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

FINANCIAL SERVICES AUTHORITY REGULATION
OF THE REPUBLIC OF INDONESIA
NUMBER 36 OF 2025
ON
STRENGTHENING THE HEALTH INSURANCE ECOSYSTEM
BY THE GRACE OF THE ALMIGHTY GOD

THE BOARD OF COMMISSIONERS OF THE FINANCIAL SERVICES AUTHORITY,

Considering:
a. that the provision of health insurance products is related to the role of other parties in the health insurance ecosystem, so it is necessary to strengthen the health insurance ecosystem to ensure balanced benefits for policyholders, insured persons, or participants, and the sustainability of the insurance industry; b. that to support the strengthening of the health insurance ecosystem, insurance companies and Sharia insurance companies need to apply prudent principles and risk management, so comprehensive regulations are needed in the provision of health insurance business lines;
c. that based on the considerations as referred to in letters a and b, it is necessary to establish a Financial Services Authority Regulation on Strengthening the Health Insurance Ecosystem;

Recalling:

1. Law Number 21 of 2011 concerning the Financial Services Authority (State Gazette of the Republic of Indonesia Year 2011 Number 111, Supplement to the State Gazette of the Republic of Indonesia Number 5253) as amended by Law Number 4 of 2023 concerning the Development and Strengthening of the Financial Sector (State Gazette of the Republic of Indonesia Year 2023 Number 4, Supplement to the State Gazette of the Republic of Indonesia Number 6845);
2. Law Number 40 of 2014 concerning Insurance (State Gazette of the Republic of Indonesia Year 2014 Number 337, Supplement to the State Gazette of the Republic of Indonesia Number 5618) as amended by Law Number 4 of 2023 concerning the Development and Strengthening of the Financial Sector (State Gazette of the Republic of Indonesia Year 2023 Number 4, Supplement to the State Gazette of the Republic of Indonesia Number 6845);

DECIDES:

Establish: FINANCIAL SERVICES AUTHORITY REGULATION ON STRENGTHENING THE HEALTH INSURANCE ECOSYSTEM.

CHAPTER I
GENERAL PROVISIONS

Article 1
In this Financial Services Authority Regulation:

1. Insurance Product is a service program for risk coverage/management conducted by general insurance companies and/or life insurance companies, including those conducted based on Sharia principles.
2. Health Insurance Product is an Insurance Product that provides protection against one (1) or more types of risks related to the health condition of an insured person or the decline of the health condition of the insured person.
3. Investment-Linked Insurance Product, hereinafter referred to as PAYDI, is an Insurance Product that provides at least protection against death risk and provides benefits referring to the investment results of a fund pool specifically formed for the Insurance Product, whether stated 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 community, especially low-income communities.
5. Insurance Policy is an insurance agreement deed or other documents equivalent to an insurance agreement deed, and other documents that are 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. Company means insurance company, Sharia insurance company, and Sharia unit of an insurance company.
7. 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 risk management for themselves, the insured, or other participants.
8. Insured is a party facing risks as regulated in an insurance agreement or reinsurance agreement.
9. Participant is a party facing risks as regulated in a Sharia insurance agreement or Sharia reinsurance agreement.
10. Premium is an amount of money determined by the insurance company or reinsurance company and approved by the Policyholder to be paid based on an insurance agreement or reinsurance agreement, or an amount of money determined based on statutory regulations underlying mandatory insurance programs to obtain benefits.
11. Contribution is an amount of money determined by the Sharia insurance company or Sharia reinsurance company and approved by the Policyholder to be paid based on a Sharia insurance agreement or Sharia reinsurance agreement to obtain benefits from Tabarru' funds and/or Participant investment funds and to pay management costs, or an amount of money determined based on statutory regulations underlying mandatory insurance programs to obtain benefits.
12. Social Health Insurance Implementing Agency, hereinafter referred to as BPJS Kesehatan, is a public legal entity formed to implement health insurance programs as regulated in laws concerning social security implementing agencies.
13. 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.
14. Medical Advisory Board (Dewan Penasihat Medis), hereinafter abbreviated as DPM, is a board that assists the Company in providing advice or proposals regarding medical services provided by Health Service Facilities.
15. Third Party Administrator (TPA) is a third-party administrative service that assists the Company in administrative services, including claims management, Insurance Policy management, and other administrative functions.
16. Utilization Review is an evaluation of the appropriateness of health services provided to the Insured or Participant conducted to control costs and monitor service quality.
17. Coordination Among Insurance Implementers, hereinafter abbreviated as KAPJ, is coordination conducted between the Company, BPJS Kesehatan, and other insurance implementers in providing health service benefits.

Article 2
Strengthening the health insurance ecosystem aims to:
a. strengthen governance, risk management, and effective supervision to protect the rights and interests of Policyholders, Insured persons, or Participants, as well as related parties in the health insurance ecosystem; b. encourage collaboration among parties involved in the national health insurance ecosystem;
c. ensure the creation of a stable, healthy, and competitive health insurance ecosystem; and
d. prioritize consumer protection principles in the provision of health insurance.

Article 3
In realizing the objectives of strengthening the health insurance ecosystem as referred to in Article 2, the Financial Services Authority coordinates with:
a. ministries responsible for government affairs in the health sector; b. Health Service Facility associations;
c. BPJS Kesehatan and other insurance implementers;
d. health professional associations; and e. other relevant agencies regarding the national health insurance ecosystem.

Article 4
Coordination between the Financial Services Authority and parties as referred to in Article 3 letters a and e may be formulated in the form of inter-agency memoranda of understanding.

CHAPTER II
PROVISION OF HEALTH INSURANCE
First Section
Criteria for Companies That Can Provide Health Insurance Business Lines

Article 5
(1) Companies providing health insurance business lines must possess:
a. adequate medical capabilities; b. digital capabilities demonstrated by ownership of adequate information systems; and
c. adequate DPM capabilities.
(2) Companies must first obtain approval from the Financial Services Authority before providing health insurance business lines.

