articles or article members of this Chapter the clause "the recalculated partial amount" is used for a cluster of performance referred to in those articles or item members, it shall be intended to be based on the first and second member for the affected cluster of performance calculated amount.


Article 3.13

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To the extent that they are covered by health insurance, the ZorgInstitute shall, by means of a ministerial arrangement, share the types of care and other services which cannot be allocated to a certain cost category without further provision. to the variable care costs, the fixed care costs, the costs of medical mental health care, the cost of nursing and care, or the cost of long-term mental health, in accordance with an allocation key to be determined under that scheme. health care.


Article 3.14

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The Zorginstitute notes for a section of the different rates applicable to a ministerial arrangement within the cost of medical specialist care, costs as variable care costs.


Article 3.15

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  • 1 The Institute of Care notes a section of the various rates applicable to a ministerial arrangement within the cost of medical-specialist care, and costs as fixed care costs.

  • 2 The Care Institute recalculates the amount of fixed health care costs on the basis of the realised insurance numbers.

  • 3 The Care Institute, in a degree to be determined by ministerial arrangement, after the difference between the fixed cost of care in the year in question, and the amount of fixed costs calculated on the basis of the second paragraph, leading to a new partial amount per health insurer.


Article 3.17

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  • 1 Where, for a health insurer, the difference between, on the one hand, Article 3.12 recalculated part amount for the cluster 'medical mental health services' and on the other hand, the realised costs of the cluster 'medical mental health care', divided by the number of insured persons who are registered with him of 18 year and parent on which Article 24 of the Act does not apply, more than an amount to be determined by ministerial arrangement deviates from the average market result of the health insurers for the 'medical mental health care system' cluster, the Zorginstitute is calculearing the outside or less than those referred to above, to a percentage determined by that ministerial arrangement.

  • 2 If, for a health insurer, the difference between, on the one hand, Article 3.12 recalculated part amount for the cluster 'nursing and care' cluster and on the other hand, the realised costs of the cluster 'nursing and care', divided by the number of insured persons enrolled in the cluster aged 18 years and over which Article 24 of the Act does not apply, more than an amount to be determined by ministerial arrangement deviates from the average market result of the health insurers for the cluster "nursing and care", the Zorginstitute is calculearing the outside of the intended range higher or lower costs for a percentage to be determined by that ministerial arrangement.

  • 3 Where, for a health insurer, the difference between, on the one hand, Article 3.12 recalculated part amount for the cluster 'long-term mental health care' cluster and on the other hand the realised cost to the cluster 'long-term mental health care', divided by the number of insured persons enrolled in the cluster of eighteen years and parent on which Article 24 of the Act does not apply, more than an amount to be determined by ministerial arrangement deviates from the average market result of health insurers for the cluster 'long-term mental health care', the Zorginstitute is calculearing the outside or less than those referred to above, to a percentage determined by that ministerial arrangement.


Article 3.18

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The Care Institute sommeert the following Article 3.12 recalculated sub-amounts for the clusters 'variable care costs', 'medical mental health care', 'nursing care and care', and 'long-term mental health care' means Article 3.15 calculated new sub-amount and, as applicable, the amount calculated on the basis of Article 3.17 calculated amounts, up to one normative amount per health insurer.


Article 3.19

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  • 1 The Institute of Care then brings on the normative amount, which is intended to be Article 3.18 , by deduction, the yield from the nominal unit of account, calculated for the health insurer, from the nominal calculation premium and the income from the health insurer's income from the required own risk, calculated for the health insurer.

  • 2 The calculation of the proceeds of the nominal calculation premium calculated by the nominal amount of the calculation and the yield from the income of the insured persons of the required own risk shall be calculated by means of a ministerial meeting of the the arrangements to be laid down.

  • 3 The Care Institute shall determine the contribution contribution to the outcome of the calculation referred to in the first paragraph.

  • 4 The Care Institute shares to the health insurer the normative amount, intended in Article 3.18 , and the amount of the corresponding contribution referred to in paragraph 3, shall indicate the amounts referred to in paragraph 1 when determining the contribution to be made to the settlement.


§ 1.4. Detailed provisions relating to: § 1.3

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Article 3.20

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  • 1 The Institute of Care can be the normative amount, referred to in Article 3.18 , and the contribution contribution, for the purpose of Article 3.19 , for the purpose of establishing a health insurer for the time being.

  • 2 The Institute of Care may, in the course of a provisional determination as referred to in paragraph 1, the nacalculation, as referred to in paragraph 1. Article 3.15 or 3.17 No, no, no, no.


Article 3.21

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  • Where the Zorginstitute is used to calculate the normative amount referred to in Article 4 (2) of the Article 3.9 or 3.18 In order to make use of historical data for a health insurer, if such data are not available, it may be based on another basis which gives a good approach to the missing historical data.

  • 2 If the application of historical data leads to unreasonable and unintended outcomes, the Zorginstitute shall be empowered to assume an alternative basis.


§ 1.5. Complements to the settlement contribution to a health insurer

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Article 3.22

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  • 1 In addition to the settlement contribution, intended in the Articles 3.10 and 3.19 , the Zorginstitute shall provide a payment relating to execution costs for insured persons under the age of 18.

  • 2 The benefit is equal to an annual amount to be determined by ministerial order, multiplied by the number of insured under the age of 18 on 1 July of the year to which the contribution to the settlement relates.


Article 3.23

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  • 1 In addition to the settlement contribution, intended in the Articles 3.10 and 3.19 , the Zorginstitute can make a contribution in relation to a substantial difference between costs and part amount per insurer directly linked to higher costs of insured persons as a result of a very exceptional circumstance.

