Don't Be Mistaken: 21 Diseases and Services Not Covered by BPJS Kesehatan
Participants of the BPJS Kesehatan programme need to understand that not all diseases or medical services can be financed through the scheme. The provisions regarding services not guaranteed by BPJS Kesehatan are regulated under Presidential Regulation (Perpres) Number 82 of 2018 concerning Health Insurance.
According to the regulation, there are 21 categories of diseases and health services that fall outside the scope of BPJS Kesehatan benefits. Based on these regulations, non-guaranteed health services generally include services that do not follow proper procedures, those of an aesthetic nature, and diseases or injuries resulting from specific actions as regulated by law.
Furthermore, several services such as infertility treatments, care resulting from alcohol or drug addiction, and healthcare services performed abroad are also not included in the benefits provided by BPelse Kesehatan.
Below is the list of 21 diseases and services not covered by BPJS Kesehatan based on Presidential Regulation Number 82 of 2018:
Diseases in the form of outbreaks or extraordinary events (EOC).
Treatments related to beauty and aesthetics, such as plastic surgery.
Dental alignment, such as braces.
Diseases resulting from criminal acts, such as assault or sexual violence.
Diseases or injuries resulting from intentional self-harm or suicide attempts.
Diseases resulting from alcohol consumption or drug addiction.
Treatment for sterility or infertility.
Diseases or injuries resulting from unavoidable incidents, such as brawls.
Healthcare services performed abroad.
Medical treatments and procedures 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 provisions, including referrals made at the patient’s own request and other services not in accordance with regulations.
Healthcare services in facilities that do not partner with BPJS Kesehatan, except in emergencies.
Healthcare services for diseases or injuries resulting from work-related accidents or employment relationships that are already covered by the work accident insurance programme or are the responsibility of the employer.
Healthcare services guaranteed by mandatory traffic accident insurance programmes, up to the value covered by the traffic accident insurance programme in accordance with the participant’s ward class rights.
Specific healthcare services related to the Ministry of Defence, the Indonesian National Armed Forces (TNI), and the National Police (Polri).
Healthcare services organised as part of social service activities.
Services already covered by other programmes.
Other services that have no connection to the health insurance benefits provided.