Implementation of Health Insurance Products

To:

1. Directors of General Insurance Companies; and
2. Directors of Sharia Insurance Companies,
   At their respective locations.

COPY

CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 7/SEOJK.05/2025

CONCERNING
THE IMPLEMENTATION OF HEALTH INSURANCE PRODUCTS

In accordance with the mandate of Article 3B paragraph (3) of Financial Services Authority Regulation Number 36 of 2024 concerning Amendments to Financial Services Authority Regulation Number 69/POJK.05/2016 concerning the Implementation of Business by General Insurance Companies, Sharia Insurance Companies, Reinsurance Companies, and Sharia Reinsurance Companies (State Gazette of the Republic of Indonesia Year 2024 Number 48/OJK, Additional State Gazette of the Republic of Indonesia Number 116/OJK), it is necessary to further regulate the criteria for insurance companies, Sharia insurance companies, and Sharia units within insurance companies that may implement health insurance lines of business, as well as the application of prudent principles and adequate risk management for insurance companies, Sharia insurance companies, and Sharia units within insurance companies in implementing health insurance lines of business, in this Financial Services Authority Circular Letter as follows:

I. GENERAL PROVISIONS

In this Financial Services Authority Circular Letter, the following terms are defined:

1. Insurance Product is a program of risk coverage/management conducted by general insurance companies and/or life insurance companies, including those implemented based on Sharia principles.

2. Health Insurance Product is an Insurance Product that promises to provide protection against 1 (one) or more types of risks related to a person's health condition or the deterioration of a person's health status being insured.

3. Investment-Linked Insurance Product, hereinafter referred to as PAYDI, is an Insurance Product that provides at least protection against mortality risk and provides benefits referring to the investment results of a fund pool specifically formed for the Insurance Product, whether expressed in unit form or non-unit form.

4. Micro Insurance Product is an Insurance Product designed to provide protection against financial risks faced by the public, particularly low-income communities.

5. Insurance Policy is an insurance agreement deed or other documents equivalent to an insurance agreement deed, and other documents that form an inseparable part of the insurance agreement, containing an agreement between the insurance company or Sharia insurance company and the policyholder, made in writing in either printed or electronic form.

6. Insurance Company refers to general insurance companies and life insurance companies.

7. Sharia Insurance Company refers to Sharia general insurance companies and Sharia life insurance companies.

8. Sharia Unit is a work unit at the headquarters of an Insurance Company that functions as the head office of offices outside the headquarters that conduct business based on Sharia principles.

9. Policyholder is a party that binds itself based on an agreement with an Insurance Company, Sharia Insurance Company, reinsurance company, or Sharia reinsurance company to obtain protection or management of risk for themselves, the insured, or other participants.

10. Insured is a party facing risks as regulated in an insurance agreement or reinsurance agreement.

11. Participant is a party facing risks as regulated in a Sharia insurance agreement or Sharia reinsurance agreement.

12. Premium is an amount of money determined by an Insurance Company or reinsurance company and approved by the Policyholder to be paid based on an insurance or reinsurance agreement, or an amount of money determined based on statutory regulations underlying mandatory insurance programs to obtain benefits.

13. Contribution is an amount of money determined by a Sharia Insurance Company or Sharia reinsurance company and approved by the Policyholder to be paid based on a Sharia insurance or Sharia reinsurance agreement to obtain benefits from the tabarru' fund and/or participant investment fund and to pay management costs, or an amount of money determined based on statutory regulations underlying mandatory insurance programs to obtain benefits.

14. Social Health Insurance Implementing Agency, hereinafter referred to as BPJS Kesehatan, is a public legal entity established to implement health insurance programs as referred to in Law Number 24 of 2011 concerning Social Health Insurance Implementing Agencies.

15. Health Service Facility is a tool and/or place for health services used to implement health service efforts, whether promotive, preventive, curative, rehabilitative, and/or palliative, implemented by the government, local governments, and/or the community.

16. Medical Advisory Board (Dewan Penasihat Medis), hereinafter abbreviated as DPM, is a board that assists Insurance Companies and Sharia Insurance Companies in providing advice or proposals regarding medical services provided by Health Service Facilities.

17. Third Party Administrator (Penyedia Layanan Administrasi Pihak Ketiga), hereinafter referred to as TPA, is a third-party administrative service that assists Insurance Companies and Sharia Insurance Companies in administrative services, including claims management, Insurance Policy management, and other administrative functions.

