OJK Regulation Number 36 of 2025 Tightens the Health Insurance Ecosystem and Limits Premium Increases

Introduction

On 17 December 2025, the Financial Services Authority (“OJK”) issued Financial Services Authority Regulation Number 36 of 2025 on the Strengthening of the Health Insurance Ecosystem (“POJK 36/2025”), which will take effect on 22 March 2026. This Regulation aims to strengthen governance, risk management, and effective supervision in order to protect the interests of policyholders, insured parties, or participants. In addition, this Regulation promotes collaboration among stakeholders within the health ecosystem and ensures the stability of a competitive industry.

OJK observes that the provision of health insurance products is closely interconnected with various parties within the ecosystem and therefore requires strengthening to ensure a balanced distribution of benefits. OJK considers that insurance companies must apply more prudent principles and more comprehensive risk management in conducting this line of business. Through POJK 36/2025, OJK seeks to address challenges in medical cost management and to ensure the sustainability of the national health insurance industry.

 

Key Provisions

Obligations of Health Insurance Providers

Companies that conduct health insurance business activities are now required to fulfill three main capabilities, namely medical capability, digital capability, and the capability of the Medical Advisory Board (Dewan Penasihat Medis or “DPM”). Article 6 stipulates that companies must employ medical personnel qualified as physicians for medical analysis and human resources certified in health insurance expertise. Furthermore, Article 7 requires companies to have information systems capable of digital data exchange with healthcare facilities (hospitals/clinics) and to maintain databases for a minimum period of 10 years after the coverage has ended.

Prohibition of Arbitrary Premium Increases (Repricing)

Article 21 prohibits companies from conducting repricing based on claims history or health inflation more than 1 (one) time within 1 (one) year. If a company intends to increase premiums, it must submit a written notification to the policyholder no later than 30 calendar days prior to the effective date, complete with reasons and supporting data. Article 23 also prohibits companies from taking profit margins exceeding the initial assumptions when conducting repricing.

Waiting Period Provisions

Article 14 stipulates that the maximum waiting period is 30 calendar days, or 6 months specifically for critical or chronic diseases. However, Article 15 prohibits the application of a waiting period for individual health insurance products with a short coverage period, namely a maximum of 3 months. These provisions do not apply to emergency conditions resulting from accidents and/or force majeure events.

Risk Sharing Mechanism (Cost Sharing)

Companies are required to provide options for health insurance products without a risk sharing feature. If a customer chooses a product with a risk sharing feature, Article 24 limits the portion of risk borne by the customer to 5% of the total claim. OJK sets the maximum amount payable by the customer under this scheme at IDR 300,000.00 per outpatient claim and IDR 3,000,000.00 per inpatient claim.

Obligation to Conduct Utilization Review

Pursuant to Article 29, companies are required to conduct Utilization Reviews to control costs and maintain quality. A Utilization Review is an evaluation of the appropriateness of the use of medical services (whether medications or treatments are in accordance with medical necessity). This process must involve physicians and health insurance experts and must include an evaluation of the conformity of services with clinical pathways and drug efficacy.

Priority of Coordination with BPJS Kesehatan (KAPJ)

Under Article 42, companies are required to prioritize the implementation of Coordination Among Benefit Providers (Koordinasi Antar Penyelenggara Jaminan or “KAPJ”) with BPJS Kesehatan. This requirement aims to ensure financing efficiency, whereby private health insurance products must include features that enable coordination of claim payments with BPJS Kesehatan.

 

Sanctions

Under Article 10, Article 17, Article 27, Article 31, Article 40, and Article 45, violations of the provisions of POJK 36/2025 may be subject to administrative sanctions in the form of written warnings, prohibition on marketing Health Insurance Products, and/or a downgrade in the company’s soundness rating.

In addition to these general sanctions, Article 10 (2) stipulates an administrative fine of IDR 100,000,000.00 (one hundred million rupiah) for companies that conduct health insurance business activities without first obtaining approval from OJK. Furthermore, OJK is authorized to conduct a re-assessment of Key Parties (such as the Board of Directors and the Board of Commissioners) in the event of violations of administrative sanction provisions, which may affect their fitness and propriety to lead a financial services company.

 

Transitional Provisions

Article 50 stipulates that companies that already have health insurance products prior to 22 March 2026 are required to adjust such products no later than 22 December 2026. Likewise, companies that are already conducting health insurance business activities are required to obtain renewed approval from OJK regarding the fulfillment of the required capabilities (medical, digital, and DPM) no later than 22 December 2026.

 

Closing

POJK 36/2025 requires a fundamental transformation of the health insurance industry through the enhancement of medical and digital capability standards, more transparent premium controls, and stronger consumer protection. For businesses, this Regulation entails the obligation to promptly adjust infrastructure and products, where failure to comply will have direct consequences in the form of sanctions ranging from written warnings and prohibition on the marketing of health insurance products to a re-assessment of the fitness and propriety of company management.