Article 6
(1) Adequate medical capabilities as referred to in Article 5 paragraph (1) letter a must include at least:
a. medical personnel with physician qualifications who play a role in analyzing medical actions and Utilization Reviews; and b. human resources holding health insurance expertise certificates with the lowest level being 1 (one) level below the highest qualification of professional certification bodies in the insurance sector registered with the Financial Services Authority. (2) In the event that professional certification bodies registered with the Financial Services Authority as referred to in paragraph (1) letter b are not yet available, health insurance expertise certificates are obtained from professional certification bodies that have conducted certification activities in the health insurance sector. (3) Health insurance expertise certificates as referred to in paragraph (1) letter b may use equivalent competence certificates 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 insurance, guarantee, and pension sectors.

Article 7
(1) Digital capabilities as referred to in Article 5 paragraph (1) letter b are evidenced by ownership of information systems that meet at least the following requirements:
a. capable of exchanging data digitally with Health Service Facilities; b. capable of providing access to membership data;
c. capable of providing data containing services and medical summaries, including drug and health equipment services, provided to Policyholders, Insured persons, or Participants;
d. capable of providing claim data paid for each Policyholder, Insured person, or Participant; e. capable of supporting the processing, storage, and security of electronic data to prevent potential fraud in the health insurance sector; and f. supported by a database with the following requirements:

1. having a disease classification standard according to applicable regulations;
2. having the ability to analyze the suitability of medical services and drugs provided; and
3. having the ability to conduct Utilization Reviews with Health Service Facilities.
   (2) Information systems as referred to in paragraph (1) may be developed by the Company independently or in cooperation with:
   a. TPAs; b. BPJS Kesehatan and other insurance implementers;
   c. companies that can provide digital services; or
   d. other Companies.
   (3) In the event that information system development is conducted by third parties as referred to in paragraph (2), the Company must have a cooperation agreement covering confidentiality and the use of Policyholder, Insured person, or Participant data. (4) Companies must store databases as referred to in paragraph (1) letter f for at least 10 (ten) years after the expiration of the Insurance Policy coverage period.

Second Section
Medical Advisory Board

Article 8
(1) Adequate DPM capabilities as referred to in Article 5 paragraph (1) letter c are evidenced by the ownership of a DPM consisting of a group of specialists with specific expertise needed by the Company in providing health insurance business lines. (2) Companies may have a DPM as referred to in paragraph (1) independently or in cooperation with:
a. other Companies; b. TPAs; or
c. other DPM providers.
(3) Ownership of a DPM as referred to in paragraph (1) must be evidenced by a document of DPM appointment by the Board of Directors and approved by the Board of Commissioners.

Article 9
Companies must ensure that the DPM performs its duties to provide:
a. advice to the Company to support the implementation of Utilization Reviews; and b. proposals regarding health services, including new developments in medical services and recommendations to the Company.

Third Section
Administrative Sanctions

Article 10
(1) Violations of the provisions as referred to in Article 5, Article 7 paragraph (3), paragraph (4), and/or Article 9 are subject to administrative sanctions in the form of:
a. written warnings; b. prohibitions on marketing Health Insurance Products; and/or
c. downgrade of health status.
(2) Violations of the provisions as referred to in Article 5 paragraph (2) are subject to additional administrative sanctions in the form of an administrative fine of Rp100,000,000.00 (one hundred million rupiah). (3) In the event of violations of the provisions as referred to in paragraph (1) and the violations have been rectified, the Financial Services Authority provides written warning sanctions that end automatically. (4) In the event that violations of the provisions as referred to in paragraph (1) letters a and b have been fulfilled, the Financial Services Authority revokes the administrative sanctions.

Article 11
Regarding violations of administrative sanctions as referred to in Article 10 paragraph (1), the Financial Services Authority may conduct a re-evaluation of the Company's main parties in accordance with Financial Services Authority Regulations concerning re-evaluation for main parties of financial service institutions.

CHAPTER III
DESIGN OF HEALTH INSURANCE PRODUCTS
First Section
Types and Mechanisms of Health Insurance Products

Article 12
Health Insurance Products marketed by Companies based on membership include:
a. Individual Health Insurance Products; and b. Group Health Insurance Products.

Article 13
(1) Health Insurance Products are implemented by:
a. reimbursement principles; and b. managed health service schemes.
(2) Health Insurance Products with reimbursement principles as referred to in paragraph (1) letter a consist of:
a. Health Insurance Products with maximum cost limits per benefit (inner limit); and b. Health Insurance Products as charged.
(3) Health Insurance Products with managed health service schemes as referred to in paragraph (1) letter b are integrations of financing and comprehensive healthcare provision conducted as efforts of:
a. promotive; b. preventive;
c. curative;
d. rehabilitative; and/or e. palliative, which include first-level outpatient care, advanced-level outpatient care, structured inpatient care, and tiered care.

Second Section
Waiting Periods for Health Insurance Products

Article 14
(1) Companies marketing Individual Health Insurance Products as referred to in Article 12 letter a may apply waiting periods.
(2) In the event that Companies establish waiting periods as referred to in paragraph (1), waiting periods must meet the following requirements:
a. at most 30 (thirty) calendar days; and/or b. at most 6 (six) months for Individual Health Insurance Products providing benefits for critical, chronic, and/or specific diseases clearly stated in the Insurance Policy. (3) For Individual Health Insurance Products that can be automatically extended, the waiting period provisions as referred to in paragraph (2) letter b only apply to the first coverage period. (4) Waiting periods for Individual Health Insurance Products that are additional insurance (riders) from PAYDI refer to Financial Services Authority regulations concerning investment-linked insurance products. (5) Waiting periods for Individual Health Insurance Products that are Micro Insurance Products refer to Financial Services Authority regulations concerning micro insurance products and marketing channels for micro insurance products. (6) The application of waiting periods for Individual Health Insurance Products is excluded for:
a. emergency conditions caused by accidents; and/or b. emergency conditions caused by urgent circumstances.

Article 15
Companies marketing Individual Health Insurance Products as referred to in Article 12 letter a are prohibited from applying waiting periods for Individual Health Insurance Products with coverage periods of at most 3 (three) months.

Article 16
For Group Health Insurance Products, Companies may apply specific waiting period provisions referring to agreements agreed upon between the Policyholder and the Company.

