Check the List: 21 Services Not Covered by BPJS Health
Jakarta — BPJS Health members should be aware of the types of medical services that are not covered by the National Health Insurance (JKN) programme. Not all treatment and medical procedures are automatically covered by BPJS Health.
The provisions on excluded services are set out in Article 52 of Presidential Regulation No. 82/2018 on Health Insurance, most recently amended by Presidential Regulation No. 59/2024.
The regulation lists 21 categories of healthcare that are not covered by JKN. They range from services for aesthetic purposes and infertility treatment to services already covered by another programme.
However, members should understand that a service not covered by BPJS Health does not necessarily mean that they must pay the entire cost themselves. Some services may be covered through other schemes, such as work-accident insurance, traffic-accident insurance or government funding.
So, which healthcare services are not covered by BPJS Health? Here are the 21 categories listed under Article 52 of Presidential Regulation No. 59/2024.
- Services that do not comply with laws and regulations
BPJS Health does not cover healthcare services that do not comply with applicable laws and regulations, including referrals requested by patients themselves and other services that do not follow the rules.
- Services at healthcare facilities that do not partner with BPJS
As a general rule, services at healthcare facilities that do not have a partnership with BPJS Health are not covered, except in emergencies as provided for under the applicable rules.
- Services resulting from work-related accidents or employment relationships
Healthcare services resulting from work-related accidents or employment relationships are not covered by JKN if they are already covered by the Work Accident Insurance programme or are the employer’s responsibility.
This means members are not automatically required to pay themselves for treatment resulting from a work-related accident. Coverage depends on the applicable scheme.
- Services covered by a traffic-accident programme
Healthcare services resulting from traffic accidents are not covered by JKN to the extent that they are covered by a compulsory traffic-accident insurance programme, subject to the applicable coverage limits and rules.
- Healthcare services overseas
Healthcare services provided outside Indonesia are not included among the services covered by JKN.
- Healthcare services for aesthetic purposes
Healthcare services intended for aesthetic purposes are not covered by BPJS Health. This should be distinguished from medical procedures carried out because of a patient’s health needs.
- Infertility treatment
Healthcare services intended to treat infertility or fertility disorders fall into a category not covered by JKN.
- Teeth-straightening or orthodontic services
Treatment to straighten teeth, or orthodontic treatment, is not covered by BPJS Health.
- Health disorders resulting from drug or alcohol dependence
Health disorders or illnesses resulting from dependence on drugs and/or alcohol are among the services not covered by JKN.
- Health disorders resulting from deliberate self-harm
Services to treat health disorders resulting from deliberate self-harm or taking part in hobbies that endanger oneself fall into a category not covered by JKN.
The classification of health disorders in this category is determined in accordance with the Minister of Health’s regulations.
- Alternative treatments not deemed effective
Complementary, alternative and traditional treatments that have not been deemed effective following a health technology assessment are not covered by BPJS Health.
This does not mean that all traditional treatments are automatically excluded. Their status depends on the criteria set out in the regulations.
- Experimental treatment and medical procedures
Treatment and medical procedures classified as trials or experiments are not covered by JKN. Their classification is determined in accordance with the Minister of Health’s regulations.
- Contraceptives, contraceptive medicines and cosmetics
Contraceptive devices and medicines, as well as cosmetics, are among the categories not covered under Article 52.
However, this provision should be distinguished from family-planning services. The same presidential regulation includes certain family-planning services among its promotive and preventive benefits, including counselling and contraceptive services in accordance with the applicable rules.
- Household health supplies
Household health supplies are among the healthcare services or needs not covered by JKN.
- Healthcare services arising from disasters, extraordinary events or outbreaks
Healthcare services arising from disasters during the emergency response period, extraordinary events or outbreaks fall into a category not covered by JKN.
- Services related to preventable adverse events
Healthcare services related to preventable adverse events are among the categories not covered. The classification of events in this category is determined in accordance with the Minister of Health’s regulations.
- Healthcare services provided as part of social-service activities
Healthcare services organised as part of social-service activities are not covered by JKN.
However, this does not automatically mean patients must pay themselves, as such activities may have their own sources of funding.
- Services resulting from criminal acts that are already covered by another scheme
Healthcare services resulting from criminal assault, sexual violence, terrorism or human trafficking are not covered by JKN if they are already covered through another funding scheme run by a ministry, agency or regional government in accordance with the law.
Victims of crime therefore do not automatically lose access to funding. Coverage must be assessed under the applicable scheme.
- Certain healthcare services related to the Ministry of Defence, the Indonesian National Armed Forces and the National Police
Certain healthcare services related to the Ministry of Defence, the Indonesian National Armed Forces (TNI) and the Indonesian National Police (Polri) are among the categories not covered by JKN.
- Services unrelated to JKN benefits
Other services that are not related to the health-insurance benefits available to members are not covered by the JKN programme.
- Services already covered by another programme
Healthcare services already covered by another programme are not the responsibility of JKN. This provision makes clear that coverage must be assessed according to which programme is responsible for funding the service.
Do members have to pay for all these services themselves?
Not necessarily. The regulation refers to healthcare services that are not covered by JKN; this does not mean that every case automatically becomes a bill for the member.
For example, the cost of services resulting from a work-related accident may be covered by the Work Accident Insurance programme or the employer. Certain traffic-accident services may also be covered through a traffic-accident insurance programme, subject to the applicable rules. Certain criminal cases may have a government-funded scheme.
Members should also take note of the rules governing healthcare facilities and referral procedures. Under Health Minister Regulation No. 16/2024 on the Referral System for Individual Healthcare Services, referrals take into account medical needs, the capabilities of healthcare facilities, accessibility and quality of service.
Exceptions to referral procedures apply in certain circumstances, such as emergencies, in accordance with the regulations.
Before undergoing treatment, members should therefore confirm coverage with their healthcare facility or BPJS Health. This will help them establish whether the cost is covered by JKN, another programme or is their personal responsibility.