Hello Insurance League Friends! Welcome back to the education channel trusted insurance with us, the best place to discuss everything aboutHealth Insurance, risk management, and the latest regulations from OJK. This time, we will review the new rules that have attracted quite a lot of attention, namely the obligation cost sharing 10% in commercial health insurance. What does this policy mean? How does it affect individual participants, companies, and hospitals? And what does it look like?An important role insurance broker in helping you adapt to these changes? Come on, read more in this article!
New Regulation: Mandatory Health Insurance Cost Sharing 10%
In May 2025, OJK issuedSEOJK 7/SEOJK.05/2025 which obliges all participants of commercial health insurance to bear a minimum cost sharing fee 10%of the total cost of medical services. This regulation is expected to increase transparency, prevent abuse of insurance benefits, and maintain the long-term financial stability of insurance companies.
What is Cost Sharing in Health Insurance?
Cost sharing is a system in which insurance participants share part of the costs of service health. There are three forms of cost sharing that are commonly used:
- Deductible: initial costs paid out of pocket before insurance covers the rest.
Co-payment: fixed fee per medical service visit.
Co-insurance: percentage of the total cost (example: 10%) paid by the participant.
Why did OJK issue this Cost Sharing Regulation?
- Increasing transparency and fairness in the health insurance system.
- Controlling moral hazard, namely excessive use of medical services.
- Maintaining the financial sustainability of insurance companies in order to continue to pay claims in the long term.
Impact on Individuals, Companies and Service Providers
For individual participants:
- Must start taking personal costs into account when seeking medical treatment.
- Can no longer rely on full claims from insurance.
For companies/HR:
- It is necessary to socialize this change to employees to prevent misunderstandings.
For hospitals & service providers:
- The claims system needs to be adjusted to automatically calculate participants’ share of costs.
Benefits of Cost Sharing for Insurance Participants
- Premiums are more affordable because the risk is shared.
- Participants are wiser and more responsible in using health services.
- Reducing the potential for abuse of insurance benefits.
Risks and Disadvantages of Cost Sharing
- Additional costs when accessing health services.
- Uncertainty regarding the amount of personal costs.
- Obstacles for participants with limited funds during emergencies.
Tips for Dealing with These Changes
- Study and understand the contents of your policy, especially the sections co-payment, deductible, and claim limits.
- Discuss with your insurance broker to understand the benefit structure.
- Use feature Coordination of Benefit (CoB)with BPJS to reduce personnel costs.
What is Coordination of Benefits (CoB)?
CoB is a cooperation mechanism between BPJS Health and private insurance, where both share the claim burden according to the portion of benefits.
Example:
If the hospital costs IDR 10 million, BPJS covers IDR 6 million, private insurance covers IDR 3 million, and the participant paysco-payment Rp1 jute.
Conditions in order CoB walk:
- Participants must be registered in the CoB system.
- The hospital has integrated CoB.
- Participants must bring their BPJS card and insurance card when seeking treatment.
The Important Role of Insurance Brokers in the Cost Sharing System
As a strategic partner, insurance broker have a critical role in helping clients navigate regulatory changes:
- Analyze client needs and risk profile.
- Develop health insurance programs according to the latest regulations.
- Provide comprehensive education to HR and participants.
- Monitor the claims process to ensure it runs smoothly.
- Conduct annual reviews of benefits to remain efficient and competitive.
Conclusion
SEOJK Regulation 7/2025 has stipulated that10% cost sharing on health insurance is now mandatory. It is important to understand these changes so that participants, companies, and service providers can adapt well.
If you are evaluating a health insurance program for employees or need a recommendation for a policy with optimal benefits,consult with a trusted insurance broker such as L&G Insurance Broker.
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