Third Section
Administrative Sanctions

Article 17
(1) Violations of the provisions as referred to in Article 14 paragraph (2) and/or Article 15 are subject to administrative sanctions in the form of:
a. written warnings; b. prohibitions on marketing Health Insurance Products; and/or
c. downgrade of health status.
(2) In the event of violations of the provisions as referred to in paragraph (1) and the violations have been rectified, the Financial Services Authority provides written warning sanctions that end automatically. (3) In the event that violations of the provisions as referred to in paragraph (1) letters a and b have been fulfilled, the Financial Services Authority revokes the administrative sanctions.

Article 18
Regarding violations of administrative sanctions as referred to in Article 17 paragraph (1), the Financial Services Authority may conduct a re-evaluation of the Company's main parties in accordance with Financial Services Authority Regulations concerning re-evaluation for main parties of financial service institutions.

CHAPTER IV
IMPLEMENTATION OF RISK MANAGEMENT
First Section
General

Article 19
In providing health insurance business lines, Companies must apply prudent principles and risk management.

Second Section
Insurance Policies, Premiums, and Contributions Paragraph 1 General

Article 20
(1) Companies marketing Health Insurance Products may include exclusions or coverage limitations for conditions of Policyholders, Insured persons, or Participants that existed prior to coverage. (2) Companies must create and provide coverage summaries to facilitate prospective Policyholders, Insured persons, or Participants in studying coverage policies. (3) The calculation and determination of Premiums or Contributions are conducted according to the risks and benefits obtained by Policyholders, Insured persons, or Participants as regulated in Financial Services Authority Regulations concerning insurance products and marketing channels for insurance products.

Paragraph 2
Review and Determination of Premiums or Contributions

Article 21
(1) Companies are prohibited from reviewing and determining Premiums or Contributions based on:
a. the claim history of Policyholders, Insured persons, or Participants; b. increased risks of Policyholders, Insured persons, or Participants; and/or
c. inflation rates in the health sector,
more than 1 (one) time in 1 (one) year.
(2) Companies must provide written notifications to Policyholders, Insured persons, or Participants regarding the determination of Premiums or Contributions as referred to in paragraph (1), including:
a. clear explanations of factors driving the determination of Premiums or Contributions, including supporting data; b. comparisons of renewed Premium or Contribution rates with current Premium or Contribution rates; and
c. explanations of alternatives provided specifically for Policyholders, Insured persons, or Participants.
(3) Written notifications to Policyholders, Insured persons, or Participants as referred to in paragraph (2) must be provided at least 30 (thirty) calendar days before the determination of Premiums or Contributions.

Article 22
Companies must:
a. develop internal policies and procedures for the calculation and determination of Premiums or Contributions as referred to in Article 21 paragraph (1); and b. ensure that all implementation of Premium or Contribution determinations is conducted in accordance with their internal policies and procedures.

Article 23
Companies are prohibited from determining Premiums or Contributions as referred to in Article 21 paragraph (1) that result in the Company obtaining profit margins above initial assumptions at the time of approval/reporting of Health Insurance Products.

Paragraph 3
Risk Sharing

Article 24
(1) In marketing Health Insurance Products, Companies must provide Health Insurance Products without risk-sharing features.
(2) In addition to providing Health Insurance Products without risk-sharing features as referred to in paragraph (1), Companies may provide Health Insurance Products with risk-sharing features. (3) In the event that prospective Policyholders, Insured persons, or Participants choose Health Insurance Products with risk-sharing features as referred to in paragraph (2), Companies must meet the following risk-sharing provisions:
a. determining the risks borne by Policyholders, Insured persons, or Participants at 5% (five percent) of total claim submissions with maximum limits 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. determining a specific annual amount (deductible) as agreed between the Company and Policyholders, Insured persons, or Participants and stated in the Insurance Policy. (4) In the provision of Health Insurance Products with risk-sharing features as referred to in paragraph (2), the risk-sharing provisions as referred to in paragraph (3) do not apply to:
   a. emergency conditions caused by accidents; b. critical diseases stated in the Insurance Policy; and/or
   c. emergency conditions caused by urgent circumstances.
   (5) In marketing Health Insurance Products with risk-sharing features as referred to in paragraph (2), Companies must provide comparisons of Premium or Contribution prices for products applying risk-sharing features and without risk-sharing features to prospective Policyholders, Insured persons, or Participants at the initial coverage or Policy renewal.

Third Section
Risk Selection

Article 25
(1) Companies marketing Individual Health Insurance Products as referred to in Article 12 letter a must ensure that prospective Policyholders, Insured persons, or Participants understand all information in the health insurance application form and that the form is filled out by the prospective Policyholder, Insured person, or Participant themselves. (2) Companies marketing Individual Health Insurance Products as referred to in paragraph (1) must consider the implementation of health examinations for prospective Policyholders, Insured persons, or Participants adjusted to the Company's underwriting policies at the time of Policy closure.

Article 26
(1) Companies marketing Group Health Insurance Products as referred to in Article 12 letter b must obtain claim performance reports for Policyholders at the time of Policy closure. (2) Claim performance reports as referred to in paragraph (1) must include at least the following data:
a. reporting period; b. tax identification numbers (NPWP) of each Policyholder;
c. number of Insured persons or Participants;
d. amount of Premiums or Contributions; e. amount of claims paid; and f. loss ratio information.

Fourth Section
Administrative Sanctions

Article 27
(1) Violations of the provisions as referred to in Article 19, Article 20 paragraph (2), Article 21, Article 22, Article 23, Article 24 paragraph (1), paragraph (3), paragraph (5), and/or Article 25 are subject to administrative sanctions in the form of:
a. written warnings; b. prohibitions on marketing Health Insurance Products; and/or
c. downgrade of health status.

(2) In the event that violations of the provisions as referred to in paragraph (1) occur and the violation has been remedied, the Financial Services Authority shall impose a written warning sanction that terminates automatically. (3) In the event that violations of the provisions as referred to in paragraph (1) letters a and b have been fulfilled, the Financial Services Authority shall revoke the administrative sanction.

