BPJS Eng.pdf

8/11/2019 BPJS Eng.pdf

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NATIONAL SOCIAL HEALTH INSURANCE(JAMINAN KESEHATAN NASIONAL)

Jakarta, 15 April 2014

Jenni Wihartini

Head of Marketing Group


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NATIONAL SOCIAL SECURITY SYSTEM(NSSS)


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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 s urvivors benefits)

Convention of ILO102 /1952

Everyone has the right to social security that allows the developmentas a useful human being ".

Chapter 28 H Artc 3Act 1945

" The nation/goverment develop social security system for all peopleand empower poor people based on human dignity ".

Chapter 34 Artc 2Act 1945

Constitutional right of every citizen The state form of responsibility

To actualize an Independent, Advanced, Equitable, and Prosperous Society


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NSSS : OBLIGATIONS AS A NATIONConstitutional Mandate: Nation of Indonesia which shall protect all Indonesian people

and the entire country of Indonesia and to promote the generalwelfare ... "- (opening constitution 1945 para 4)

Nation of Indonesia d evelops social security system for allIndonesian people ..., "- (Article 34 paragraph 2 of theConstitution 1945)

Act No 40/ 2004 on National Social Security System

(UU SJSN)

19 October 2004BPJS Kesehatan copyright : Do not quote

without permission


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SOCIAL SECURITY HEALTH MANAGEMENT SCHEME

REVENUE COLLECTION1. Population

Coverage2. Methode of

Finance

RISK POOLING3. Level of

Fragmentaton4. Compotition of

Risk Pool

PURCHASING

5. BenefitPackage

6. ProviderPayment

7. AdministrativeEficiency

RESOURCESGENERATION

(Sufficient & Sustainable)

OPTIMALRESOURCES USE

Fin Accesibility ofHealth Services for All

*Currin G & James C


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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)


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Mutual Cooperation

Not for profit

Openess

Prudent Accountable

Portability

Compulsary

Trust Fund

The result of fundmanagement is used fordevelopment programand members benefits

9 PrinciplesHealth Insurance

Occupational

AccidentInsurance

Old-age Benefit

Pension/Retirement

InsuranceLife Insurance

5 ProgramsHumanity

Benefit

Social justice for all

Indonesian people

3 Basis

National Social Security System


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2013 2014 - 2019

Presidential Decree No 111/2013 Article 6 :(1) Membership is MANDATORY and Health Insurance

(2) includes the ENTIRE population of Indonesia

UniversalCoverage 2019

Legal Entity PRIVATEUnder the Minister of SOEsOriginally Health Insurance Just ForRetired civil servants and army / police+ Pioneers + Veterans Independence

PUBLIC Legal EntityDirectly responsible to the PresidentTo Manage Social Health InsuranceTHE ENTIRE POPULATION OF INDONESIA
http://localhost/var/www/apps/conversion/tmp/scratch_3/BPJS%20FIN_19-10-13_PAL_mout.mpg


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MEMBERSHIP


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MEMBERSHIP

(Basic Regulation: Act No. 24 /2011 on BPJS Article 14, states".... Every citizen, including foreigners who work at least 6months in Indonesia, shall be the Social Security program

participants)


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Members/Enroleeseveryone who has paid contribution/premium or forwhom it has been paid

Two categories of members:a. People with 40% the lowest incomes premium

paid by goverment (national & local) called PBIb. All others pay the premium formal workers &

informal sector (incl foreigners who work at list6 months in Indonesia)

MEMBERSHIP


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Members

Non PBI

FormalWorkers

InformalSector Non Worker

PBI

PoorPeople

IndigentPeople


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13

PBI(Jamkesmas)

Military /Police andRetired

CivilServants &Retired

JPK

JAMSOSTEK

The first

phasebegan onJanuary1, 2014

The entire population has

not been

entered asParticipantBPJS

Kesehatan, thelatest 1st

January , 2019

NextPhase

Phasing of Membership


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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 January2016 the latest

Informal sector : Self-employed and Nonworker (Others); 1st January 2019 the latest


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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 bydata migration

a . Ex Askes Members

b. Ex Jamkesmas Members

c. Ex JPK Jamsostek

d. The member of Indonesian Army & Police Dept/ andCivil Servant in Ministry of Defense

Registered bythemselves

Self-employed

Non Worker

Being registered bytheir employer/local

Gov

b. Employee of State Own Enterprisesc. Employee of Private Enterprises

c. Member of local HI which has integrated toJKN

at BPJS KES office

via WEB at BPJS KES office through the

collaboration of

banks

at BPJS KES office


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MEMBERSHIP ENROLLEMENT

FORMAL WORKERS(COLLECTIVELY)

16

Employees areregistered by

their Employer

- Filled in registration form forbusiness entity or other legalentity

- Submit data of employees

- Registration form and data ofemployess are submitted to BPJSOffice

- Every entity will receive VirtualAccount as customer number forpaying contribution to BPJS viaBank : BRI, Mandiri, BNI

Formal workers who have not registered by his/ her Employer can register as anindividual participant basis to BPJS


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MEMBERSHIP ENROLLEMENTINFORMAL WORKERS AND NON WORKER

(INDIVIDUALLY)

17

Applicant enrollindividually/ by

community at BPJSOffice

-

- Filled in registration form

- Submitt identity (Identitycard. Family card)

- Received Virtual Accountindividually

-

- Virtual Account ascustomer number forpaying contribution toBPJS via Bank : BRI,Mandiri, BNI


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Indentity Card


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CONTIBUTION/ PREMIUM


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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

Paid by government

Paid by employerand employee

Paid by themselves

PBI

FormalWorker *)

