Transcript national social health insurance (jaminan kesehatan nasional)

NATIONAL SOCIAL HEALTH INSURANCE
(JAMINAN KESEHATAN NASIONAL)
Central Office
BPJS Kesehatan
Jl. Letjen. Soeprapto - Cempaka Putih
Central Jakarta, Indonesia - 10510
Introduction
Membership
Contribution / Premium
Health Care Benefit
Coordination of Benefit
Health Care Facilities
PT. Askes (Persero)
INTRODUCTION
National Social Security System
Everyone’s Constitutional Right
Convention of ILO
102 /1952
Chapter 28 H Artc 3
Act 1945
Chapter 34 Artc 2
Act 1945
+
Responsibility of Government
• 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)
• “Everyone has the right to social security that allows the development
as a useful human being ".
• "The nation/goverment develop social security system for all people
and empower poor people based on human dignity ".
To actualize an Independent, Advanced, Equitable, and Prosperous Society
CHOICE OF HEALTH CARE PAYMENT SISTEM
1. Users fee (rate)  Developing Country, the effect of pauperization
2. Tax based  England and 2 (two) common wealth country (NHS)
3. Insurance
a. Commercial
b. Social
4. Mix system
• Poor People
• Non-poor
People
• Formal
• Non-formal
Registered
Memb
er
Health Service Package
Contribution
Security
Regu
lator
Ascobat/JKN Labor Force 03014
Primary
Care
Fasilities
• FFS
• Capitation
• DRG/CBG
Claim
BP –
Askes/
Jamkes
• Primary Health Care
• Referral Health
Care
• Government Health
Care
• Private Health Care
National Social Security System
3 Basis
5 Programs 9 Principles
Humanity
Health Insurance
Benefit
Occupational
Accident
Insurance
Social justice
for all
Indonesian
people
Mutual Cooperation
Not for profit
Openess
Prudent
Accountable
Old-age Benefit
Portability
Pension/
Retirement
Insurance
Compulsary
Life Insurance
Trust Fund
The result of fund
management is used for
development program
and members benefits
NSSS ACT and SSA ACT
Act No 40/ 2004 on National Social Security System
(UU SJSN)
Act No 24/2011 on Social Security Agency
(BPJS)
MEMBERSHIP
Formal Workers
PBI
Informal Workers
Non Workers
Members
Poor People
Non PBI
Indigent People
Family Member of Formal Workers
National Health Insurance guarantee 5 (five) person
MEMBER
Legal Wife/Husband
of Member
Own child, stepchild,
or adopted child
legally
• Single status or she/he doesn’t have own
income
• A person who is under 21 years old or
under 25 years old and still continue his
formal studies
Non PBI Member can allow his/her another families to join in JKN
The fourth child, so on, mother, father, mother/father in law (additional families)
PHK dan Cacat Total Tetap
FormalWork
ers
PHK/Cacat
Total Tetap
Tidak bekerja kembali
dan tidak mampu
bayar iuran (6 bulan)
PBI
Bekerja kembali
(6 bulan)
Perpanjang status
kepesertaan dan
bayar iuran
Phasing of Membership
The first
phase
began on
January
1, 2014
• PBI
(Jamkesmas)
• Military /
Police and
Retired
• Civil
Servants &
Retired
• JPK
JAMSOSTEK
Next
Phase
The entire
population has
not been
entered as
Participant
BPJS
Kesehatan, the
latest 1st
January , 2019
12
Phasing of Membership
Registration of membership starting 1st January 2014,
for :
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
13
CONTRIBUTION
/ PREMIUM
Contribution
PBI
Paid by government
Rp. 19.225,- PMPM
Employer 4% Employee 0,5%
Formal
Worker *)
Informal Worker
and
Non Worker
Paid by employer
and employee
Paid by themselves
*) For Gov Employee : contribution 5%  3% Gov, 2 % Employee
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
SALARY, CONTRIBUTION AND BENEFITS OF INPATIENT SERVICES