Article 28
Regarding violations of administrative sanction provisions as referred to in Article 27 paragraph (1), the Financial Services Authority may conduct a re-evaluation of the Principal Parties of the Company in accordance with the Financial Services Authority Regulation regarding re-evaluation for principal parties of financial service institutions.

CHAPTER V
UTILIZATION REVIEW
First Section
Implementation of Utilization Review

Article 29
(1) Companies are required to conduct Utilization Review.
(2) Utilization Review as referred to in paragraph (1) is conducted to ensure that health services provided to Policyholders, Insured Persons, or Participants meet quality standards and are organized efficiently for the purpose of cost control. (3) Utilization Review as referred to in paragraph (1) is conducted through the fulfillment of quality standards which include:
a. input standards at Healthcare Facilities; b. health service process standards; and
c. output quality standards for the health of Insured Persons or Participants.

Article 30
(1) Utilization Review must be implemented by doctors as referred to in Article 6 paragraph (1) letter a and health insurance experts as referred to in Article 6 paragraph (1) letter b. (2) Companies may seek advice from DPM in the implementation of Utilization Review. (3) Utilization Review may be conducted at the time:
a. Healthcare Facility requests approval from the Company before providing certain treatment or services; b. Healthcare Facility requests approval for treatment or services while the patient is still receiving treatment; and/or
c. The Company reviews the patient's medical records after treatment is completed.

(4) Utilization Review conducted by the Company must at least cover:
a. evaluation of suitability and need for services provided against clinical pathways; and b. evaluation of suitability and need for drug efficacy.

Second Section
Administrative Sanctions

Article 31
(1) Violations of the provisions as referred to in Article 29 paragraph (1) and/or Article 30 paragraph (1) shall be subject to administrative sanctions in the form of:
a. written warning; b. prohibition on marketing Health Insurance Products; and/or
c. downgrade of health status.
(2) In the event that violations of the provisions as referred to in paragraph (1) occur and the violation has been remedied, the Financial Services Authority shall impose a written warning sanction that terminates automatically. (3) In the event that violations of the provisions as referred to in paragraph (1) letters a and b have been fulfilled, the Financial Services Authority shall revoke the administrative sanction.

Article 32
Regarding violations of administrative sanction provisions as referred to in Article 31 paragraph (1), the Financial Services Authority may conduct a re-evaluation of the Principal Parties of the Company in accordance with the Financial Services Authority Regulation regarding re-evaluation for principal parties of financial service institutions.

CHAPTER VI
ROLES OF PARTIES IN STRENGTHENING THE HEALTH INSURANCE ECOSYSTEM First Section General

Article 33
(1) Strengthening of the health insurance ecosystem is carried out by Companies through cooperation with:
a. Healthcare Facilities; b. TPAs;
c. BPJS Kesehatan and other insurance organizers;
d. Other Companies; e. digital service provider companies; and/or f. other parties providing DPM.
(2) Cooperation with Healthcare Facilities as referred to in paragraph (1) letter a is conducted for the provision of health services for Health Insurance Products, applying prudent principles and adequate risk management.

(3) Cooperation with TPAs as referred to in paragraph (1) letter b is conducted in the provision of:
a. administrative and claims management services; b. information systems; and/or
c. DPM services,
applying prudent principles and adequate risk management.
(4) Cooperation with BPJS Kesehatan and other insurance organizers as referred to in paragraph (1) letter c is conducted for the purpose of KAPJ and/or cooperation in the provision of information systems, applying prudent principles and adequate risk management. (5) Cooperation with Other Companies as referred to in paragraph (1) letter d is conducted for the purpose of providing:
a. information systems; and/or b. DPM services, applying prudent principles and adequate risk management.
(6) Cooperation with digital service provider companies as referred to in paragraph (1) letter e is conducted for the purpose of providing information systems, applying prudent principles and adequate risk management. (7) Cooperation with other parties providing DPM as referred to in paragraph (1) letter f is conducted for the purpose of providing DPM services, applying prudent principles and adequate risk management.

Second Section
Role of Healthcare Facilities

Article 34
(1) The role of Healthcare Facilities as referred to in Article 33 paragraph (1) letter a is conducted to support Companies in the provision of:
a. data access through the Company's information system; b. health services according to clinical pathways and medical efficacy as regulated in health legislation;
c. infrastructure enabling the sharing of claim bills between the Company and BPJS Kesehatan and other insurance organizers, in the event of KAPJ; and
d. settlement for every action at the end of each working day or as agreed in the cooperation agreement, for inpatient facilities for Policyholders, Insured Persons, or Participants, to accelerate the claims service process.

(2) Cooperation with Healthcare Facilities as referred to in paragraph (1) must be embodied in a cooperation agreement which must at least contain:
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; e. obligation of the parties to maintain data confidentiality; f. dispute resolution between both parties; g. conditions and procedures for changing the agreement; h. force majeure;
i. conditions causing the termination of the agreement;
j. settlement of rights and obligations of each party upon termination of the agreement; k. statement from the Healthcare Facility to provide data access through the Company's information system;
l. commitment of the Healthcare Facility to carry out health services according to clinical pathways and medical efficacy as regulated in health legislation;
m. commitment of the Healthcare Facility regarding infrastructure enabling the sharing of claim bills between the Company and BPJS Kesehatan, in the event of KAPJ with BPJS Kesehatan; and n. commitment of the Healthcare Facility to perform settlement for every action at the end of each working day or as agreed in the cooperation agreement, for inpatient facilities for Policyholders, Insured Persons, or Participants, to accelerate the claims service process.

Third Section
Role of Third Party Administrator (TPA)

Article 35
(1) The role of TPA as referred to in Article 33 paragraph (1) letter b is conducted to support Companies in order to:
a. maintain data confidentiality as regulated in legislation regarding personal data protection, in the event that the information system as referred to in Article 5 paragraph (1) letter b is provided by the TPA; and/or b. provide DPM function services as referred to in Article 5 paragraph (1) letter c, in the event that the Company's DPM is provided by the TPA.

