Overview of BPJS Kesehatan

BPJS Kesehatan, commonly referred to as the Social Security Agency for Health, is a critical component of Indonesia's national health insurance system, known as Jaminan Kesehatan Nasional (JKN). Established in January 2014, BPJS Kesehatan aims to provide universal health care to all Indonesian citizens and foreigners residing in Indonesia for at least six months.1,2

Structure and Objectives

Mandate and History

BPJS Kesehatan was formed pursuant to Law No. 40 of 2004 on the National Social Security System and further reinforced by Law No. 24 of 2011, mandating the creation of a comprehensive social security system. Initially, it was operated by PT Askes (Persero), a state-owned company. On January 1, 2014, PT Askes transitioned into BPJS Kesehatan, becoming a public agency responsible for managing the JKN program

Types of Coverage

BPJS Kesehatan offers three main classes of health insurance coverage, each varying in terms of facility access and service levels:

1. Class I:Provides the highest level of care.Typically self-paid by individuals, ranging from approximately Rp150,000 to Rp160,000 per month
2. Class II:Offers moderate-level care.Also typically self-paid by individuals, ranging from approximately Rp100,000 to Rp110,000 per month
3. Class III:Offers basic-level care.Includes recipients of Health Insurance Contribution Assistance (PBI JK), who are categorized as poor and disadvantaged individuals. Their contributions are subsidized by the government, making the monthly premium significantly lower (approximately Rp35,500)

Enrollment Requirements

Enrollment in BPJS Kesehatan is mandatory for certain groups:

1. Employees: Employers are required to register their employees under the BPJS Kesehatan program. Contributions are usually deducted directly from employee salaries
2. Freelancers: Freelancers can register themselves voluntarily and contribute monthly fees personally
3. KITAS Holders: Foreign nationals holding Investor KITAS (Kartu Izin Tinggal Terbatas) can arrange BPJS Kesehatan coverage for themselves and up to five immediate family members

Key Features

1. Coverage Scope:Comprehensive coverage includes medical examinations, treatments, consultations, administrative services, pre-medical and medical procedures, and some dental and oral health services
2. Payment Mechanism:Monthly premiums vary according to the chosen class of coverage. Payments are often automatic deductions from bank accounts
3. Digital Innovations:To address operational inefficiencies and enhance user experience, BPJS Kesehatan introduced the Mobile JKN app. This digital platform allows users to register, update profiles, check premiums, schedule appointments, query program details, and file complaints remotely

Impact and Challenges

Despite its ambitious goals, BPJS Kesehatan faced initial challenges regarding service delivery and financial sustainability. Notably, the program experienced significant deficits within a few years after inception, prompting adjustments in premium rates. From 2016 onwards, the government raised monthly premiums by 80% to 100% for some classes to mitigate financial strain 1

1. Efforts to streamline operations via technological advancements have helped reduce office visits and improve user satisfaction scores 4
2. BPJS Kesehatan plays a pivotal role in Indonesia's quest towards achieving universal health coverage, balancing public expectations with fiscal realities while continuously innovating to improve service delivery.

To get treatment through the BPJS Kesehatan program in Indonesia, follow these steps:

1. Registration and Assignment to Primary Facility-Patients must register with BPJS Kesehatan either individually or through their employers.Upon registration, they are assigned to a specific primary health care facility, which can be a community health center (Puskesmas) or a designated family doctor
2. Initial Consultation-For non-emergency cases, patients start by visiting their assigned primary health care facility for an initial consultation. At Puskesmas, patients undergo preliminary checks and diagnostic tests to determine whether they require further specialized care
3. Referral Process-If the condition warrants specialized attention, the primary health care facility refers the patient to a secondary or tertiary care facility.The referral process involves documenting the diagnosis and treatment plan, ensuring that all relevant information is accurately recorded and transmitted to the next level of care
4. Treatment and Billing Process-Once admitted to a health facility, patients receive treatment according to their insurance class (Class 1, 2, or 3).

Class Differences:

1. Class 1: Entitles patients to single-patient room accommodations.
2. Class 2: Allows shared-room accommodations.
3. Class 3: Requires sharing larger rooms with multiple patients

Claim Verification and Payment-

Claims are verified by BPJS Kesehatan administrators to ensure completeness and accuracy of documentation.Any discrepancies found during verification lead to delays in payment processing, potentially causing issues for hospitals collaborating with BPJS

By following these steps, patients can effectively utilize the BPJS Kesehatan program to access various levels of healthcare services across different types of health facilities in Indonesia.