bpjs eng.pdf
TRANSCRIPT
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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19 October 2004BPJS Kesehatan copyright : Do not quote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
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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
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- Filled in registration form
- Submitt identity (Identitycard. Family card)
- Received Virtual Accountindividually
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- 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