coordination-of-benefit-english.pdf

5/19/2018 coordination-of-benefit-english.pdf

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Private Health Insurance in

the era of National Health

Insurance (JKN)

15 April 2014


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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 ?

FACT


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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)

FACT


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Exclusions under JKN

1. Medical treatment which isnot 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 injury10. 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.

:

Insurer?

Opportunity for Private Health

Insurer?


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Buy BPJS only, it creates costefficiency but less convenience for

employees (especially for medium and up

market)

Buy BPJS and Private Insurers policy

separately. But company will have to

pay the premium double.

Buy BPJS and Private Insurer on COB.

The Choice of

Company


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Coordination of Benefit (COB) is aprocess where two or more payers

who pay the same person for the samehealth insurance benefit, limit the totalbenefit in a certain amount that doesnot exceed the amount paid for

healthcare.

What is COB ?


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The first party that pays the claim

invoice is called the Primary Payer,while the party that pays the rest of theinvoice is called the Secondary Payer.

In some cases, it is possible to have a

Third Payer.

What is COB ?


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Coordination of Benefit

AdditionalBenefit

HealthServices

determined bythe Ministry

AdvancedHealth

Services byreferral

First-LevelHealth

Services

BPJS

KESEHATAN

PRIVATE HEALTHINSURANCE

Coordination of

Benefit (COB)


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Regulations related to COB


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12th Presidential Decree Year2013

LegalBasis

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 healthinsurance, or by personally paying the differencebetween the amount paid by BPJS Kesehatanand the amount that has be paid for a classupgrade.


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Regulations by the Ministryof Health No. 71 2014Legal Basis

Clause 21

(1) Members who wish to have a higher class thanwhat he/she is entitled to, may raise his/her

entitlement by getting additional health insurance,or personally paying the difference between theamount paid by BPJS Kesehatan and the amountthat 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 tochoose a class higher than what he/she is entitledto.


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12th Presidential DecreeYear 2013

Legal Basis

Section VICoordination of Benefit

Clause 27

(1)Jaminan Kesehatan members can getadditional health insurance.

(2) BPJS Kesehatan and companies that offeradditional health insurance programs as

mentioned in point 1 may coordinate ingiving benefit for healthcare members thathave the right over the coverage for additional health insurance programs.


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111th Presidential Decree Year2013Legal Basis

Clause 27 B

In the event that the health providerdoes not work togetherwith BPJS Kesehatan, then the guarantee method is to beagreed together between BPJS Kesehatan and the

company that offers additional health insurance program orother guarantor.

Clause 28

The convention on the benefit coordination method as

mentioned in Clause 27 and Clause 27A is to be arrangedin the cooperation agreement between BPJS Kesehatanand the company that offers additional insurance programsorother guarantor.


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2) In the event that payment to a Primary Care provider

based on capitation is not possible in a certain area asmentioned in point 1, BPJS Kesehatan is given the

authority to conduct payment using other effective

methods.

1) BPJS Kesehatan conducts prospective payment to

Primary Care providers based on capitation or thenumber of members registered at Primary Careproviders.

12th Presidential Decree Year 2013

Clause 39


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3) BPJS Kesehatan pays Secondaryhealth providers by referral based onthe methods in Indonesian Case

Based Groups (INACBGs).

12th Presidential Decree Year 2013

Clause 39


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Type of Coordination between BPJS & private insurer

1. Coordination of Benefit2. Coordination of Premium

3. Coordination of membership data

4. Coordination of claim reimbursement

5. Coordination of socialization6. Coordination of information system


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Concept in BPJS Kesehatan


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COB is applied if the Private insurer has signed off the agreement with BPJSKesehatan.

COB received by insured members do not exceed the actual medical cost.

COB covered by BPJS Kesehatan is the medical treatment which corresponds withthe 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 insurers cardSecondary provider treatment in executive unitInpatient treatment in above of the entitled room.BPJS will insure the medical cost as per the JKN program, the balance will bethe responsible of Private insurer.

COB outside BPJS provider network :

Only applies for inpatient treatmentWithin the list of hospital approved by BPJSMedical cost will be paid first by Private Insurer, such Private insurer seekreimbursement to BPJSThere is no reimbursement from client to BPJS.BPJS will reimburse to Private insurer based on Ina CBGs tariff of hospitaltyped C.

COB Principles


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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.


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Alternative

MemberServiceHospital Claim

Documents

BPJS

KesehatanPrivate

Insurance

Claim compensation

according to ina

CBGs tariff and the

class the member is

entitled to

Claim compensation is the

difference between the

hospital tariff minus ina

CBGs tariff according to the

class the member is entitled

to

ICLAIM


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MemberServiceClaim and medical

documents

Askom/ Other

InsurerBPJS Kesehatan

Claim compensation is ina CBGs

tariff according to the class the

member entitled to

Claim compensationaccording to hospitals

tariff

Alternative IICLAIM


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What Avrist will do


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Avrist is actively working with AAJI/AAUI and BPJS Kesehatan indrafting the agreement to be used by commercial medical insurers.

Avrist actively explain to companies & business partners re BPJSKesehatan.

Avrist is now preparing the list of hospitals to be approved by BPJSKesehatan before signing the agreement with BPJS Kesehatan

In the process of preparing the administration and operationrelating to conduct the COB

Avrist will sign the agreement with BPJS Kesehatan

Current Status


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Company will choose to have a COB program as well as standalone.

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

vrist Policy


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