Coordination of Benefits Between BPJS for Health and Insurance Companies Regulated in Detail

The Social Security Agency (Badan Penyelenggara Jaminan Sosial-“BPJS”) for Health has just issued Regulation No. 4 of 2016 on Technical Guidelines for the Implementation of the Coordination of Benefits under the National Health-Insurance Program(“2016 Regulation”).In essence, the 2016 Regulation sets out further provisions regarding coordination between the BPJS for Health and insurance companies for the provision of health-insurance benefits to BPJS for Health participants (“Participants”) who are also holders of additional insurance policies.The 2016 Regulation is of relevance to insurance companies and their policy holders, as well as to Participants.Coordination of BenefitsIn general, the 2016 Regulation implements Article 27 (1) of Presidential Regulation No. 12 of 2013 on Public-Health Insurance, [1] which allows Participants to utilize additional health-insurance programs offered by insurance companies. In providing the same benefits for said Participants, the BPJS for Health may cooperate with insurance companies. If this is the case then the BPJS for Health will act as the first insurer while the insurance company will act as the first payer. [2] Such coordination and cooperation only applies to benefits which are being provided by advanced referral health facilities (fasilitas kesehatan rujukan tingkat lanjutan ­–“FKRTL”) which are already working with the BPJS for Health. Furthermore, any such services can only cover non-specialist, advanced inpatient services (rawat inap tingkat lanjutan–“RITL”). However, in the event of an emergency, any such coordination can also involve FKRTL which have not been involved in any prior cooperation with the BPJS for Health. [3] In addition to the above-mentioned benefit coordination, the BPJS for Health and insurance companies may also establish other points of coordination as regards: [4]