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BPJS Kesehatan and Private Health Insurance, What are the Differences?

By Isny Dewi R

07 September 2020

Although both provide health insurance services, there are several things that distinguish BPJS Kesehatan from private health insurance.

Photo source: Pexels
Launching Wikipedia, BPJS Kesehatan (Health Social Security Administering Agency) is a public legal entity that reports directly to the President and has the duty to administer National Health insurance for all Indonesians. BPJS Kesehatan was established in accordance with the mandate of Law 40 of 2004 concerning the National Social Security System and Law 24 of 2011 concerning Social Security Administering Agency. BPJS Kesehatan was formerly PT Askes (Persero).
Although both provide health insurance services, there are several things that distinguish BPJS Kesehatan from private health insurance. Both also have their own advantages and disadvantages. Here are the differences between BPJS Kesehatan and private health insurance that you should know, as reported from Lifepal:
1. Specialist Doctors
At BPJS Kesehatan, if people want to do further treatment with a specialist doctor, then there must be a referral letter. The hospital referral system in BPJS Kesehatan uses vertical channel, from lower health facility to higher. That is why BPJS Kesehatan participants have to come to Level 1 health facility first if they want to do treatment at the next level of health facility.
Another case with private health insurance. People can immediately register with a specialist doctor and leave the payment to the insurance company.
2. Illness Covered
With lower premiums, BPJS Kesehatan has more comprehensive benefits than private health insurance. Apart from inpatient and outpatient care, other benefits that can be used from BPJS Kesehatan are the cost of giving birth including caesarean section, dental care, and others.
In private health insurance, usually there will be riders if people want to take advantage of critical illness, give birth, dental care, etc. The more riders that are taken, the more expensive the premium that must be paid.

3. Use in Outside the City and Abroad
There is a special procedure for everyone who wants to use BPJS Kesehatan outside the city or outside the health facility where someone is registered. First, the patient must visit the nearest BPJS Kesehatan office to ask for a cover letter to visit the First Level Health Facility (FKTP) to get services, a maximum of three times. However, this cannot be done in an emergency.
Meanwhile, private health insurance participants do not have to go through procedures such as BPJS Kesehatan. As long as the health facility has cooperated with the insurance, the patient only has to register themself directly at the nearest institution, seek treatment, and complete medical expenses with insurance.
Some private health insurance can even be used abroad. With a note, participants have bought products that can cover coverage in abroad.
4. VIP Room
Especially for inpatient benefits, private health insurance can certainly cover VIP room facilitY for participants, but not for BPJS Kesehatan.
There are three class in BPJS, namely Class I, II, and III. Class I participants will receive a more comfortable inpatient care room than class II and III participants, a room with only two to four patients. BPJS Kesehatan participants can actually choose to upgrade the VIP room, but must pay the difference in cost.
5. Pre-existing Condition
Almost all diseases can be covered by BPJS Kesehatan. In BPJS Kesehatan, there is no term pre-existing condition, a situation in which a person registers at BPJS Kesehatan with a history of certain disease. BPJS Kesehatan will continue to cover any existing diseases before the patient becomes a participant.
It is different with private health insurance, where generally there is a medical check-up requirement to determine the existence of pre-existing condition.
For example, a participant has a history of cancer and purchases health insurance without adding benefit of cancer protection. Then the participant will not get compensation for medical expenses such as chemotherapy, radiotherapy, and others.
Meanwhile, some private insurances also have waiting period that determines the revocation of pre-existing condition. So that participants can still be protected from pre-existing condition but after a certain period of time such as nine months, a year, up to three years.

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