(2) Cooperation with TPA as referred to in paragraph (1) must be embodied in a cooperation agreement which must at least contain:
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; e. obligation of the parties to maintain data confidentiality; f. dispute resolution between both parties; g. conditions and procedures for changing the agreement; h. force majeure;
i. conditions causing the termination of the agreement;
j. settlement of rights and obligations of each party upon termination of the agreement; k. commitment to mutually maintain data confidentiality as regulated in legislation regarding personal data protection, in the event that the information system as referred to in Article 7 paragraph (1) is provided by the TPA; and
l. commitment of the TPA to provide DPM function services as referred to in Article 5 paragraph (1) letter c, in the event that the Company's DPM is provided by the TPA.

Fourth Section
Role of BPJS Kesehatan and Other Insurance Organizers

Article 36
(1) The role of BPJS Kesehatan and other insurance organizers as referred to in Article 33 paragraph (1) letter c is conducted for the purpose of KAPJ and/or cooperation in the provision of information system services. (2) Cooperation with BPJS Kesehatan and other insurance organizers as referred to in paragraph (1) must be embodied in a cooperation agreement which must at least contain:
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; e. obligation of the parties to maintain data confidentiality; f. dispute resolution between both parties; g. conditions and procedures for changing the agreement; h. force majeure;
i. conditions causing the termination of the agreement;
j. settlement of rights and obligations of each party upon termination of the agreement; k. procedures and mechanisms for KAPJ; and
l. commitment to mutually maintain data confidentiality as regulated in legislation regarding personal data protection.

Fifth Section
Role of Other Companies

Article 37
(1) The role of Other Companies as referred to in Article 33 paragraph (1) letter d is conducted for the purpose of cooperation in the provision of information systems and/or DPM services. (2) Cooperation with Other Companies as referred to in paragraph (1) must be embodied in a cooperation agreement which must at least contain:
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; e. obligation of the parties to maintain data confidentiality; f. dispute resolution between both parties; g. conditions and procedures for changing the agreement; h. force majeure;
i. conditions causing the termination of the agreement;
j. settlement of rights and obligations of each party upon termination of the agreement; k. commitment to mutually maintain data confidentiality as regulated in legislation regarding personal data protection, in the event that the information system as referred to in Article 7 paragraph (1) is provided by the Other Company; and
l. commitment of the Other Company to provide DPM function services as referred to in Article 5 paragraph (1) letter c, in the event that the Company's DPM is provided by the Other Company.

Sixth Section
Role of Digital Service Provider Companies

Article 38
(1) The role of digital service provider companies as referred to in Article 33 paragraph (1) letter e is conducted for the purpose of cooperation in the provision of information systems in the implementation of Health Insurance Products. (2) Cooperation with digital service provider companies as referred to in paragraph (1) must be embodied in a cooperation agreement which must at least contain:
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; e. obligation of the parties to maintain data confidentiality; f. dispute resolution between both parties; g. conditions and procedures for changing the agreement; h. force majeure;
i. conditions causing the termination of the agreement;
j. settlement of rights and obligations of each party upon termination of the agreement; and k. commitment to mutually maintain data confidentiality as regulated in legislation regarding personal data protection.

Seventh Section
Role of Other Parties Providing DPM

Article 39
(1) The role of other parties providing DPM as referred to in Article 33 paragraph (1) letter f is conducted for the purpose of cooperation in the provision of DPM services in the implementation of Health Insurance Products. (2) Cooperation with other parties providing DPM as referred to in paragraph (1) must be embodied in a cooperation agreement which must at least contain:
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; e. obligation of the parties to maintain data confidentiality; f. dispute resolution between both parties; g. conditions and procedures for changing the agreement; h. force majeure;
i. conditions causing the termination of the agreement;
j. settlement of rights and obligations of each party upon termination of the agreement; and k. commitment of the other party providing DPM to provide DPM function services as referred to in Article 5 paragraph (1) letter c.

Eighth Section
Administrative Sanctions

Article 40
(1) Violations of the provisions as referred to in Article 34 paragraph (2), Article 35 paragraph (2), Article 36 paragraph (2), Article 37 paragraph (2), Article 38 paragraph (2), and/or Article 39 paragraph (2) shall be subject to administrative sanctions in the form of:
a. written warning; b. prohibition on marketing Health Insurance Products; and/or
c. downgrade of health status.
(2) In the event that violations of the provisions as referred to in paragraph (1) occur and the violation has been remedied, the Financial Services Authority shall impose a written warning sanction that terminates automatically. (3) In the event that violations of the provisions as referred to in paragraph (1) letters a and b have been fulfilled, the Financial Services Authority shall revoke the administrative sanction.

Article 41
Regarding violations of administrative sanction provisions as referred to in Article 40 paragraph (1), the Financial Services Authority may conduct a re-evaluation of the Principal Parties of the Company in accordance with the Financial Services Authority Regulation regarding re-evaluation for principal parties of financial service institutions.

CHAPTER VII
COORDINATION AMONG INSURANCE ORGANIZERS
First Section
General

Article 42
(1) Companies must prioritize the implementation of KAPJ.
(2) KAPJ as referred to in paragraph (1) is conducted through mechanisms for benefit arrangement and claim payment sharing between the Company and BPJS Kesehatan and other insurance organizers to ensure efficiency in health service financing.

Article 43
(1) Health Insurance Products must contain features that enable the implementation of KAPJ as referred to in Article 42 paragraph (1).
(2) KAPJ as referred to in paragraph (1) between the Company and BPJS Kesehatan and other insurance organizers is conducted by applying prudent principles and adequate risk management, and in accordance with relevant regulations.

Article 44
Companies are required to:
a. develop internal policies and procedures for the implementation of KAPJ; and b. ensure that all implementation of KAPJ as referred to in letter a is carried out in accordance with the Company's internal policies and procedures.

Second Section
Administrative Sanctions

Article 45
(1) Violations of the provisions as referred to in Article 42 paragraph (1), Article 43 paragraph (1), and/or Article 44 shall be subject to administrative sanctions in the form of:
a. written warning; b. prohibition on marketing Health Insurance Products; and/or
c. downgrade of health status.
(2) In the event that violations of the provisions as referred to in paragraph (1) occur and the violation has been remedied, the Financial Services Authority shall impose a written warning sanction that terminates automatically. (3) In the event that violations of the provisions as referred to in paragraph (1) letters a and b have been fulfilled, the Financial Services Authority shall revoke the administrative sanction.

