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NATIONAL SOCIAL HEALTH INSURANCE

(JAMINAN KESEHATAN NASIONAL)


Jakarta, 15 April 2014
Jenni Wihartini
Head of Marketing Group
NATIONAL SOCIAL SECURITY SYSTEM
(NSSS)
National Social Security System
Minimum standard of Social Security including (Health Care benefit,
sickness allowance, unemployment benefits, old-age benefits,
occupational accident benefits, family benefits, maternity benefits,
disability income benefits, and survivors benefits)
Convention of ILO
102 /1952
Everyone has the right to social security that allows the development
as a useful human being ".
Chapter 28 H Artc 3
Act 1945
"The nation/goverment develop social security system for all people
and empower poor people based on human dignity ".
Chapter 34 Artc 2
Act 1945
Constitutional right of every citizen The state form of responsibility
+
To actualize an Independent, Advanced, Equitable, and Prosperous Society
NSSS : OBLIGATIONS AS A NATION
Constitutional Mandate:
Nation of Indonesia which shall protect all Indonesian people
and the entire country of Indonesia and to promote the general
welfare ... "- (opening constitution 1945 para 4)
Nation of Indonesia develops social security system for all
Indonesian people ..., "- (Article 34 paragraph 2 of the
Constitution 1945)
Act No 40/ 2004 on National Social Security System
(UU SJSN)
19 October 2004
BPJS Kesehatan copyright : Do not quote
without permission
SOCIAL SECURITY HEALTH MANAGEMENT SCHEME *
REVENUE COLLECTION
1. Population
Coverage
2. Methode of
Finance
RISK POOLING
3. Level of
Fragmentaton
4. Compotition of
Risk Pool
PURCHASING
5. Benefit
Package
6. Provider
Payment
7. Administrative
Eficiency
RESOURCES
GENERATION
(Sufficient & Sustainable)
OPTIMAL
RESOURCES USE
Fin Accesibility of
Health Services for All
*Currin G & James C
NSSS ACT and SSA ACT
Act No 24/2011 on Social Security Agency
(BPJS)
Act No 40/ 2004 on National Social Security System
(UU SJSN)
Mutual Cooperation
Not for profit
Openess
Prudent
Accountable
Portability
Compulsary
Trust Fund
The result of fund
management is used for
development program
and members benefits
9 Principles
Health Insurance
Occupational
Accident
Insurance
Old-age Benefit
Pension/
Retirement
Insurance
Life Insurance
5 Programs
Humanity
Benefit
Social justice
for all
Indonesian
people
3 Basis
National Social Security System
2013 2014 - 2019
Presidential Decree No 111/2013 Article 6 :
(1) Membership is MANDATORY and Health Insurance
(2) includes the ENTIRE population of Indonesia
Presidential Decree No 111/2013 Article 6 :
(1) Membership is MANDATORY and Health Insurance
(2) includes the ENTIRE population of Indonesia
Universal
Coverage 2019
Legal Entity PRIVATE
Under the Minister of SOEs
Originally Health Insurance Just For
Retired civil servants and army / police
+ Pioneers + Veterans Independence
PUBLIC Legal Entity
Directly responsible to the President
To Manage Social Health Insurance
THE ENTIRE POPULATION OF INDONESIA
MEMBERSHIP
MEMBERSHIP
(Basic Regulation: Act No. 24 /2011 on BPJS Article 14, states
".... Every citizen, including foreigners who work at least 6
months in Indonesia, shall be the Social Security program
participants)
Members/Enrolees
everyone who has paid contribution/premium or for
