Financial Services Authority Regulation No. 36 of 2025 on Strengthening the Health Insurance Ecosystem

Financial Services Authority Regulation Number 36 of 2025 concerning Strengthening the Health Insurance Ecosystem

Abstract: That in the implementation of health insurance products, there is a connection with the role of other parties in the health insurance ecosystem, thus requiring the strengthening of the health insurance ecosystem to ensure a balance of benefits for policyholders, insured persons, or participants, and the sustainability of the insurance industry.

That to support the strengthening of the health insurance ecosystem, insurance companies and Sharia insurance companies need to apply prudent principles and risk management, thus requiring comprehensive regulations in the implementation of the health insurance business line.

The legal basis for this Financial Services Authority Regulation (POJK) is: Law No. 21 of 2011 as amended by Law No. 4 of 2023; and Law No. 40 of 2014 as amended by Law No. 4 of 2023.

The strengthening of the health insurance ecosystem aims to:

1. Strengthen effective governance, risk management, and supervision to protect the rights and interests of policyholders, insured persons, or participants, and related parties in the health insurance ecosystem;
2. Encourage collaboration among parties involved in the national health insurance ecosystem;
3. Ensure the creation of a stable, healthy, and competitive health insurance ecosystem; and
4. Prioritize the principle of protection in the implementation of health insurance.

In realizing the objectives of strengthening the health insurance ecosystem, the Financial Services Authority coordinates with:

1. the Ministry responsible for health government affairs;
2. health service facility associations;
3. BPJS Kesehatan and other insurance organizers;
4. professional associations in the health sector; and
5. other relevant institutions related to the national health insurance ecosystem.

Companies implementing the health insurance business line are required to possess:

1. adequate medical capabilities;
2. digital capabilities demonstrated by ownership of adequate information systems; and
3. adequate Medical Advisory Board (DPM) capabilities.

In the implementation of prudent principles and risk management, the regulations include among others:

1. The obligation for Companies to create and submit a summary of coverage to facilitate prospective policyholders, insured persons, or participants in studying the coverage policy;
2. Companies may review and set premiums or contributions again at most once in 1 year;
3. The obligation for Companies to provide health insurance products without risk-sharing features when marketing health insurance products.
4. Companies may also provide health insurance products with risk-sharing features in addition to providing health insurance products without risk-sharing features, with the following conditions: a. Setting the risk borne by the policyholder, insured person, or participant at 5% (five percent) of the total claim submissions with a maximum limit of:
   1. for outpatient care: Rp300,000.00 (three hundred thousand rupiah) per claim submission; and
   2. for inpatient care: Rp3,000,000.00 (three million rupiah) per claim submission; and/or b. Setting a specific annual amount (deductible) as agreed between the company and the policyholder, insured person, or participant, and stated in the insurance policy.

To ensure that health services for policyholders, insured persons, or participants are in accordance with quality and organized efficiently for cost control purposes, companies are required to conduct utilization reviews implemented by doctors and health insurance experts.

The Company's obligation to prioritize the implementation of KAPJ (Health Care Joint Venture/Partnership) and include features that enable the implementation of KAPJ.

The strengthening of the health insurance ecosystem is carried out by companies through cooperation with:

1. Health Service Facilities;
2. TPA (Third Party Administrator);
3. BPJS Kesehatan and other insurance organizers;
4. other companies;
5. digital service provider companies; and/or
6. other parties providing DPM.

Note: This Financial Services Authority Regulation takes effect 3 (three) months from the date of promulgation. This Financial Services Authority Regulation was promulgated on December 22, 2025, and established on December 17, 2025.

Upon the effective date of this Financial Services Authority Regulation:

1. Companies are required to adjust Health Insurance Products that have received approval from the Financial Services Authority or have been reported to the Financial Services Authority before this Regulation takes effect, in accordance with the provisions of this Regulation, at the latest 1 (one) year from the date of promulgation of this Regulation;
2. Companies that have implemented the health insurance business line before this Regulation takes effect are required to obtain approval from the Financial Services Authority at the latest 1 (one) year from the date of promulgation of this Regulation; and
3. Financial Services Authority provisions regarding the implementation of health insurance products are revoked and declared invalid.