Article 46
Regarding violations of administrative sanction provisions as referred to in Article 45 paragraph (1), the Financial Services Authority may conduct a re-evaluation of the Principal Parties of the Company in accordance with the Financial Services Authority Regulation regarding re-evaluation for principal parties of financial service institutions.

CHAPTER VIII
CONSUMER PROTECTION

Article 47
Companies apply consumer and society protection principles in accordance with regulations regarding consumer and society protection in the financial service sector.

CHAPTER IX
ROLE OF INSURANCE COMPANIES IN HEALTH EDUCATION AND PROMOTION

Article 48
Companies must:
a. have programs to encourage Policyholders, Insured Persons, or Participants to adopt healthy lifestyles; and b. actively conduct health education to increase public awareness to maintain health.

CHAPTER X
OTHER PROVISIONS

Article 49
(1) The Financial Services Authority may grant approval or different policies based on certain considerations that differ from this Financial Services Authority Regulation. (2) Provisions in this Financial Services Authority Regulation are excluded for the national health insurance program.

CHAPTER XI
TRANSITIONAL PROVISIONS

Article 50
Upon the commencement of this Financial Services Authority Regulation:
a. 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 prior to the commencement of this Financial Services Authority Regulation with the provisions in this Financial Services Authority Regulation no later than 1 (one) year since this Financial Services Authority Regulation was promulgated; b. Companies that have conducted health insurance business lines prior to the commencement of this Financial Services Authority Regulation are required to obtain approval from the Financial Services Authority no later than 1 (one) year since this Financial Services Authority Regulation was promulgated.

CHAPTER XII
CLOSING PROVISIONS

Article 51
Upon the commencement of this Financial Services Authority Regulation, provisions of the Financial Services Authority regarding the implementation of health insurance products are repealed and declared invalid.

Article 52
This Financial Services Authority Regulation commences its legal effect 3 (three) months since the date of promulgation.

In order that everyone knows it, it is ordered to promulgate this Financial Services Authority Regulation by placing it in the State Gazette of the Republic of Indonesia.

Established in Jakarta on 17 December 2025
CHAIRMAN OF THE COMMISSIONERS COUNCIL
FINANCIAL SERVICES AUTHORITY
REPUBLIC OF INDONESIA,

MAHENDRA SIREGAR

Promulgated in Jakarta on [Date]
MINISTER OF LAW OF THE REPUBLIC OF INDONESIA,

SUPRATMAN ANDI AGTAS

STATE GAZETTE OF THE REPUBLIC OF INDONESIA YEAR 2025 NUMBER [Number]

EXPLANATION
OF
FINANCIAL SERVICES AUTHORITY REGULATION
OF THE REPUBLIC OF INDONESIA
NUMBER 36 OF 2025
REGARDING
STRENGTHENING THE HEALTH INSURANCE ECOSYSTEM

I. GENERAL
In order to strengthen the national health insurance ecosystem, the Financial Services Authority issues the Financial Services Authority Regulation on Strengthening the Health Insurance Ecosystem. This Financial Services Authority Regulation is issued to strengthen governance and risk management, and to encourage more rational and sustainable health insurance practices. This regulation is also expected to strengthen synergy among all stakeholders in the health insurance ecosystem, including Companies, healthcare providers, and Policyholders, Insured Persons, or Participants, so that an effective, efficient, and consumer-oriented system is created. Strengthening prudent principles and risk management by Companies is also an important part of efforts to strengthen the governance and resilience of the national health insurance industry. This is important in driving operational efficiency, improving service quality, and ensuring the sustainability of long-term benefits for Policyholders, Insured Persons, or Participants of health insurance. Such strengthening needs to be accompanied by the formation of regulations that are appropriate with the development of needs and risks faced by the health insurance sector. The formation of such regulations is one of the efforts to rectify the health insurance ecosystem. Ultimately, the issuance of this Financial Services Authority Regulation becomes a strategic step to ensure that the national health insurance industry remains stable, healthy, and able to support the sustainability of the health financing system in Indonesia. Generally, this Financial Services Authority Regulation regulates mechanisms for conducting the health insurance business line and Health Insurance Products, risk management management in conducting the health insurance business line, Utilization Review mechanisms, roles of parties in strengthening the health insurance ecosystem, coverage of KAPJ, and the role of Companies in health education and promotion.

II. ARTICLE BY ARTICLE EXPLANATION

Article 1
Clear enough.

Article 2
Clear enough.

Article 3
Letter a
Clear enough.

Letter b
Healthcare Facility Associations include, among others, the Indonesian Hospital Association and the Indonesian Private Hospital Association.

Letter c
Other insurance organizers include, among others, BPJS Ketenagakerjaan, PT Taspen (Persero), PT Asabri (Persero), and PT Jasa Raharja (Persero).

Letter d
Professional associations in the health field include, among others, the Indonesian Medical Council, the Association of Doctors for Social Security Financing and Insurance Indonesia, and the Association of Experts in Health Insurance and Health Insurance Management Indonesia.

Letter e
Other agencies include, among others, the Ministry of Finance.

Article 4
Clear enough.

Article 5
Paragraph (1)
Clear enough.

Paragraph (2)
What is meant by "approval of the Financial Services Authority" is in the context of implementing Health Insurance Products for the first time. The assessment conducted by the Financial Services Authority includes, among others, fulfillment of medical capabilities, digital capabilities, and DPM capabilities.

Article 6
Paragraph (1)
Letter a
Utilization Review is known by the term utilization review.

Letter b
Clear enough.

Paragraph (2)
Clear enough.

Paragraph (3)
Clear enough.

Article 7
Paragraph (1)
Letter a
Clear enough.

Letter b
Clear enough.

Letter c
Clear enough.

Letter d
Clear enough.

Letter e
Fraud in the health insurance field includes, among others, fictitious insurance claims.