FORMAL WORKER ( NON : PNS,TNI/ POLRI)
CLASS II
1,5 x Non Tax Income (Married/1)
2 x Non Tax Income (Married/1)
Rp. 42.525.000/year
Rp. 56.700.000/year
Rp. 3.543.750/month
Rp.4.725.000/month
CLASS II
CLASS I
1. Contribution = 4,5% X Salary/Main Salary+ permanent allowance ( 4% paid by
employer and 0,5% paid by employee)  In July 1st, 2015 up to 5% 4% paid by
employer and 1% paid by employee)
2. Maximum Salary as the basis in calculate contribution is 2 X Non Tax Income
(Married/1) : Rp. 4.725.000.- X 4,5% ; contribution: Rp.212.625,- for 5 (five)
family members
3. Minimum Salary as the basis in calculate contribution is Province Minimum
Salary (UMP)
REGISTRATION PROCEDURES
REGISTRATION PROCEDURES
Otomatically
by data
migration
REGISTRATION
PROCEDURES
Being registered
by their
employer
Registered by
themselves
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. Employee of State Own Enterprises
b. Employee of Private Enterprises
c. Member of local HI which has integrated to
JKN
a. Self-employed
b. Non Workers
• via WEB
• at BPJS KES office
• through the collaboration of banks
REGISTRATION PROCEDURES FOR FORMAL WORKERS
1. Employees are registered by their Employer by filling in registration form for business
entity or other legal entity and submit data of employees
EMPLOYER
BPJS KESEHATANOFFICE
2. Registration form and data of employess
are submitted to BPJS Office. Every entity
will receive Virtual Account as customer
number for paying contribution
3. By using virtual account, employer pay contribution to
BPJS Kesehatan via Bank : BRI, Mandiri, BNI
BANK
4. Employer comes to BPJS Kesehatan office by
taking payment evidence to get Identity Card of
BPJS Kesehatan
REGISTRATION PROCEDURE
FOR INFORMAL WORKER AND NON WORKER
Applicant of
Member
1. Filling in registration form by taking : Identity card,
Family card, photograph 3X4 one sheet
BPJS KESEHATAN OFFICE
3. Applicant pay contribution via ATM/Cash
by using Virtual Account
BANK
Teller / ATM
2. After processing data by
BPJS Kesehatan staff, applicant
will get Virtual Account
4. Applicant comes to BPJS Kesehatan office by
taking payment evidence to get Identity Card of
BPJS Kesehatan
IDENTITY CARD
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
HEALTH CARE
Primary Health Care
Secondary and Tertiary Care
Another Health Services
stipulated by the Minister of
Health
Health Services Procedure
Member
Primary Care
Fasilities
Hospital
Emergency
Reimburse
BPJS Kesehatan
Branch Office
Refferal / Back
Reffreral
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
Secondary and Tertiary Care
Referral health services, including health care services which includes:
Inpatient which include:
Outpatient Includes:
1. Administration services;
2. Examination, treatment and specialist
consultation by a specialist and
subspecialty;
10. Non-intensive inpatient care;
and
11. Hospitalization in intensive
care.
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.
+ Other Health Services stipulated by the
Minister of Health
Accomodation
Member
Non PBI
PBI
Formal
Workers
Informal
Workers
Non Worker
Poor People
Indigent
People
Class I, II
Class I, II, III
Class I, II, III
Class III
Class III
PT. Askes (Persero)
Healthcare Tools
No
1.
Healthcare Tools
Spectacles
Amount of
Reimbursement
Class 3 : Rp.150.000,Class 2 : Rp.200.000,Class 1 : Rp. 300.000,-
Note
min : sferis 0,5D
silindris 0,25D
The fastest each 2
years in accordance
medical indications
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
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.
