21 services not covered by BPJS Kesehatan: What are they?
Jakarta (ANTARA) - BPJS Kesehatan serves as one of the social security programmes that helps the public access healthcare services. Through the National Health Insurance (JKN) programme, participants can obtain various medical services in accordance with applicable provisions and benefits.
However, the assumption that all medical costs are automatically covered by BPJS Kesehatan needs to be clarified. There are several diseases, conditions, medical procedures, and healthcare services that are indeed not included in the JKS coverage.
Provisions regarding services not guaranteed by BPJS Kesehatan are regulated under Presidential Regulation Number 82 of 2018 concerning Health Insurance, along with its amendments and applicable regulations. Therefore, JKN participants should be aware of the types of services not covered to avoid misunderstandings regarding their membership benefits when requiring care.
Based on current regulations, the following healthcare services are not included in BPJS Kesehatan coverage:
Diseases that constitute an epidemic or an extraordinary event (KLB).
Treatments related to beauty and aesthetics, such as plastic surgery performed for aesthetic purposes and not due to medical indications.
Orthodontics, including the installation of braces for aesthetic needs.
Diseases resulting from criminal acts, such as injuries due to assault or sexual violence.
Diseases or injuries resulting from intentional self-harm or attempted suicide.
Diseases resulting from alcohol consumption or drug addiction.
Treatments related to infertility.
Diseases or injuries resulting from unavoidable incidents, including injuries arising from brawls.
Healthcare services provided abroad.
Medical treatments and procedures that are still categorised as trials or experiments.
Complementary, alternative, and traditional medicine that has not been declared effective based on health technology assessments.
Contraceptives.
Household health supplies.
Healthcare services that do not comply with statutory regulations, including referrals made at the participant’s own request and other services that do not meet applicable provisions.
Services at healthcare facilities that do not collaborate with BPJS Kesehatan, except in emergency conditions.
Services for diseases or injuries resulting from work accidents or employment-related incidents that are already covered by the work accident insurance programme or are the responsibility of the employer.
Healthcare services already covered by mandatory traffic accident insurance, up to the limit covered by that programme in accordance with the participant’s ward class rights.
Specific healthcare services related to the Ministry of Defence, the TNI (National Armed Forces), and the Polri (National Police).
Healthcare services organised as part of social service activities.
Services already covered by other insurance programmes.
Services that have no connection to the health insurance benefits provided to participants.
BPJS Kesehatan does provide protection for various healthcare needs of JKN participants. However, these benefits remain subject to limitations and follow applicable regulations. Therefore, participants should not assume that all medical procedures or health needs can be carried out free of charge simply because they are registered as BPJS Kesehatan members.
Some services have specific requirements, while others are indeed outside the scope of JKN. Participants also need to understand that being ‘not covered’ does not mean the disease or condition cannot be treated. In some cases, financing may come from other insurance programmes or different mechanisms depending on the type of service and the cause of the health condition.
To avoid misunderstandings, JKN participants should first enquire about service coverage at the healthcare facility where they are receiving treatment. Participants can also use official BPJS Kesehatan channels to obtain information regarding benefits, service procedures, and financing provisions. By understanding the list of services not covered, participants can know their rights and obligations and prepare administrative and financial needs before undergoing medical procedures. Ultimately, BPJS Kesehatan can still be utilised for various healthcare needs as long as participants follow the applicable JKN procedures and regulations.