Before You Visit the Hospital, Know These 21 BPJS Kesehatan Exclusions

Many people assume that BPJS Kesehatan covers every medical treatment. In reality, that is not the case. Indonesia’s National Health Insurance program provides extensive healthcare benefits, but it also has clear limitations. Certain diseases, medical treatments, and healthcare services are specifically excluded from coverage under existing regulations.

These exclusions are regulated under Presidential Regulation (Perpres) No. 82 of 2018 on National Health Insurance. The regulation outlines 21 categories of diseases and healthcare services that cannot be financed through BPJS Kesehatan. In general, services that fall outside the program include treatments that do not follow official procedures, cosmetic procedures, and illnesses or injuries resulting from circumstances that are separately regulated under Indonesian law.

Several other healthcare services are also excluded. These include infertility treatment, medical care related to alcohol or drug dependency, and healthcare received outside Indonesia. Understanding these limitations can help BPJS participants avoid unexpected medical expenses and make better healthcare decisions.

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Below are the 21 diseases and healthcare services that are not covered by BPJS Kesehatan under Presidential Regulation No. 82 of 2018.

1. Diseases classified as outbreaks or extraordinary public health events.
2. Cosmetic and aesthetic treatments, including plastic surgery.
3. Orthodontic procedures such as braces for teeth alignment.
4. Illnesses or injuries resulting from criminal acts, including physical assault or sexual violence.
5. Diseases or injuries caused by intentional self-harm or suicide attempts.
6. Medical conditions resulting from alcohol consumption or drug addiction.
7. Infertility diagnosis and treatment.
8. Diseases or injuries caused by preventable incidents, such as involvement in riots or violent clashes.
9. Medical treatment received outside Indonesia.
10. Experimental or investigational medical treatments and procedures.
11. Complementary, alternative, or traditional medicine that has not been officially recognized as effective through health technology assessments.
12. Contraceptive devices.
13. Household health supplies.
14. Healthcare services that do not comply with applicable regulations, including self-requested referrals and other treatments provided outside the established procedures.
15. Medical services provided by healthcare facilities that are not partnered with BPJS Kesehatan, except in emergency situations.
16. Treatment for occupational diseases or workplace injuries that are already covered under the national work accident insurance program or by the employer.
17. Medical treatment for traffic accident victims that is already covered by the mandatory road traffic accident insurance program, up to the participant’s eligible hospitalization class.
18. Specific healthcare services related to the Ministry of Defense, the Indonesian National Armed Forces (TNI), or the Indonesian National Police (Polri).
19. Healthcare services provided as part of social or charitable medical programs.
20. Medical services that are already covered by other government or insurance programs.
21. Any other healthcare services that are unrelated to the benefits provided under Indonesia’s National Health Insurance program.

Knowing what BPJS Kesehatan does not cover is just as important as understanding the benefits it provides. While the program continues to serve millions of Indonesians by covering a wide range of essential healthcare services, participants should be aware of these exclusions before seeking treatment. Familiarity with the regulations can help patients prepare financially, choose the appropriate healthcare provider, and avoid misunderstandings about what expenses remain their own responsibility.