Private Health Insurance in

the era of National Health

Insurance (JKN)
15 April 2014
| 1
 FACT

• As per January 1, 2015 : National Health

Assurance (JKN) is compulsory to Large, Medium,
Small companies

• The existence of BPJS has effected the mapping of

health insurance market in Indonesia.

• Is it Positive or Negative ?

| 2
 FACT

• The JKN benefits are based on managedcare,

unlimited benefits, follow required procedure
(using primary healthcare facility as a gate
keeper, mostly use the public health centers)
• Private Insurer mostly based on indemnity,
limited benefits but free to choose the
Healthcare facility
• Current medical service issue :
• Less convenience in public health center
• Tight procedure in getting medical access
• Ina CBGs is considered very low, not many
hospitals joining
• Limited health facility network and limited
time of service
• Company (white collar staff) : pays JKN but not
expected to use it (in-efficiency)

| 3
 Exclusions under JKN
1. Medical treatment which is
not follow procedure
2. Treatment outside the BPJS
medical facility network
3. Treatment which is covered by
workmen comp : benefit
4. Medical treatment overseas
5. Treatment for beautification
6. Treatment due to Infertility
7. Treatment for Orthodontic
8. Treatment due to Drug/alcohol
abuse
Opportunity for Private Health
Insurer?
9. Self inflicted bodily injury
10. Traditional medication
11. Experimental medication
12. Contraception, cosmetic, baby
food
13. Household medical supply
14. National disaster/ outbreak
15. Any medical cost which are
not related to the JKN benefits.
| 4
 The Choice of
Company

• Buy BPJS only, it creates cost

efficiency but less convenience for
employees (especially for medium and up
market)

• Buy BPJS and Private Insurer’s policy

separately. But company will have to
pay the premium double.

• Buy BPJS and Private Insurer on COB.

| 5
What is COB ?

Coordination of Benefit (COB) is a

process where two or more payers
who pay the same person for the same
health insurance benefit, limit the total
benefit in a certain amount that does
not exceed the amount paid for
healthcare.

| 6
What is COB ?

The first party that pays the claim

invoice is called the Primary Payer,
while the party that pays the rest of the
invoice is called the Secondary Payer.
In some cases, it is possible to have a
Third Payer.

| 7
Coordination of Benefit

PRIVATE HEALTH
Additional INSURANCE
Benefit

Health
Services Coordination of
determined by Benefit (COB)
the Ministry

Advanced
Health
Services by BPJS
referral KESEHATAN

First-Level
Health
Services

| 8
Regulations related to COB

| 9
 Legal • 12th Presidential Decree Year
Basis 2013

Clause 24
Members who wish to have a higher class than
what he/she is entitled to may raise his/her
entitlement by getting additional health
insurance, or by personally paying the difference
between the amount paid by BPJS Kesehatan
and the amount that has be paid for a class
upgrade.

| 10
 • Regulations by the Ministry
Legal Basis of Health No. 71 2014

Clause 21
(1) Members who wish to have a higher class than
what he/she is entitled to, may raise his/her
entitlement by getting additional health insurance,
or personally paying the difference between the
amount paid by BPJS Kesehatan and the amount
that has be paid for a class upgrade.
(2) Exception from the provisions intended in point (1)
is for PBI Jaminan Kesehatan that is not allowed to
choose a class higher than what he/she is entitled
to.

| 11
 Legal Basis • 12th Presidential Decree
Year 2013

Section VI
Coordination of Benefit
Clause 27
(1)Jaminan Kesehatan members can get
additional health insurance.
(2) BPJS Kesehatan and companies that offer
additional health insurance programs as
mentioned in point 1 may coordinate in
giving benefit for healthcare members that
have the right over the coverage for
additional health insurance programs.

| 12
 • 111th Presidential Decree Year
Legal Basis 2013

Clause 27 B
In the event that the health provider does not work together
with BPJS Kesehatan, then the guarantee method is to be
agreed together between BPJS Kesehatan and the
company that offers additional health insurance program or
other guarantor.
Clause 28
The convention on the benefit coordination method as
mentioned in Clause 27 and Clause 27A is to be arranged
in the cooperation agreement between BPJS Kesehatan
and the company that offers additional insurance programs
or other guarantor.

| 13
 12th Presidential Decree Year 2013

Clause 39
1) BPJS Kesehatan conducts prospective payment to
Primary Care providers based on capitation or the
number of members registered at Primary Care
providers.