18. Utilization Review (Telaah Utilisasi) is an evaluation of the appropriateness of health services provided to the Insured or Participant, conducted to control costs and monitor service quality.

II. CRITERIA FOR INSURANCE COMPANIES, SHARIA INSURANCE COMPANIES, AND SHARIA UNITS WITHIN INSURANCE COMPANIES THAT MAY MARKET HEALTH INSURANCE PRODUCTS

1. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies implementing Health Insurance Products must have human resources with the following criteria:
   a. having medical personnel with the qualification of doctors who play a role in analyzing medical actions and Utilization Review; b. having human resources holding health insurance expertise certificates with a level at least 1 (one) level below the highest qualification of professional certification bodies in the insurance field registered with the Financial Services Authority; and
   c. having a Medical Advisory Board (DPM).

2. The health insurance expertise certificates as referred to in number 1 letter b may use equivalent competency certifications conducted by foreign institutions as regulated in Financial Services Authority Regulations concerning the development of human resource quality for insurance companies, guarantors, pension funds, and special institutions in the fields of insurance, guarantees, and pension funds.

3. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies implementing Health Insurance Products must have adequate information systems with the following criteria:
   a. information systems are developed by Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies independently or in cooperation with other Insurance Companies, Sharia Insurance Companies, Sharia Units within Insurance Companies, TPAs, BPJS Kesehatan, other insurance providers providing health service benefits, or companies that can provide digital services; b. information systems have the capability to perform digital data exchange with Health Service Facilities;
   c. information systems must at least meet the following requirements:
   1) able to provide access to membership data;
   2) able to provide data containing services and medical summaries, including medication and health equipment services, provided to the Policyholder, Insured, or Participant;
   3) able to provide claim data paid for each Policyholder, Insured, or Participant; and
   4) supported by a database with the following requirements:
   a) having a disease type classification standard in accordance with applicable regulations; b) having the capability to analyze the appropriateness of medical services and medications provided; and c) having the capability to conduct Utilization Review with Health Service Facilities; and d. information systems capable of supporting the processing, storage, and electronic security of data to prevent potential fraud in health insurance, including fictitious insurance claims.

4. In the event that information system development is conducted by third parties as regulated in number 3 letter a, Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies must have a cooperation agreement covering the confidentiality of Policyholder, Insured, or Participant data and its usage.

5. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies must store databases as referred to in number 3 letter c number 4) for at least 10 (ten) years after the expiration of the Insurance Policy coverage period.

III. MEDICAL ADVISORY BOARD (DPM)

The DPM as referred to in Section II number 1 letter c must meet the following requirements:

1. The DPM is tasked with:
   a. providing advice to Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies to support the implementation of Utilization Review; and b. providing input regarding health services, including new developments in medical services, and recommendations to Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies.

2. The DPM consists of a collection of specialist doctors with specific expertise needed by Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies in the implementation of health insurance.

3. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies may have a DPM independently or in cooperation with other Insurance Companies, Sharia Insurance Companies, Sharia Units within Insurance Companies, or with TPAs.

4. The ownership of the DPM as referred to in number 3 is evidenced by a document of DPM appointment by the directors and approved by the board of commissioners of Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies.

IV. HEALTH INSURANCE PRODUCT DESIGN

A. Implementation of Health Insurance Products

1. Health Insurance Products may be implemented in the following ways:
   a. Health Insurance Products with the indemnity principle, which is the reimbursement of medical care costs with a maximum reimbursement charged by Health Service Facilities and paid by Insurance Companies, Sharia Insurance Companies, or Sharia Units within Insurance Companies according to the limit set in the Insurance Policy; and b. Health Insurance Products with managed care schemes, which are health services with structured and tiered referrals according to medical needs, starting from health facilities providing basic/general health services to health facilities providing specialist and sub-specialist health services.