  • 2 As a result of the first paragraph, no contributions shall be made than after having been established by ministerial arrangement of a disaster which cannot be accommodated within the regular method of determining the contribution to be made to the health insurers.

  • 3 The arrangements for determining the contribution referred to in paragraph 1 shall be laid down by ministerial arrangement.


Article 3.24 [ Reports from 29-12-2011]

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Chapter 3a. The compensation for the mandatory own risk [ Expired by 04-02-2015]

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Article 3a.1 [ Expired by 04-02-2015]

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Article 3a.2 [ Expaed by 04-02-2015]

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Article 3a.3 [ Expaed by 04-02-2015]

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Article 3a.4 [ Expaed by 04-02-2015]

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Chapter 3b. Designation of forms of care not medically necessary for certain groups of foreign nationals

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Article 3b.1

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As forms of care as intended in Article 122a, second paragraph, of the Act The following shall be designated:

  • a. Gender treatments;

  • b. In vitro fertilisation treatments.

Chapter 4. Final provisions

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Article 4.1

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On the entry into force of the Law may be a health insurer responsible for the new legal person Law the data of its legal predecessor shall be considered as historical data.


Article 4.2

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The State tax authority shall provide the health insurance provider with a request as referred to in Article 4 (1). Article 89, first paragraph, of the Act , the personal person who is a non-resident who is subject to payroll tax in respect of employment in the Netherlands or as a non-resident in income tax is subject to the income tax in the Netherlands professional work carried out in relation to the employment of services.


Article 4.3 [ Expired by 19-12-2012]

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Article 4.4

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This decision is cited as: 'Care insurance decision'.

Charges and orders that this Decision will be placed in the Official Journal by means of the note of explanatory note accompanying it.

' s-Gravenhage, 28 June 2005

Beatrix

The Minister for Health, Welfare and Sport,

J. F. Hoogervorst

Published the second of August 2005

The Minister of Justice, a.i.,

M. C. F. Verdonk


Annex 1. of the Decision on health insurance

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Annex of Annex Article 2.6, second paragraph .

  • 1. The disorders, intended in Article 2.6, second paragraph , concerning:

    • a. One of the following disorders of the nervous system:

      • 1 °. cerebrovascular accident;

      • 2 °. spinal cord disorder;

      • 3 °. multiple sclerosis;

      • 4 ° peripheral nerve disorder if there is an engine failure;

      • 5 °. extrapyramidal condition;

      • 6 °. motor retardation or a developmental disorder of the nervous system and he is less than 17 years old;

      • 7 °. congenital abnormation of the central nervous system;

      • 8 °. cerebellar disorder;

      • 9 °. causes of symptoms due to a tumour in the brain or spinal cord or as a result of brain injury;

      • 10 °. radicular syndrome with motor loss;

      • 11 °. muscle disease;

      • 12 °. myasthenia gravis;

    • b. Or any of the following muscul-skeletal disorders:

      • 1 °. congenital abnormation;

      • 2 ° progressive scoliosis;

      • 3 °. juvenile osteochondrosis and he is less than 22 years old;

      • 4 °. reflexdystrophy;

      • 5 °. [ Red: expired;]

      • 6 °. fracture due to Kahler morbus, bone metastasis, or morbus Paget;

      • 7 °, frozen shoulder (capsulitis adhaesiva);

      • 8 °. [ Red: expired;]

      • 9 °. [ Red: expired;]

      • 10 °. [ Red: expired;]

      • 11 °. [ Red: expired;]

      • 12 °. [ Red: expired;]

      • 13 °. hyperostotic spondylosis (morbus Forestier);

      • 14 °. collagen diseases;

      • 15 °. status after amputation;

      • 16 °. whiplash;

      • 17 ° postpartum pelvic instability;

      • 18 °. fractures if treated conservatively;

    • c. [ Red: Expiring;]

    • d. or any of the following disorders:

      • 1 °. Chronic obstructive pulmonary disease where there is stage II or above of the GOLD Classification for COPD;

      • 2 °. congenital abnormation of the tractus respirator;

      • 3 °. lymphedema

      • 4 °. scar tissue of the skin whether or not after a trauma;

      • 5 degrees. status after hospitalisation, a nursing facility or a rehabilitation facility or post-day treatment in a rehabilitation facility and aid to speed up the recovery following dismissal of the home or the termination of the rehabilitation of the hospital. day treatment;

      • 6 ° claudication intermittent (vascular) grade 2 or 3 Fontaine;

      • 7 ° weke share tumors;

      • 8 °. diffuse interstitial lung disease, if there is a fan restriction or a diffusion disorder.

  • 2. In the case of a condition referred to in paragraph 1 (a), (10) or (b), Subpart 17, the duration of treatment shall not exceed three months.

  • 3. If it concerns a condition as referred to in paragraph 1 (b), Subpart 18, the duration of treatment shall be limited to six months after conservative treatment.

  • 4. In the case of a condition referred to in paragraph 1 (b), (7) or (d), (6), the duration of treatment shall not exceed 12 months.

  • 5. In the case of a condition referred to in paragraph 1 (d), subparagraph (5), the duration of treatment shall be limited to 12 months in connection with resignation to the home or termination of treatment in the institution, as provided for in paragraph 1. First paragraph, part d, Subpart 5.

  • 6. In the case of a condition as referred to in paragraph 1 (b), Subpart 16, the duration of treatment shall not exceed three months. If the triassic movement loss, condition loss and cognitive impairment are still present below, this period may be extended by up to six months.

  • 7. In the case of a condition referred to in paragraph 1 (d), Subpart 7, the duration of treatment shall not exceed two years after irradiation.