Informal Workerand

Non Worker


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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 ContributionFor 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)


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HEALTH CARE BENEFIT


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Health Care Benefit

Characteristically of personal health services; including health promotion, preventive, curative, rehabilitative medicine services,medical consumable materials in accordance with the necessarymedical 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 withcertain conditions stipulated by BPJS


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Primary Health Care

Primary health

care, includingnon-specialisthealth care

services whichincludes:

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


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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 andsubspecialty;

3. Specialist medical treatment in accordancewith the medical indications;

4. Drug services, medical consumables andmaterials;

5. Advanced diagnostic services inaccordance 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 intensivecare.

+ Other Health Services stipulated by theMinister of Health


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Healthcare Tools

No Healthcare Tools Amount of

ReimbursementNote

1. Spectacles Class 3 : Rp.150.000,- min : sferis 0,5Dsilindris 0,25D

The fastest each 2years 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 5years in accordancemedical indications

3. Denture Max. Rp. 1.000.000,- (full

denture

The fastest each 2

years in accordancemedical indications

Max. Rp. 500.000,- foreach jaw


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Healthcare Tools

No Healthcare Tools Amount ofReimbursement

Note

4. Hand / Feet Prostheses Max. Rp.2.500.000,- The fastest each 5years in accordancemedical indications

5. Spine corset Ma. Rp. 350.000,- The fastest each 2years in accordancemedical indications

6. Collar Neck Max. Rp. 150.000,- The fastest each 2years in accordancemedical indications

7. Crutch Max. Rp. 350.000,- The fastest each 5years in accordancemedical indications


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PT. Askes (Persero)

Member

Non PBI

FormalWorkers

Class I, II

InformalSector

Class I, II, III

Non Worker

Class I, II, III

PBI

Poor People

Class III

IndigentPeople

Class III

Accomodation


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EXCLUSIONSa. 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 oroccupational relationship;

d. Health care program that has been guaranteed by traffic accidentsprogram until the value assumed by the traffic accident insuranceprogram

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;


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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 healthtechnology 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 isgiven.


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HEALTHCARE SERVICE SYSTEM


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ERA BPJS:Reforming HEALTH CARE SYSTEMGATE KEEPER CONCEPT PROMOTIVE PREVENTIVEStrengthens Primary Care Services position in the Pyramid : As The Gate Keeper in TieredHealth Care Systems

Percentage Healthcare Cost

28 %

56 %

15 %

76 %

24 %

NHSEngland

67 %

33 %

Askes NHITaiwan

Gate KeeperCapitation

INA CBGs

SubSpecialistic

Specialistic

All health problems,promotive, preventive,

survailance


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Member

Primary Care

FasilitiesHospitalEmergency

Refferal / Back Reffreral

Reimburse

BPJS KesehatanBranch Office

Health Services Procedure


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HEALTH CARE FASILITIES


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Shall cooperate withBPJSHC Fasilities

Government

can cooperatewith BPJS

HC FasilitiesPrivate

HEALTH CARE FASILITIES


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No HC Fasilities Amount

1 Public Health Center 9.5992 General Practicioner 3.715

3 Private Primary Clinic 1.724

4 Army Primary Clinic Navy Army Air force Army headquater Ministry of defence

144

509117

54

5 Police Primary Clinic 558

Subtotal I 163756 Primary Hospital (Type D) 19

7 Dentist 620

Subtotal II 639

TOTAL 17.014

PRIMARY CARE FASILITIES


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No HC Fasilities Amount

1 Government Hospital 641

2 Private Hospital 919

3 Army Hospital Army Navy Air Force

632223

4 Police Hospital 45

5 Specialist Clinic 37

TOTAL 1.750

HOSPITAL & SPECIALIST CLINIC


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COORDINATION OF BENEFIT (COB)


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Coordination of Benefits(COB) is a condition in which

two or more payer who bearthe same person for thesame health insurancebenefits, limiting the totalbenefit in a certain amount ofnot exceeding amount ofexpensed health care .

Definition COB


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Pres Decree No 12/ 2013Legal Basis

Article 24

Participants who want a higher-class treatment fromthe right, can increase their rights by followingsupplemental health insurance (private insurance), orpay for itself the difference between the cost of

which is guaranteed by BPJS at a cost to be paid dueto increased maintenance class.


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Pres Decree No 12/ 2013Legal Basis

CHAPTER VICOORDINATION OF BENEFITS

Article 27

(1) The Insured can follow supplemental healthinsurance program.

(2) BPJS and organizers of supplemental health

insurance programs as referred to in paragraph (1)may coordinate in providing Health InsuranceBenefits for Participants who have a right toprotection supplemental health insurance program.


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Pres Decree No. 111/ 2013Amendment of Pres Decree No. 12/ 2013Legal Basis

Article 27 B

In terms of health facilities did not cooperate with BPJS Kesehatan , thebail mechanism agreed between BPJS Health with supplemental healthinsurance program providers or other guarantor entities.

Article 28

Provisions concerning the coordination of procedures for Benefits asdescribed in Article 27 and Article 27A of the agreement between BPJSKesehatan and the organizers of social security programs in the field ofoccupational accidents and traffic accidents or organizers supplementalhealth insurance programs or other guarantor entities.


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Coordination Of Benefit

AdditionalBenefits

Health Servicesstipulated by

the Minister ofHealth

Secondary &Tertiery HealthCare Services

Primary HealthCare Services

BPJSKESEHATAN

Private Health Insurace

Coordinationof Benefit

(COB)


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THANK YOU

Documents

BPJS Eng.pdf