2. Health Insurance Products with the indemnity principle as referred to in number 1 letter a consist of:
   a. Health Insurance Products with maximum cost limits per benefit (inner limit) which provide care cost coverage with separate benefit limits for each type of care guaranteed. For example, there are surgery costs of IDR 10,000,000.00 (ten million rupiah), general doctor consultation costs of IDR 250,000.00 (two hundred fifty thousand rupiah), and other care costs of IDR 5,000,000.00 (five million rupiah). In this case, Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies will provide limits according to each action listed in the benefit table of the Insurance Product. If the costs exceed the regulations, the cost difference will be borne by the Policyholder, Insured, or Participant; and b. Health Insurance Products as charged, which are Health Insurance Products that provide reimbursement of medical care costs according to the charges with annual limits and/or lifetime limits.

3. Health Insurance Products as referred to in number 1 letter b constitute an integration of financing and comprehensive health care provision implemented as part of:
   a. promotive activities, namely health promotion/health education activities; b. preventive activities, namely disease prevention;
   c. curative activities, namely treatment for disease recovery;
   d. rehabilitative activities, namely recovery; and/or e. palliative activities, namely special medical care to improve the quality of life of patients and families of patients suffering from chronic and difficult-to-cure diseases, including first-level outpatient care, advanced-level outpatient care, and structured and tiered inpatient care.

B. Health Insurance Product Regulations

1. Health Insurance Products must have a waiting period of at most 30 (thirty) calendar days.

2. The waiting period as referred to in number 1 may be applied for at most 1 (one) year for Health Insurance Products providing benefits for critical, chronic, and specific diseases, provided it is clearly stated in the Insurance Policy.

3. The waiting period as referred to in number 1 and number 2 does not apply to Health Insurance Products with a coverage period of at most 3 (three) months.

4. The waiting period on Health Insurance Products that are additional insurance (riders) from PAYDI refers to the regulations of the Financial Services Authority Circular Letter concerning investment-linked insurance products.

5. The waiting period on Health Insurance Products that are Micro Insurance Products refers to the regulations of the Financial Services Authority Circular Letter concerning micro insurance products and micro insurance product marketing channels.

6. The regulations regarding waiting periods as referred to in numbers 1 through 5 only apply to individual Health Insurance Products.

7. For group Health Insurance Products, different waiting period regulations may be applied from the waiting period as referred to in number 1, referring to agreements agreed upon between the Policyholder and Insurance Companies, Sharia Insurance Companies, or Sharia Units within Insurance Companies.

V. APPLICATION OF RISK MANAGEMENT IN THE IMPLEMENTATION OF HEALTH INSURANCE PRODUCTS

In implementing health insurance lines of business, Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies are required to apply prudent principles and adequate risk management.

A. Policy, Premium, and Contribution Regulations

1. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies marketing Health Insurance Products may include exclusions or coverage limitations for conditions of the Policyholder, Insured, or Participant that existed prior to coverage (pre-existing conditions).

2. The calculation and determination of Premiums or Contributions are conducted according to the risks and benefits obtained by each Policyholder, Insured, or Participant as regulated in Financial Services Authority Regulations concerning insurance products and marketing channels for insurance products.

3. Health Insurance Products must apply risk sharing (co-payment) borne by the Policyholder, Insured, or Participant of at least 10% (ten percent) of the total claim submissions with maximum limits of:
   a. for outpatient care, IDR 300,000.00 (three hundred thousand rupiah) per claim submission; and b. for inpatient care, IDR 3,000,000.00 (three million rupiah) per claim submission.

4. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies may apply higher maximum limits as referred to in number 3 letters a and b, provided they are agreed upon between Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies and the Policyholder, Insured, or Participant, and stated in the Insurance Policy.

5. In the event that Health Insurance Products apply benefit coordination among insurance providers, the risk sharing (co-payment) of at least 10% (ten percent) of the total claim submissions as referred to in number 3 is calculated from the total claim submissions that are the obligation of Insurance Companies, Sharia Insurance Companies, or Sharia Units within Insurance Companies.

6. Risk sharing (co-payment) as referred to in numbers 3 through 5 only applies to Health Insurance Products with the indemnity principle as referred to in Section IV Part A number 1 letter a and Health Insurance Products with managed care schemes as referred to in Section IV Part A number 1 letter b.

7. Risk sharing (co-payment) for managed care schemes is implemented starting from advanced-level health facilities.

8. Risk sharing (co-payment) as referred to in numbers 3 through 5 is exempted for Micro Insurance Products.

9. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies have the authority to review and determine Premiums and Contributions (repricing) upon the renewal of Insurance Policies based on the claim history of the Policyholder, Insured, or Participant and/or the level of inflation in the health sector.

10. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies may review and determine Premiums and Contributions outside the periods as referred to in number 9, provided they obtain approval from the Policyholder, Insured, or Participant.

B. Risk Selection

1. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies marketing Health Insurance Products must ensure that prospective Policyholders, Insured, or Participants understand all information in the Health Insurance Request Letter (SPAK) and fill it out themselves.

2. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies marketing Health Insurance Products for individuals must consider the implementation of medical check-ups (MCU) for prospective Policyholders, Insured, or Participants, adjusted to the underwriting policies of Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies at the time of policy closure.

3. The MCU examination package as referred to in number 2 refers to age and health questionnaire results filled out by prospective Policyholders, Insured, or Participants.

4. For group Health Insurance Products, Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies must obtain claim performance reports for Policyholders at the time of policy closure.

5. In order to obtain claim performance reports as referred to in number 4, associations of Insurance Companies and Sharia Insurance Companies must create databases regarding claim performance reports that at least include data:
   a. reporting period; b. tax identification numbers (NPWP) of each Policyholder;
   c. number of Insured or Participants;
   d. amount of Premiums or Contributions; e. amount of claims paid; and f. loss ratio information.

6. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies must submit claim performance reports for each Policyholder to the database as referred to in number 5, submitted quarterly at the latest 14 (fourteen) working days after the end of the respective quarter.

VI. BENEFIT COORDINATION BETWEEN INSURANCE COMPANIES, SHARIA INSURANCE COMPANIES, AND SHARIA UNITS WITHIN INSURANCE COMPANIES WITH OTHER INSURANCE PROVIDERS

1. Health Insurance Products must include features that enable benefit coordination between Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies with other insurance providers.

2. Benefit coordination between Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies with other insurance providers is implemented by applying prudent principles and adequate risk management.

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3. Coordination of benefits between Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies with other benefit organizers is conducted in accordance with the provisions of applicable laws and regulations, including regulations regarding coordination among benefit organizers and regulations regarding cost difference guidelines.

VII. COOPERATION WITH OTHER PARTIES

1. In implementing Health Insurance Products, Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies cooperate with other parties, including:
   a. Health Service Facilities; b. TPAs;
   c. Other Insurance Companies, Sharia Insurance Companies, or Sharia Units within Insurance Companies;
   d. companies that can provide digital services; and/or e. BPJS Kesehatan and other benefit organizers.

2. Cooperation with Health Service Facilities as referred to in item 1 letter a is conducted for the provision of health services for Health Insurance Products, by applying prudent principles and adequate risk management.

3. Cooperation with TPAs as referred to in item 1 letter b is conducted in the context of providing administrative services and claim management, providing information systems as referred to in Roman II item 3, and in the context of providing DPM services as referred to in Roman III, by applying prudent principles and adequate risk management.

4. Cooperation with other Insurance Companies, Sharia Insurance Companies, or Sharia Units within Insurance Companies as referred to in item 1 letter c is conducted in the context of providing information systems as referred to in Roman II item 3 and DPM services as referred to in Roman III, by applying prudent principles and adequate risk management.

5. Cooperation with companies that can provide digital services as referred to in item 1 letter d is conducted in the context of providing information systems as referred to in Roman II item 3, by applying prudent principles and adequate risk management.

6. Cooperation with BPJS Kesehatan and other benefit organizers as referred to in item 1 letter e is conducted in the context of coordination among benefit organizers as referred to in Roman VI, by applying prudent principles and adequate risk management.

7. The content of cooperation agreements with other parties as referred to in item 1 must at least include:
   a. identity of the parties; b. duration of the cooperation agreement;
   c. rights and obligations of each party;
   d. scope of cooperation of each party; https://jdih.ojk.go.id/

e. obligations of the parties to maintain data confidentiality; f. dispute resolution between the two parties; g. conditions and procedures for changing the agreement; h. force majeure;
i. conditions causing the agreement to end; and
j. settlement of rights and obligations of each party when the agreement ends.

