LEGAL UPDATE ON THE ISSUANCE OF FINANCIAL SERVICES AUTHORITY REGULATION NUMBER 36 OF 2025 CONCERNING THE STRENGTHENING OF THE HEALTH INSURANCE ECOSYSTEM

Financial Services Authority (Otoritas Jasa Keuangan “OJK”) has issued Financial Services Authority Regulation Number 36 of 2025 concerning the Strengthening of the Health Insurance Ecosystem (“POJK 36/2025”), which substantively enhances and consolidates regulatory provisions previously governed under OJK Circular Letter Number 7/SEOJK.05/2025 concerning Administration of Health Insurance Products (“SEOJK 7/2025”).

POJK 36/2025 updates the regulatory framework for health insurance products by emphasizing the provision of actual protection to policyholders and formally introducing the concept of Coordination Among Benefit Providers (Koordinasi Antar Penyelenggara Jaminan “KAPJ”), involving insurance companies, BPJS Kesehatan, and/or other guarantee providers in delivering health care benefits. The regulation also affirms OJK’s role in coordinating with relevant ministries, healthcare facility associations, professional organizations, and other institutions to support a stable and sustainable health insurance ecosystem.

Compared to SEOJK 7/2025, POJK 36/2025 imposes more stringent requirements on insurance companies conducting health insurance business activities, including (i) mandatory medical capability, (ii) digital capability, and (iii) the establishment or appointment of a Medical Advisory Board (Dewan Penasihat Medis “DPM”), as explained in detail below.

1. Adequate medical capability at the minimum includes: (a) medical personnels with qualifications of doctors who conduct analysis of medical actions and utilization review, and (b) human resources who hold a health insurance expertise certificate with a level at least 1 (one) level below the highest qualification, from a professional certification institution in the insurance sector registered with the OJK
2. Digital capability is evidenced by the ownership of an information system, which shall fulfill at least the following provisions:     

   a.     capable in conducting digital data exchange with healthcare service facilities;

   b.     capable in providing access to membership data;

   c.   capable in providing data containing services and medical resumes, including pharmaceutical services and medical devices, provided to policyholders, insured parties, or participants;

   d.     capable in providing data on claims paid for each policyholder, insured party, or participant;

   e.     capable in supporting electronic data processing, storage, and security to prevent potential fraud in the health insurance sector; and

   f.       supported by a database.

3. Adequate DPM capability is evidenced by the ownership of a DPM consisting of a group of specialist doctors with specific expertise required by the company in the implementation of the health insurance business line.

Prior approval from OJK is required before commencing health insurance business activities, and digital capability may be fulfilled either through internal systems or through cooperation with third parties.

POJK 36/2025 introduces more clear rules on the classification of health insurance products, waiting periods (for individual health insurance products), premium or contribution adjustments, and policy transparency. Companies that market individual health insurance products may apply a waiting period, subject to the following provisions:

1. maximum of 30 (thirty) calendar days; and/or
   
2. maximum of 6 (six) months for individual health insurance products that provide benefits for critical, chronic, and/or specific illnesses as clearly stated in the insurance policy.

Premium or contribution adjustments are limited to once per year and must be supported by prior written notification and internal policies. Insurance companies are also required to prepare policy summaries to ensure that prospective policyholders and participants have a clear understanding of coverage and benefits.

The regulation further limits the application of risk-sharing mechanisms in health insurance products, generally requiring products to be offered without risk sharing. In addition, POJK 36/2025 strengthens medical governance through mandatory utilization review processes conducted by qualified medical professionals to ensure the appropriateness and effectiveness of healthcare services.

POJK 36/2025 also formalizes cooperation among insurance companies, healthcare facilities, Third Party Administrators, BPJS Kesehatan, and other DPM service providers through written cooperation agreements and internal policies, and the roles of those parties.

To ensure compliance, the regulation introduces a comprehensive administrative sanctions regime and provides a one-year transitional period for insurance companies to align existing products and obtain the required approvals. POJK 36/2025 will enter into force 3 (three) months after its promulgation and does not apply to the National Health Insurance program.

Overall, POJK 36/2025 represents a significant shift from the framework under SEOJK 7/2025 toward a more integrated and enforceable regulatory regime.