COORDINATION OF BENEFIT
National Health Insurance – Coordination of Benefit
JKN
• OBLIGATION  Every Person, including foreigners who work at least 6
months in Indonesia
• Act No 24/2011 Chapter 14
JKN
• It is created to fulfill basic medical needs
• In other hand, it cannot fulfill basic medical needs of all Indonesian
society  Maximum class I (There is no class VIP/VVIP)
COB
• In order to implement the obligation  to fulfill medical needs 
additional benefit  Additional Insurance / Another Guarantor
• COORDINATION OF BENEFIT (COB)
Coordination Of Benefit
Additional
Benefits
Private Health Insurace
Coordination
of Benefit
(COB)
Health Services
stipulated by
the Minister of
Health
Secondary &
Tertiery Health
Care Services
Primary Health
Care Services
BPJS
KESEHATAN
Coordination of Benefit
Health Care
Facilities
which has a
contract with
BPJS
KESEHATAN
Health Care
Facilities
which
doesn’t have
a contract
with BPJS
KESEHATAN
• Obeying the phases referral system
• Using Identity Card of BPJS Kesehatan dan and
another insurance card
• COB is valid for a member who wants a higherclass treatment from his/her right
•
•
•
•
HOSPITALIZATION:
There are list of hospitals which is proposed to join with BPJS Kesehatan
There is specific rule for referral system
COB can be applied by members, either for their right or upgrade their
class
• Health Care Service can be paid by additional insurance / another
guarantor earlier
• Reimbursment of health care service payment based on hospital rate,
maximum type C
• Outpatient Service  Not covered
COB of Health Care
-
www.bpjs-kesehatan.go.id
List Of COB Hospitals
No
NAMA RS
Kab/Kota
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
RS Siloam Bali
Siloam Hospitals Balikpapan
RS Urip Sumoharjo
RSU Santosa Hospital Bandung Central
RS Mitra Keluarga BekasiTimur
RSU Puri Cinere
Siloam Hospitals Kebon Jeruk
RS Mitra Kemayoran
RS Pondok Indah
RS MMC
RS Mitra Internasional
RS Pantai Indah Kapuk
Siloam Hospitals Makassar
Siloam Hospitals Manado
RS Permata Bunda
RS Eka Hospital Pekanbaru
RS "JIH"
RS Premier Surabaya
RS Awal Bros (Global Medika)
RS Premier Bintaro
Badung
Balikpapan
Bandar Lampung
Bandung
Bekasi
Depok
Jakarta Barat
Jakarta Pusat
Jakarta Selatan
Jakarta Selatan
Jakarta Timur
Jakarta Utara
Makassar
Manado
Medan
Pekanbaru
Sleman
Surabaya
Tangerang
Tangerang Selatan
Rumah Sakit
Umum
Tipe B
Perseroan
Terbatas
(PT)
List of Private Health Insurace Which Has Sign Agreement
With
BPJS Kesehatan
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
PT Asuransi Jiwa Inhealth Indonesia
PT. Sinar Mas
PT. Tugu Mandiri
PT. Asuransi Mitra Maparya Tbk
PT. Lippo Gerneral Insurance
PT. AXA Financial Indonesia
PT. AXA Mandiri Financial Service
PT Arthagraha General Insurance
PT Asuransi Astra Buana
PT Avrist Assurance
11.
12.
13.
14.
15.
16.
17.
18.
19.
PT Asuransi Umum Mega
PT Asuransi Jiwa Central Asia Raya
PT Asuransi Takaful Keluarga
PT Asuransi Bina Dana Arta Tbk
PT Asuransi Jiwasraya (Persero)
PT Asuransi Jiwa Sinarmas MSIG
PT Asuransi Jiwa Generali Indonesia
PT Tugu Pratama Indonesia
PT Asuransi Multi Artha Guna Tbk
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
PT Asuransi Central Asia
PT AIA Financial
PT Asuransi Jiwa Recapital
PT Asuransi Allianz Life Indonesia
PT Astra Aviva Life
PT Bosowa Asuransi
PT Asuransi Jiwa Bringin Jiwa Sejahtera
PT Equity Life Indonesia
PT Great Eastern Life Indonesia
PT MNC Life Assurance
PT Asuransi Jiwa Adisarana Wanaartha
HEALTH CARE FASILITIES
HEALTH CARE FASILITIES
HC Fasilities
Government
• Shall cooperate with
BPJS
HC Fasilities
• can cooperate
Private
with BPJS
THANK YOU