8. The content of cooperation agreements with Health Service Facilities as referred to in item 2, in addition to stating the provisions as referred to in item 7, must at least also include:
   a. a statement from the Health Service Facility to provide data access through the information system of Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies; b. commitment of the Health Service Facility to provide health services in accordance with clinical pathways and medical efficacy as regulated in applicable health laws and regulations;
   c. commitment of the Health Service Facility regarding infrastructure that enables the distribution of claim bills to Insurance Companies, Sharia Insurance Companies, Sharia Units within Insurance Companies, and BPJS Kesehatan, in the event of coordination among benefit organizers with BPJS Kesehatan as regulated in Roman VI; and
   d. commitment of the Health Service Facility to settle every procedure at the end of each working day or as agreed in the cooperation agreement, regarding inpatient facilities for Policyholders, Insured Persons, or Participants, to accelerate the claim service process.

9. The content of cooperation agreements with TPAs as referred to in item 3, in addition to stating the provisions as referred to in item 7, must at least also include:
   a. commitment to mutually maintain data confidentiality as regulated in applicable laws and regulations regarding personal data protection, in the event that the information system as referred to in Roman II item 3 is provided by the TPA; and b. commitment of the TPA to provide DPM function services as referred to in Roman III, in the event that DPM of Insurance Companies, Sharia Insurance Companies, and/or Sharia Units within Insurance Companies is provided by the TPA.

10. The content of cooperation agreements with other Insurance Companies, Sharia Insurance Companies, or Sharia Units within Insurance Companies as referred to in item 4, in addition to stating the provisions as referred to in item 7, must at least also include:
    a. commitment to mutually maintain data confidentiality as regulated in applicable laws and regulations regarding personal data protection, in the event that the information system as referred to in Roman II item 3 https://jdih.ojk.go.id/

is provided by other Insurance Companies, Sharia Insurance Companies, or Sharia Units within Insurance Companies; and b. commitment of other Insurance Companies, Sharia Insurance Companies, or Sharia Units within Insurance Companies to provide DPM function services as referred to in Roman III, in the event that DPM of Insurance Companies, Sharia Insurance Companies, and/or Sharia Units within Insurance Companies is provided by other Insurance Companies, Sharia Insurance Companies, or Sharia Units within Insurance Companies.

11. The content of cooperation agreements with other companies that can provide digital services as referred to in item 5, in addition to stating the provisions as referred to in item 7, must at least also include commitment to mutually maintain data confidentiality as regulated in applicable laws and regulations regarding personal data protection.

12. The content of cooperation agreements with BPJS Kesehatan and other social benefit organizers as referred to in item 6, in addition to stating the provisions as referred to in item 7, must at least also include commitment to mutually maintain data confidentiality as regulated in applicable laws and regulations regarding personal data protection.

VIII. OTHER PROVISIONS

1. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies must have programs to encourage Policyholders, Insured Persons, or Participants to adopt healthy lifestyles.

2. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies must actively conduct health campaigns to increase public awareness to maintain health.

3. Insurance Companies, Sharia Insurance Companies, and Sharia Units within Insurance Companies must apply consumer and public protection principles in marketing Health Insurance Products in accordance with applicable laws and regulations regarding consumer protection in the financial services sector.

IX. TRANSITIONAL PROVISIONS

1. Coverage or participation in Health Insurance Products that are already in effect at the time this Otoritas Jasa Keuangan Circular Letter is established, are declared to remain valid until the coverage or participation period ends.

2. For Health Insurance Products that:
   a. can be automatically renewed; and b. have received approval from Otoritas Jasa Keuangan or have been reported to Otoritas Jasa Keuangan before this Otoritas Jasa Keuangan Circular Letter takes effect, must be adjusted to this Otoritas Jasa Keuangan Circular Letter no later than December 31, 2026.

3. Provisions as referred to in Roman II item 1 letter
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This copy is consistent with the original
Director of Legal Development
Legal Department signed
Aat Windradi b and item 2 apply since the establishment of a professional certification body for organizers registered with Otoritas Jasa Keuangan.

4. Submission of claim performance reports as referred to in Roman V letter B item 6, will apply for the submission of reports for the second quarter of 2026.

X. CLOSING PROVISIONS

Provisions in this Otoritas Jasa Keuangan Circular Letter take effect starting from January 1, 2026.

Established in Jakarta on May 19, 2025
EXECUTIVE HEAD OF INSURANCE, INSURANCE AND PENSION FUND SUPERVISOR OF THE FINANCIAL SERVICES AUTHORITY OF THE REPUBLIC OF INDONESIA, OGI PRASTOMIYONO signed https://jdih.ojk.go.id/