whom it has been paid
Two categories of members:
a. People with 40% the lowest incomes premium
paid by goverment (national & local) called PBI
b. All others pay the premium formal workers &
informal sector (incl foreigners who work at list
6 months in Indonesia)
MEMBERSHIP
Members
Non PBI
Formal
Workers
Informal
Sector
Non Worker
PBI
Poor
People
Indigent
People
13
PBI
(Jamkesmas)
Military /
Police and
Retired
Civil
Servants &
Retired
JPK
JAMSOSTEK
The first
phase
began on
January
1, 2014
The entire
population has
not been
entered as
Participant
BPJS
Kesehatan, the
latest 1st
January , 2019
Next
Phase
Phasing of Membership
Registration of membership starting 1st January 2014,
for :
14
Phasing of Membership
Employer of SOE (BUMN), large enterprises,
medium enterprises and small enterprises; 1st
January 2015 the latest
Employer of micro enterprises; 1st January
2016 the latest
Informal sector : Self-employed and Non
worker (Others); 1st January 2019 the latest
REGISTRATION PROCEDURES
R
E
G
I
S
T
R
A
T
I
O
N

P
R
O
C
E
D
U
R
E
S
Otomatically by
data migration
Otomatically by
data migration
a. Ex Askes Members
b. Ex Jamkesmas Members
c. Ex JPK Jamsostek
d. The member of Indonesian Army & Police Dept/ and
Civil Servant in Ministry of Defense
a. Ex Askes Members
b. Ex Jamkesmas Members
c. Ex JPK Jamsostek
d. The member of Indonesian Army & Police Dept/ and
Civil Servant in Ministry of Defense
Registered by
themselves
Self-employed
Non Worker
Being registered by
their employer/local
Gov
Being registered by
their employer/local
Gov
b. Employee of State Own Enterprises
c. Employee of Private Enterprises
c. Member of local HI which has integrated to
JKN
b. Employee of State Own Enterprises
c. Employee of Private Enterprises
c. Member of local HI which has integrated to
JKN
at BPJS KES office
via WEB
at BPJS KES office
through the
collaboration of
banks
at BPJS KES office
MEMBERSHIP ENROLLEMENT
FORMAL WORKERS
(COLLECTIVELY)
16
Employees are
registered by
their Employer
- Filled in registration form for
business entity or other legal
entity
- Submit data of employees
- Registration form and data of
employess are submitted to BPJS
Office
- Every entity will receive Virtual
Account as customer number for
paying contribution to BPJS via
Bank : BRI, Mandiri, BNI
Formal workers who have not registered by his/ her Employer can register as an
individual participant basis to BPJS
MEMBERSHIP ENROLLEMENT
INFORMAL WORKERS AND NON WORKER
(INDIVIDUALLY)
17
Applicant enroll
individually/ by
community at BPJS
Office
-
- Filled in registration form
- Submitt identity (Identity
card. Family card)
- Received Virtual Account
individually
-
- Virtual Account as
customer number for
paying contribution to
BPJS via Bank : BRI,
Mandiri, BNI
Indentity Card
CONTIBUTION/ PREMIUM
Contribution Contribution
Rp. 19.225,- PMPM
Employer 4% Employee 0,5%
Per 1 July 2015 :
Employer 4% Employee 1%
Class 1 Rp.59.500,- PMPM
Class 2 Rp.42.500,- PMPM
Class 3 Rp. 25,500,- PMPM
*) For Gov Employee : contribution 5% 3% Gov, 2 % Employee *) For Gov Employee : contribution 5% 3% Gov, 2 % Employee
Paid by government
Paid by employer
and employee
Paid by themselves
PBI
Formal
Worker *)
Informal Worker
and
Non Worker
OTHER FAMILY MEMBERS :
Fourth children and so on....
