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The OJK Will Regulate The Integration Of BPJS Kesehatan Claims With Private Insurance

The Financial Services Authority (OJK) has announced that a circular letter (SE) regarding improvements in health insurance processes is set to be issued next year. This circular aims to enhance the business processes associated with health insurance products.

Ogi Prastomiyono, the Executive Head of Insurance, Guarantee, and Pension Fund Supervision at OJK, stated that the authority has been collaborating with the Ministry of Health of the Republic of Indonesia (Kemenkes) to formulate policies aimed at improving the health insurance ecosystem.

Ogi elaborated that the policy is related to BPJS Kesehatan and hospitals. He also mentioned the Coordination of Benefit (CoB) mechanism, which regulates the total health insurance benefits that an individual can receive when covered by multiple insurers. This mechanism allows insurance participants to access benefits from two or more insurance providers.

"Thus, the primary health insurance benefits will be from BPJS, followed by additional health insurance. This process is already in place," Ogi remarked at Padma Hotel Legian on Wednesday, November 20, 2024.

Furthermore, the OJK circular will establish standards and limits on the benefits that can be claimed. In this regard, OJK anticipates the formation of an advisory board to oversee these matters.

"This will clarify what is permissible and what is not, thereby establishing cost standards," Ogi stated.

He continued by emphasizing the need for alignment between claims and premiums. Ogi pointed out that the current ratio of claims to premiums in health insurance is notably high.

"This does not even account for the combined ratio and other expenses; the comparison between claims and received premiums alone is already elevated. This reflects operational costs, which is a challenge we need to address," he concluded.

It is noteworthy that medical inflation has surged significantly following the COVID-19 pandemic, with increases ranging from 18% to 20%. As a result, life insurance companies are now compelled to cover health insurance claims due to the rising medical inflation, which has led to a deficit in the claims-to-premium ratio.

The life insurance company has disbursed health claims amounting to IDR 11.83 trillion in the first semester of 2024. Freddy Thamrin, the Chairman of the Literacy & Consumer Protection Division of the Indonesian Life Insurance Association (AAJI), stated that the health insurance claims ratio has exceeded the premiums received. This ratio stands at over 100%, specifically at 105.7%.

In other words, the insurance company is spending more on health claims for its policyholders than it is receiving in premium payments from them.

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Tag: BPJS Financial Services Authority OJK