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National Social Security System (NSSS) 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"
National Social Security System (NSSS) 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"
National Social Security System (NSSS) 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"
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
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