2) In the event that payment to a Primary Care provider

based on capitation is not possible in a certain area as
mentioned in point 1, BPJS Kesehatan is given the
authority to conduct payment using other effective
methods.

| 14
 12th Presidential Decree Year 2013

Clause 39

3) BPJS Kesehatan pays Secondary

health providers by referral based on
the methods in Indonesian Case
Based Groups (INACBG’s).

| 15
 Type of Coordination between BPJS & private insurer

1. Coordination of Benefit
2. Coordination of Premium
3. Coordination of membership data
4. Coordination of claim reimbursement
5. Coordination of socialization
6. Coordination of information system

| 16
Concept in BPJS Kesehatan

| 17
 COB Principles
COB is applied if the Private insurer has signed off the agreement with BPJS
Kesehatan.

COB received by insured members do not exceed the actual medical cost.

COB covered by BPJS Kesehatan is the medical treatment which corresponds with
the agreement of BPJS and Private Insurer

COB in the BPJS provider network :

Require referral procedure from Primary care gate keeper
Show the BPJS card and Private insurer’s card
Secondary provider treatment in executive unit
Inpatient treatment in above of the entitled room.
BPJS will insure the medical cost as per the JKN program, the balance will be
the responsible of Private insurer.

COB outside BPJS provider network :

Only applies for inpatient treatment
Within the list of hospital approved by BPJS
Medical cost will be paid first by Private Insurer, such Private insurer seek
reimbursement to BPJS
There is no reimbursement from client to BPJS.
BPJS will reimburse to Private insurer based on Ina CBG’s tariff of hospital
typed C.

| 18
 Treatment related to Emergency

Medical treatment outside BPJS provider network :

• Outside the List of Hospital for COB :
• Members has to be referred to BPJS provider after the
emergency medical condition is stabilized
• Hospital claim to BPJS

• In the List of Hospital for COB :

• Members can be treated until it is recovered. Claim will be
paid by Private insurer first, then private insurer seeks
reimbursement to BPJS.

• Emergency treatment which is covered must corresponds to the

criteria of emergency applied in BPJS.

| 19
 CLAIM Alternative I

Hospital Claim Service Member

Documents

BPJS Private
Kesehatan Insurance
Claim compensation Claim compensation is the
according to ina difference between the
CBG’s tariff and the hospital tariff minus ina
class the member is CBG’s tariff according to the
entitled to class the member is entitled
to
 CLAIM
Alternative II
Claim and medical Service Member
documents

Askom/ Other
BPJS Kesehatan
Insurer
Claim compensation
according to hospital’s Claim compensation is ina CBG’s
tariff tariff according to the class the
member entitled to
What Avrist will do
 Current Status

Avrist is actively working with AAJI/AAUI and BPJS Kesehatan in

drafting the agreement to be used by commercial medical insurers.
Avrist actively explain to companies & business partners re BPJS
Kesehatan.
Avrist is now preparing the list of hospitals to be approved by BPJS
Kesehatan before signing the agreement with BPJS Kesehatan
In the process of preparing the administration and operation
relating to conduct the COB
Avrist will sign the agreement with BPJS Kesehatan

| 23
 Avrist Policy

Company will choose to have a COB program as well as stand

alone.
For policies with COB, premium is expected less than stand alone.
Program is tailor made to be complemented to BPJS Kesehatan.
Companies that prefer to register directly to BPJS, COB can also
be conducted.
Program for overseas medical treatment
Program for certain level of employees
Non medical program : Hospital cash plan, Critical illness

| 24
THANK YOU

| 25