Private Health Insurance in the era of National Health Insurance (JKN) 15 April 2014

Transcription

1 Private Health Insurance in the era of National Health Insurance (JKN) 15 April

2 FACT As per January 1, 2015 : National Health Assurance (JKN) is compulsory to Large, Medium, Small companies The existence of BPJS has effected the mapping of health insurance market in Indonesia. Is it Positive or Negative? 2

3 FACT The JKN benefits are based on managedcare, unlimited benefits, follow required procedure (using primary healthcare facility as a gate keeper, mostly use the public health centers) Private Insurer mostly based on indemnity, limited benefits but free to choose the Healthcare facility Current medical service issue : Less convenience in public health center Tight procedure in getting medical access Ina CBGs is considered very low, not many hospitals joining Limited health facility network and limited time of service Company (white collar staff) : pays JKN but not expected to use it (in-efficiency) 3

4 Exclusions under JKN 1. Medical treatment which is not follow procedure 2. Treatment outside the BPJS medical facility network 3. Treatment which is covered by workmen comp : benefit 4. Medical treatment overseas 5. Treatment for beautification 6. Treatment due to Infertility 7. Treatment for Orthodontic 8. Treatment due to Drug/alcohol abuse 9. Self inflicted bodily injury 10. Traditional medication 11. Experimental medication 12. Contraception, cosmetic, baby food 13. Household medical supply 14. National disaster/ outbreak 15. Any medical cost which are not related to the JKN benefits. Opportunity for Private Health Insurer? 4

5 The Choice of Company Buy BPJS only, it creates cost efficiency but less convenience for employees (especially for medium and up market) Buy BPJS and Private Insurer s policy separately. But company will have to pay the premium double. Buy BPJS and Private Insurer on COB. 5

6 What is COB? Coordination of Benefit (COB) is a process where two or more payers who pay the same person for the same health insurance benefit, limit the total benefit in a certain amount that does not exceed the amount paid for healthcare. 6

7 What is COB? The first party that pays the claim invoice is called the Primary Payer, while the party that pays the rest of the invoice is called the Secondary Payer. In some cases, it is possible to have a Third Payer. 7

8 Coordination of Benefit Additional Benefit PRIVATE HEALTH INSURANCE Health Services determined by the Ministry Advanced Health Services by referral BPJS KESEHATAN Coordination of Benefit (COB) First-Level Health Services 8

9 Regulations related to COB 9

10 Legal Basis 12 th Presidential Decree Year 2013 Clause 24 Members who wish to have a higher class than what he/she is entitled to may raise his/her entitlement by getting additional health insurance, or by personally paying the difference between the amount paid by BPJS Kesehatan and the amount that has be paid for a class upgrade. 10

11 Legal Basis Regulations by the Ministry of Health No Clause 21 (1) Members who wish to have a higher class than what he/she is entitled to, may raise his/her entitlement by getting additional health insurance, or personally paying the difference between the amount paid by BPJS Kesehatan and the amount that has be paid for a class upgrade. (2) Exception from the provisions intended in point (1) is for PBI Jaminan Kesehatan that is not allowed to choose a class higher than what he/she is entitled to. 11

12 Legal Basis 12 th Presidential Decree Year 2013 Section VI Coordination of Benefit Clause 27 (1)Jaminan Kesehatan members can get additional health insurance. (2) BPJS Kesehatan and companies that offer additional health insurance programs as mentioned in point 1 may coordinate in giving benefit for healthcare members that have the right over the coverage for additional health insurance programs. 12

13 Legal Basis 111 th Presidential Decree Year 2013 Clause 27 B In the event that the health provider does not work together with BPJS Kesehatan, then the guarantee method is to be agreed together between BPJS Kesehatan and the company that offers additional health insurance program or other guarantor. Clause 28 The convention on the benefit coordination method as mentioned in Clause 27 and Clause 27A is to be arranged in the cooperation agreement between BPJS Kesehatan and the company that offers additional insurance programs or other guarantor. 13

14 12 th Presidential Decree Year 2013 Clause 39 1) BPJS Kesehatan conducts prospective payment to Primary Care providers based on capitation or the number of members registered at Primary Care providers. 2) In the event that payment to a Primary Care provider based on capitation is not possible in a certain area as mentioned in point 1, BPJS Kesehatan is given the authority to conduct payment using other effective methods. 14

15 12 th Presidential Decree Year 2013 Clause 39 3) BPJS Kesehatan pays Secondary health providers by referral based on the methods in Indonesian Case Based Groups (INACBG s). 15

16 Type of Coordination between BPJS & private insurer 1. Coordination of Benefit 2. Coordination of Premium 3. Coordination of membership data 4. Coordination of claim reimbursement 5. Coordination of socialization 6. Coordination of information system 16

17 Concept in BPJS Kesehatan 17

18 COB Principles COB is applied if the Private insurer has signed off the agreement with BPJS Kesehatan. COB received by insured members do not exceed the actual medical cost. COB covered by BPJS Kesehatan is the medical treatment which corresponds with the agreement of BPJS and Private Insurer COB in the BPJS provider network : Require referral procedure from Primary care gate keeper Show the BPJS card and Private insurer s card Secondary provider treatment in executive unit Inpatient treatment in above of the entitled room. BPJS will insure the medical cost as per the JKN program, the balance will be the responsible of Private insurer. COB outside BPJS provider network : Only applies for inpatient treatment Within the list of hospital approved by BPJS Medical cost will be paid first by Private Insurer, such Private insurer seek reimbursement to BPJS There is no reimbursement from client to BPJS. BPJS will reimburse to Private insurer based on Ina CBG s tariff of hospital typed C. 18

19 Treatment related to Emergency Medical treatment outside BPJS provider network : Outside the List of Hospital for COB : Members has to be referred to BPJS provider after the emergency medical condition is stabilized Hospital claim to BPJS In the List of Hospital for COB : Members can be treated until it is recovered. Claim will be paid by Private insurer first, then private insurer seeks reimbursement to BPJS. Emergency treatment which is covered must corresponds to the criteria of emergency applied in BPJS. 19

20 CLAIM Alternative I Hospital Claim Documents Service Member BPJS Kesehatan Claim compensation according to ina CBG s tariff and the class the member is entitled to Private Insurance Claim compensation is the difference between the hospital tariff minus ina CBG s tariff according to the class the member is entitled to

21 CLAIM Alternative II Claim and medical documents Service Member Askom/ Other Insurer Claim compensation according to hospital s tariff BPJS Kesehatan Claim compensation is ina CBG s tariff according to the class the member entitled to

22 What Avrist will do

23 Current Status Avrist is actively working with AAJI/AAUI and BPJS Kesehatan in drafting the agreement to be used by commercial medical insurers. Avrist actively explain to companies & business partners re BPJS Kesehatan. Avrist is now preparing the list of hospitals to be approved by BPJS Kesehatan before signing the agreement with BPJS Kesehatan In the process of preparing the administration and operation relating to conduct the COB Avrist will sign the agreement with BPJS Kesehatan 23

24 Avrist Policy Company will choose to have a COB program as well as stand alone. For policies with COB, premium is expected less than stand alone. Program is tailor made to be complemented to BPJS Kesehatan. Companies that prefer to register directly to BPJS, COB can also be conducted. Program for overseas medical treatment Program for certain level of employees Non medical program : Hospital cash plan, Critical illness 24

25 THANK YOU 25