Parents : Father, Mother
Parent in law : Father in law, Mother in law
Additional contribution 1% of wage PMPM
Addtional Contribution
For Formal Worker
RELATIVES :
In addtion of other family members
Eg. siblings, cousins, nieces, housekeeper, driver
Contribution as individually member
(nominal: Class 1, 2 0r 3)
HEALTH CARE BENEFIT
Health Care Benefit
Characteristically of personal health services; including health
promotion, preventive, curative, rehabilitative medicine services,
medical consumable materials in accordance with the necessary
medical indications
1. Medical benefits are not tied to the amount of contributions paid
2. Non-medical benefits are determined based on the amount of
contributions paid scale, including accommodation benefits
Ambulance is given to referral patients from health facilities with
certain conditions stipulated by BPJS
Primary Health Care
Primary health
care, including
non-specialist
health care
services which
includes:
Administration services;
Promotive and preventive services;
Examination, treatment, and medical
consultation;
Non-specialist medical treatment, both
operative and non-operative;
Drug services, medical consumables and
materials;
Blood transfusion in accordance with
medical needs;
Laboratory diagnostic primary level; and
Primary hospitalization in accordance with
medical indications
Administration services;
Promotive and preventive services;
Examination, treatment, and medical
consultation;
Non-specialist medical treatment, both
operative and non-operative;
Drug services, medical consumables and
materials;
Blood transfusion in accordance with
medical needs;
Laboratory diagnostic primary level; and
Primary hospitalization in accordance with
medical indications
Referral health services, including health care services which includes:
Secondary and Tertiary Care
Outpatient Includes:
1. Administration services;
2. Examination, treatment and specialist
consultation by a specialist and
subspecialty;
3. Specialist medical treatment in accordance
with the medical indications;
4. Drug services, medical consumables and
materials;
5. Advanced diagnostic services in
accordance with medical indications;
6. Medical rehabilitation;
7. Blood services;
8. Forensic medical services; and
9. Corpse in the Health Care Facilities.
Inpatient which include:
10. Non-intensive inpatient care;
and
11. Hospitalization in intensive
care.
+ Other Health Services stipulated by the
Minister of Health
Healthcare Tools
No Healthcare Tools Amount of
Reimbursement
Note
1. Spectacles Class 3 : Rp.150.000,- min : sferis 0,5D
silindris 0,25D
The fastest each 2
years in accordance
medical indications
Class 2 : Rp.200.000,-
Class 1 : Rp. 300.000,-
2. Hearing aid
Max. Rp. 1.000.000,-
The fastest each 5
years in accordance
medical indications
3. Denture Max. Rp. 1.000.000,- (full
denture
The fastest each 2
years in accordance
medical indications
Max. Rp. 500.000,- for
each jaw
Healthcare Tools
No Healthcare Tools Amount of
Reimbursement
Note
4. Hand / Feet Prostheses Max. Rp.2.500.000,- The fastest each 5
years in accordance
medical indications
5. Spine corset
Ma. Rp. 350.000,-
The fastest each 2
years in accordance
medical indications
6. Collar Neck Max. Rp. 150.000,- The fastest each 2
years in accordance
medical indications
7. Crutch Max. Rp. 350.000,- The fastest each 5
years in accordance
medical indications
PT. Askes (Persero)
Member
Non PBI
Formal
Workers
Class I, II
Informal
Sector
Class I, II, III
Non Worker
Class I, II, III
PBI
Poor People
Class III
Indigent
People
Class III
Accomodation
EXCLUSIONS
a. Health care services performed without going through the procedures
as stipulated in regulations;
b. Health care services in health facilities that do not cooperate with
BPJS, except for emergency cases;
c. Health care services has been secured by a occupational accident
insurance program to disease or injury due to accidents or
occupational relationship;
d. Health care program that has been guaranteed by traffic accidents
program until the value assumed by the traffic accident insurance
program
e. Health care services performed in foreign countries;
f. Health care services for aesthetic purposes;
g. Health care services for overcome infertility (to have children);
h. Orthodontic;
i. Health disorders / diseases caused by drug addiction and / or alcohol;
EXCLUSIONS
j. health problems as a result of deliberate self-harm, attempted suicide, or as a
result of doing a hobby that endanger themselves;
k. complementary medicine, alternative and traditional, including acupuncture,
shin she, chiropractic, which has not been declared effective by health
technology assessment (health technology assessment);
l. medication and medical treatment categorized as an experiment (experiment);
m. contraceptives, cosmetics, baby food, and milk;
n. household health supplies;
o. catastrophic health care in the emergency response period, extraordinary
events / outbreaks;
p. The cost of health care services on the incidence of unexpected preventable
(preventable adverse events)
q. Other service charges are not related to the Health Insurance Benefits are is
given.
