Health Insurance

Health Insurance is one type of insurance product which specifically guarantees the health costs or maintenance of the members The insurance if they fall ill or have an accident.

In speaking there are two treatments that offered companies insurance, namely: hospitalization (in-patient treatment) and ambulatory (out-patient treatment).

Insurance is a system for degrading loss by channeling financial risk of loss of a person to the agency other. Someone who channel called the insured risk, while entities that receive so-called risk insurer. Agreement between the two This entity is called the policy, this is a legal contract that explains any terms and conditions are protected. Fees paid insured the risk borne by the insurer for the so-called premium, which usually determined by the insurer. PT. Askes Indonesia (Persero) is a State Owned assigned exclusively by government to hold health care insurance for Civil Servants, Pension Recipients civil servants and TNI / police, Veteran, Independence Pioneers and their families and other business entities

• Health insurance purposes

The purpose of government organizes a social insurance is basically the same, namely to provide social security for the community. Likewise, health insurance terms, the aim is to pay hospital fees, medical expenses and indemnify the insured for loss of income due to injury due to an accident or illness. While the purpose of health insurance is to improve health care services for the participants and their family members. Askes also aims to provide assistance to participants in financing the maintenance of health. PT. Askes (Persero), Indonesia as the governing body of the Health Insurance in Indonesia aims to preserve, maintain and improve the health of the Civil Servants, Pension Recipients, and their family members, in an effort to create a healthy state apparatus, strong and dynamic and has a life of devotion to the homeland and nation.

• Type of Health Insurance Services

Type of Askes Social services include: 

1. Type of health services IS GUARANTEED. a. The first level of health services at the health center or family doctor, which includes first-rate services Outpatient and Inpatient level pertama.

1 b. Advanced level of health care in hospital services which include: 

1) Outpatient advanced level. 

2) Hospitalization advanced level. 

3) Hospitalization dedicated space (ICU, ICCU). 

4) Emergency Services (Emergency). 

5) Delivery. 

6) blood transfusion services. 

7) Service and ceiling medication according to a list of drug prices (DPHO) PT. Askes. 

8) medical action operative and non-operative medical action. 

9) Care dialysis. 

10) graft (transplanted) kidney and ESWL (gunshot kidney stones).

• Types of health services ARE NOT GUARANTEED.

a. Services that do not follow procedures or applicable regulations.

b. Diseases due to suicide attempts or self-harm deliberately.

c. Cosmetic plastic surgery, including medicines. d. Check Up or General Check Up.

e. Immunization beyond basic immunization whole series of businesses want to have children (infertility) diseases caused by drug or alcohol dependency.

f. Circumcision without a medical indication.

g. Drugs outside DPHO- including liniment, vitamins, cosmetics, baby food.

h. Services wheelchairs, crutches, corsets, and others.

i. Treatment abroad.

j. Prenatal care, interruption of pregnancy, labor action, puerperal third child and so on.

k. Leveling effort to clean teeth and tartar.

• Service guarantee

1. Keep in cooperation / contracts with health facilities. To be able to provide benefits in the form of service, it would require a cooperative ties or contracts with health facilities. Of course, not all health facilities can be contracted. For that there is a process kredensialing.

2. Reducing the moral hazard of the participant / policyholder. Provision of benefits through contracted health facilities has two advantages. First, participants were led on a service that charges / tariffs have been agreed or are known making it easier to estimate costs. Second, it can be done and the cost control and moral hazard. Use of an agreed formulary for example, will be able to control the cost of medicines. Contract with a health facility, must be realized, does not guarantee the absence of moral hazard by health facility itself.

 3. Payment of health facilities can vary. By performing a contract with a health facility, then open the possibility of various ways of payment to health facilities. Method of payment can be made by the preferred services health facilities with certain rebates or without rebates. Another way of payment is with a certain package rates both patient per day, per action, per diagnosis (in Indonesia undeveloped), as well as the risk of payment responsibilities called capitation.

4. The options are limited health facilities. Contract with a health facility would not be carried out on all existing health facilities in the city. As a result, not as wide choice of health facilities providing benefits in the form of money or reimbursement. The insured must choose a network service to certain health facilities, although sometimes the facility was not familiar with either. It required incentives to the insured will use contracted network of health facilities. If there is no financial incentive, then the system will not work service contracts.

 5. Satisfaction of participants is low. Contract health facilities resulted in a limited selection of health facilities have the potential complaints and dissatisfaction of participants. If there is a little less pleasing service, the participants will complain or even denounce it.

 6. Keep in quality control. Due to contract health facilities provide a limited choice of health facilities, then the candidate should be reassured that health facilities have contracted a certain quality standard. This raises the necessity asuradur perform quality control efforts. Quality control through health facilities is very useful for marketing purposes, participant satisfaction, and compliance of these facilities against agreed standards. This quality control applies to all asuradur who perform contract services. So the quality control is not the monopoly of managed care organization / form of managed care.

7. In certain payments, such as capitation, there needs to be research utilization (utilization review). If payment is made by the health facility-based systems such as capitation risk, then there is a potential health facility compromising quality of service or reduce the amount of services that should be accepted by the insured. Therefore, capitation payment method is intrinsically require the utilization study.

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