Letter f
Clear enough.

Paragraph (2)
Clear enough.

Paragraph (3)
Clear enough.

Paragraph (4)
Clear enough.

Article 8
Paragraph (1)
Clear enough.

Paragraph (2)
What is meant by "other parties" is parties that have the capability to provide DPM.

Paragraph (3)
Clear enough.

Article 9
Clear enough.

Article 10
Clear enough.

Article 11
Clear enough.

Article 12
Not included in the scope of health insurance are insurance products with additional health benefits, for example, travel insurance products and motor vehicle insurance products that have additional health or accidental death benefits.

Article 13
Paragraph (1)
Letter a
Health Insurance Products with the principle of indemnity are known by the term indemnity.
What is meant by "Health Insurance Products with the principle of indemnity" is the reimbursement of medical care costs with maximum reimbursement charged by Healthcare Facilities and paid by the Company in accordance with the limit set in the Insurance Policy.

Letter b
Health Insurance Products with managed care schemes are known by the term managed care.
What is meant by "Health Insurance Products with managed care schemes" is health services with hierarchical and structured referrals according to medical needs that

starting from Health Service Facilities that provide basic/general health services, up to Health Service Facilities that provide specialist and sub-specialist health services.

Paragraph (2)
Letter a
Health Insurance Products with a maximum cost limit per benefit are known as the term "inner limit".
What is meant by "Health Insurance Products with a maximum cost limit per benefit" is Health Insurance Products that provide coverage for care costs with separate benefit limits for each type of guaranteed care cost. Example:
There are surgery costs amounting to Rp10,000,000.00 (ten million rupiah), general doctor consultation costs amounting to Rp250,000.00 (two hundred fifty thousand rupiah), and other care costs amounting to Rp5,000,000.00 (five million rupiah). In this case, the Company will provide limits according to each action listed in the benefit table of the Insurance Product. If the aforementioned costs exceed the regulations, the cost difference will be borne by the Policyholder, Insured, or Participant.

Letter b
Health Insurance Products according to the bill are known as the term "as charged".
What is meant by "Health Insurance Products according to the bill" is Health Insurance Products that provide reimbursement for medical care costs according to the bill with an annual value limit (annual limit) and/or a lifetime value limit (life limit). Generally, Health Insurance Products according to the bill in Indonesia only have an annual value limit (annual limit), but can also apply a life limit for long-term health products. Example of application for Health Insurance Products that have both annual limit and life limit, for example, Health Insurance Product A provides medical cost reimbursement with a maximum total annual value of Rp100,000,000.00 (one hundred million rupiah) and a lifetime value limit of Rp500,000,000.00 (five hundred million rupiah). In this case, when a Policyholder, Insured, or Participant has accumulated claims in previous years amounting to Rp450,000,000.00 (four hundred fifty million rupiah), then medical cost reimbursement this year is at most Rp50,000,000.00 (fifty million rupiah) even though the annual limit is Rp100,000,000.00 (one hundred million rupiah).

Paragraph (3)
Letter a
What is meant by "promotive" is activities that are health promotion or health education in nature.

Letter b
What is meant by "preventive" is prevention against a disease.

Letter c
What is meant by "curative" is treatment for curing disease.

Letter d
What is meant by "rehabilitative" is recovery.

Letter e
What is meant by "palliative" is special medical care to improve the quality of life of patients and patient families suffering from chronic and incurable diseases.

Article 14
Paragraph (1)
Waiting period is known as the term "waiting period".
What is meant by "waiting period" is a certain period of time that must be passed by the Policyholder, Insured, or Participant since the Insurance Policy becomes effective, where the Policyholder, Insured, or Participant is not yet entitled to submit claims or certain insurance benefits.

Paragraph (2)
Is clear enough.

Paragraph (3)
Is clear enough.

Paragraph (4)
Is clear enough.

Paragraph (5)
Is clear enough.

Paragraph (6)
Letter a
Is clear enough.

Letter b
Emergency conditions caused by force majeure are known as the term "force majeure".
What is meant by "emergency conditions caused by force majeure" is health services for emergency conditions caused by unexpected events that occur outside human control, such as emergencies due to natural disasters, terrorist attacks, and others.

Article 15
Is clear enough.

Article 16
Is clear enough.

Article 17
Is clear enough.

Article 18
Is clear enough.

Article 19
Is clear enough.

Article 20
Paragraph (1)
Conditions of the Policyholder, Insured, or Participant that already exist before coverage are known as the term "pre-existing condition".

Paragraph (2)
Is clear enough.

Paragraph (3)
Is clear enough.

Article 21
Paragraph (1)
Setting Premium or Contribution again is known as the term "repricing".
Repricing can be done including due to the aging of the Policyholder, Insured, or Participant.
What is meant by 1 (one) year is 1 (one) year of Insurance Policy coverage.

Paragraph (2)
Explanation of alternatives provided specifically for the Policyholder, Insured, or Participant, is an explanation regarding alternative options for Health Insurance Products or modifications of existing Health Insurance Products with more affordable Premium or Contribution rates compared to the Premium or Contribution repricing rate. Example of modification of an existing Health Insurance Product is by adding risk sharing portions or reducing benefits.

Paragraph (3)
Example:
The Company sells Health Insurance Products to the Policyholder, Insured, or Participant with a coverage period starting from April 1, 2025 to March 31, 2026. The Company plans to conduct repricing on December 31, 2025, then the Company is required to submit written notice to the Policyholder, Insured, or Participant no later than December 1, 2025.

Article 22
Is clear enough.

Article 23
Example:
In a Health Insurance Product that has received approval from the Financial Services Authority, the Company sets an assumption of profit margin at 8% (eight percent). During the running coverage period, this Health Insurance Product generates a very small profit margin below the initial margin assumption or tends to generate losses. Due to this condition, the Company may only set Premium or Contribution again (repricing) at the time of Insurance Policy renewal, which results in the highest profit margin of 8% (eight percent) according to the initial profit margin assumption.

Article 24
Paragraph (1)
Risk sharing is known as the term "risk sharing".

Paragraph (2)
Is clear enough.

