The 5% co-payment: what you actually pay when you claim on health insurance

In mid 2025, OJK issued a circular setting a 10% co-payment for private health insurance. It drew wide objections and was postponed before it ever applied. It was replaced by OJK Regulation No. 36 of 2025, issued in December 2025 and in force from 22 March 2026.

The trouble is that old headlines about 10% keep circulating. In July 2026 a message saying “using insurance now costs you 10%” went viral, and OJK had to correct it. So if you have seen 10%, that is not the rule today.

A co-payment is the small part of a bill you pay yourself when you claim, while the insurer pays the rest. OJK says the aim is to make healthcare financing more efficient over the long term, as medical costs keep rising.

A co-payment is not a penalty. It is a small share you carry, with a clear ceiling.

The rule is simple: 5% of the claimed bill, but never more than the cap. The cap is Rp300k for outpatient and Rp3m for inpatient, per claim.

Three more examples. A doctor visit billed at Rp1m: you pay Rp50k. A hospital stay of Rp20m: you pay Rp1m. A hospital stay of Rp80m: 5% would be Rp4m, but the cap means you pay Rp3m. The bigger the bill, the more the cap matters.

One important note: the co-payment applies to costs the policy actually covers. Anything above your limits, outside your benefits or excluded is still yours to pay separately, just as it was before this rule. That is why limits and exclusions remain the first thing to understand.

The new rule requires insurers to keep offering products without co-payment. So the question is not “am I forced into this”, but “which suits me”.

Products with co-payment can usually be priced lower, because you share a small slice of the risk. That makes sense if your emergency fund can comfortably cover up to Rp3m per hospital stay. Products without co-payment tend to cost more, but leave you no share of covered bills. That makes sense if household cash flow is tight, or someone in the family needs care often.

How the new rule applies to policies already in force can differ by product and insurer, especially for policies that renew every year. The safest route: check your policy summary, or ask your insurer or agent directly whether your policy has a co-payment feature and when the new terms apply to it. The rule also requires insurers to give a benefit summary to prospective and existing policyholders, so you are entitled to ask for one.

The second piece of news: OJK is pushing benefit coordination between BPJS Kesehatan and private insurers, called KAPJ (Koordinasi Antar Penyelenggara Jaminan). In early September 2026, five insurers and seven hospital networks became the first to apply it, and OJK aims for every health insurer to join by the end of 2026.

For you, the direction is smoother claims when you use BPJS and private insurance together. It is still rolling out, so ask your insurer whether your policy already supports coordination with BPJS, and at which hospitals.

First, does my policy have a co-payment, and if so, what percentage and what cap? Second, what are my room limit and annual limit, and what is excluded? Third, can my policy be coordinated with BPJS Kesehatan? These three answers matter far more than the co-payment figure itself.

General information, not financial or legal advice, and not a recommendation of any product. Co-payment terms, limits and exclusions vary by product. Speak to a licensed adviser or your insurer before deciding.