What BPJS Kesehatan Does Not Cover: A Must-Know for Citizens
BPJS Kesehatan guarantees the medical costs of JKN participants as long as their membership status is active. If a JKN participant has arrears and only reactivates their membership during inpatient care at a hospital, they will be subject to a service penalty. The amount is 5% of the estimated healthcare service cost multiplied by the number of months in arrears, up to a maximum of 12 months. The maximum service penalty is IDR 20 million, though the nominal amount is usually much lower. BPJS emphasised that the service penalty only applies to patients receiving inpatient care at a hospital within 45 days of their JKN status becoming active again.
“The provisions for the service penalty are stipulated in Presidential Regulation Number 59 of 2024. For non-healthcare services, they are not covered by BPJS Kesehatan. In fact, the scope of benefits under the JKN programme managed by BPJS Kesehatan is very broad,” said BPJS Kesehatan Head of Public Relations, Rizzky Anugerah, in a written statement on Thursday (18/6). According to Rizzky, thousands of types of disease diagnoses are covered by JKN as listed in Minister of Health Regulation Number 3 of 2023, not just high-cost illnesses.
BPJS Kesehatan covers healthcare services requiring long-term, lifelong treatment, such as dialysis for kidney failure patients, thalassemia, haemophilia, cancer treatment, insulin for diabetics, and others. “Some examples of healthcare services not covered by BPJS Kesehatan are because they are already handled by other agencies. For instance, health disorders due to drug dependency are handled by the National Narcotics Agency (BNN), contraceptives and related drugs are handled by the Ministry of Population and Family Development, or healthcare services for victims of violence and abuse are handled by the Witness and Victim Protection Agency (LPSK),” he said.
According to him, healthcare services are not covered by BPJS Kesehatan if performed for cosmetic purposes, such as plastic surgery and fitting braces for aesthetic enhancement. Furthermore, healthcare services are not covered if performed abroad, as the JKN Programme’s guarantee mechanism only applies within Indonesia. “Complementary, alternative, and traditional medicine that has not been declared effective based on health technology assessments is included in the healthcare services not covered by BPJS Kesehatan. However, some healthcare services are not included in BPJS Kesehatan’s coverage because they are already guaranteed by other institutions. For example, injuries due to workplace accidents are covered by BPJamsostek, PT Taspen, PT ASABRI, or other guaranteeing institutions,” he said.
Rizzky explained that the rules regarding non-covered healthcare services have existed since before BPJS Kesehatan began operations. The first regulation referred to Law Number 40 of 2004, which was then derived through Presidential Regulation Number 12 of 2013 on Health Insurance, and updated periodically until the latest issuance of Presidential Regulation Number 59 of 2024 on the Third Amendment to Presidential Regulation Number 82 of 2018 on Health Insurance. “So this policy is not a newly implemented rule. We have repeatedly conducted socialisation on various occasions. Our hope is that JKN participants pay their contributions regularly so that the JKN Programme continues to protect the Indonesian people, especially since many people have already felt the immense benefits of this programme,” he concluded.