Paragraph (3)
Letter (a)
Is clear enough.

Letter (b)
The imposition of a certain amount (deductible) is applied annually and the deductible value can be applied differently for outpatient and inpatient care.
Illustration of risk sharing and deductible application:
Product 1: no risk sharing
Product 2: risk sharing of 5% (five percent) per claim submission Product 3: risk sharing of 5% (five percent) per claim submission and annual deductible of Rp5,000,000.00 (five million rupiah) Product 4: annual deductible of Rp5,000,000.00 (five million rupiah) A Policyholder submits claims 4 (four) times in the same year.

Claim	Insurer	Policyholder
Product 1
Inpatient Total Rp 10,000,000.00	10,000	0
Product 2
Inpatient Total Rp 10,000,000.00	9,500	500
Inpatient Total Rp 50,000,000.00	47,500	2,500
Inpatient Total Rp 100,000,000.00	97,000	3,000*
Outpatient Total Rp 5,000,000.00	4,750	250
Product 3
Inpatient Total Rp 10,000,000.00	9,500	500
Inpatient Total Rp 50,000,000.00	47,500	2,500
Inpatient Total Rp 100,000,000.00	98,000	2,000
Outpatient Total Rp 5,000,000.00	5,000	0
Product 4
Inpatient Total Rp 10,000,000.00	5,000	5,000
Inpatient Total Rp 50,000,000.00	50,000	0
Inpatient Total Rp 100,000,000.00	100,000	0
Outpatient Total Rp 5,000,000.00	5,000	0

Note:
*3,000 because the maximum risk sharing for the Policyholder for inpatient care is Rp3,000,000.00 (three million rupiah).
2,000 because the maximum annual deductible is Rp5,000,000.00 (five million rupiah) and before this claim the Policyholder had already paid a total of Rp3,000,000.00 (three million rupiah). So for this claim, the Policyholder pays at most Rp2,000,000.00 (two million rupiah).

Paragraph (4)
See explanation of Article 14 paragraph (6) letter b.

Paragraph (5)
The comparison of Premium or Contribution prices for products that apply risk sharing features and without risk sharing features can be applied by presenting a comparison of Premium or Contribution prices on different Health Insurance Products or within the same Health Insurance Product feature.

Article 25
Paragraph (1)
Is clear enough.

Paragraph (2)
Considerations for implementing health examinations for prospective Policyholders, Insured, or Participants include among others standard operating procedures owned by the Company regarding the implementation of health examinations. What is meant by "health examination" is a medical check-up that refers to age and the results of health questionnaires filled out by prospective Policyholders, Insured, or Participants.

Article 26
Is clear enough.

Article 27
Is clear enough.

Article 28
Is clear enough.

Article 29
Paragraph (1)
Is clear enough.

Paragraph (2)
Is clear enough.

Paragraph (3)
Letter a
What is meant by "input standards at Health Service Facilities" covers various aspects that form the basis of operational and service quality. This input includes human resources (health personnel), facilities and infrastructure (physical facilities, medical equipment, medicines), systems and procedures supporting services, as well as data and information used in services, such as patient medical records and other related standards.

Letter b
What is meant by "health service process standards" is a series of rules and procedures established to ensure that health services are delivered with quality, efficiency, and effectiveness, for example, clinical pathways and medical efficacy.

Letter c
What is meant by "health quality output standards for the Insured or Participant" refers to benchmarks or criteria used to measure and evaluate the results or impact of health interventions on Insured or Participants receiving health services.

Article 30
Paragraph (1)
In the event that a doctor has a health insurance expertise certificate, Utilization Review can be conducted by that doctor.

Paragraph (2)
Is clear enough.

Paragraph (3)
Is clear enough.

Paragraph (4)
Letter a
What is meant by "evaluation of suitability and needs for services provided with clinical pathways" is the process of assessing the suitability of medical services provided to the Policyholder, Insured, or Participant against established clinical procedure standards in order to improve the effectiveness and efficiency of medical services.

Letter b
What is meant by "evaluation of suitability and needs for drug efficacy" is the assessment process to ensure that drugs prescribed to the Policyholder, Insured, or Participant are in accordance with medical needs.

Article 31
Is clear enough.

Article 32
Is clear enough.

Article 33
Is clear enough.

Article 34
Is clear enough.

Article 35
Is clear enough.

Article 36
Is clear enough.

Article 37
Is clear enough.

Article 38
Is clear enough.

Article 39
Is clear enough.

Article 40
Is clear enough.

Article 41
Is clear enough.

Article 42
Paragraph (1)
What is meant by "prioritizing the implementation of KAPJ" is prioritizing the existence of KAPJ as an effort to ensure optimal benefits for the Insured or Participant, prevent benefit duplication, optimize efficiency, and ensure certainty and fairness in service delivery, among others, there is a cooperation agreement between the Company and BPJS Kesehatan and/or Health Service Facilities.

Paragraph (2)
Is clear enough.

Article 43
Paragraph (1)
Is clear enough.

Paragraph (2)
What is meant by "related regulations" includes among others regulations regarding guidelines for implementing the payment of cost differences by additional health insurance through KAPJ.

Article 44
Is clear enough.

Article 45
Is clear enough.

Article 46
Is clear enough.

Article 47
Is clear enough.

Article 48
Programs to encourage the application of healthy lifestyle patterns include among others conducting literacy activities or providing incentives in the form of no claim bonus.

Article 49
Paragraph (1)
The granting of different approvals or policies is intended among others for:
a. supporting national policies; b. maintaining public interests;
c. maintaining industry growth; and/or
d. maintaining healthy business competition.
Example of conditions requiring specific consideration, among others, extraordinary events that can cause a large increase in morbidity and mortality and also impact the economy and society, thus requiring attention and handling by all relevant parties and regulated in other regulations regarding considerations in facing possible extraordinary events.

Paragraph (2)
Is clear enough.

Article 50
Is clear enough.

Article 51
Is clear enough.

Article 52
Is clear enough.

SUPPLEMENT TO THE STATE GAZETTE OF THE REPUBLIC OF INDONESIA NUMBER ⸙ ---