HEALTHCARE SERVICE SYSTEM
ERA BPJS: Reforming HEALTH CARE SYSTEM
GATE KEEPER CONCEPT PROMOTIVE PREVENTIVE
Strengthens Primary Care Services position in the Pyramid : As The Gate Keeper in Tiered
Health Care Systems
Percentage Healthcare Cost
28 %
56 %
15 %
76 %
24 %
NHS
England
67 %
33 %
Askes
NHI
Taiwan
Gate Keeper
Capitation
INA CBGs
Sub
Specialistic
Specialistic
All health problems,
promotive, preventive,
survailance
Member
Primary Care
Fasilities
Hospital
Emergency
Refferal / Back Reffreral
Reimburse
BPJS Kesehatan
Branch Office
Health Services Procedure
HEALTH CARE FASILITIES
Shall cooperate with
BPJS
HC Fasilities
Government
can cooperate
with BPJS
HC Fasilities
Private
HEALTH CARE FASILITIES
No HC Fasilities Amount
1 Public Health Center 9.599
2 General Practicioner 3.715
3 Private Primary Clinic 1.724
4 Army Primary Clinic
Navy
Army
Air force
Army headquater
Ministry of defence
144
509
117
5
4
5 Police Primary Clinic 558
Subtotal I 16375
6 Primary Hospital (Type D) 19
7 Dentist 620
Subtotal II 639
TOTAL 17.014
PRIMARY CARE FASILITIES
No HC Fasilities Amount
1 Government Hospital 641
2 Private Hospital 919
3 Army Hospital
Army
Navy
Air Force
63
22
23
4 Police Hospital 45
5 Specialist Clinic 37
TOTAL 1.750
HOSPITAL & SPECIALIST CLINIC
COORDINATION OF BENEFIT (COB)
Coordination of Benefits
(COB) is a condition in which
two or more payer who bear
the same person for the
same health insurance
benefits, limiting the total
benefit in a certain amount of
not exceeding amount of
expensed health care.
Definition COB Definition COB
Pres Decree No 12/ 2013
Legal Basis
Article 24
Participants who want a higher-class treatment from
the right, can increase their rights by following
supplemental health insurance (private insurance), or
pay for itself the difference between the cost of
which is guaranteed by BPJS at a cost to be paid due
to increased maintenance class.
Pres Decree No 12/ 2013 Legal Basis
CHAPTER VI
COORDINATION OF BENEFITS
Article 27
(1) The Insured can follow supplemental health
insurance program.
(2) BPJS and organizers of supplemental health
insurance programs as referred to in paragraph (1)
may coordinate in providing Health Insurance
Benefits for Participants who have a right to
protection supplemental health insurance program.
Pres Decree No. 111/ 2013
Amendment of Pres Decree No. 12/ 2013
Legal Basis
Article 27 B
In terms of health facilities did not cooperate with BPJS Kesehatan, the
bail mechanism agreed between BPJS Health with supplemental health
insurance program providers or other guarantor entities.
Article 28
Provisions concerning the coordination of procedures for Benefits as
described in Article 27 and Article 27A of the agreement between BPJS
Kesehatan and the organizers of social security programs in the field of
occupational accidents and traffic accidents or organizers supplemental
health insurance programs or other guarantor entities.
Coordination Of Benefit
Additional
Benefits
Health Services
stipulated by
the Minister of
Health
Secondary &
Tertiery Health
Care Services
Primary Health
Care Services
BPJS
KESEHATAN
Private Health Insurace
Coordination
of Benefit
(COB)
THANK YOU