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When you incur high medical care costs

Your copayment for medical care costs is capped. If your copayment calculated based on certain standards exceeds the maximum, the excess amount will be paid as “High-Cost Medical Care Benefits”.

If you incur high medical care costs, statutory and non-statutory programs (e.g., High-Cost Medical Care Benefits, Patient Cost-Sharing Reimbursements) are available to reduce your copayment below the standard 30% (20% for family members under six years of age).

  • i. No action is needed to use the above programs. The amount calculated automatically by the computer system will be refunded about three months after the month of examination or treatment.
    A sealed postcard will be sent by post to the insured person's home address in the latter third of the month in which these benefits are paid, as both notice of payment details and proof of payment.
  • ii. The amount you are required to pay at the medical care institution out of pocket (advance payment) may be significant for cases involving high medical care costs. You can reduce this amount in line with certain rules by submitting a Certificate of Application of Maximum Copayment Amount.
INDEX

High-Cost Medical Care Benefits (for dependents, “Dependents' High-Cost Medical Care Benefits”)

If the copayment amount for medical care costs paid at the reception desk of the hospital becomes high, the Health Insurance Society will pay the amount beyond a certain figure later (the Cost-Sharing Maximum Amount) to help ease the burden of medical care costs. This is referred to as “High-Cost Medical Care Benefits” (for dependents, “Dependents' High-Cost Medical Care Benefits”).

High-Cost Medical Care Benefits are calculated for medical care costs incurred over a one-month period, from the first through the last day of the month. High-Cost Medical Care Benefits are also calculated on a per-person, per-hospital (outpatient/inpatient, medical/dental, etc.) basis.

If you want to make sure the amount you pay at the reception desk of the hospital will not exceed the Cost-Sharing Maximum Amounts

If a person under 70 years of age expects to incur high medical care costs, it can be more convenient to obtain “Request for Certificate of Limited Amount Authorization for Health Insurance” in advance. By showing this “Request for Certificate of Limited Amount Authorization for Health Insurance” to the medical care institution together with your health insurance card, you can ensure that the amount of medical care costs for which the hospital bills you (per month) will not exceed the Cost-Sharing Maximum Amount and reduce the amount of medical care costs you must pay at the hospital on any single visit (You can use this certificate for both inpatient and outpatient care).

Prior application required

“Request for Certificate of Limited Amount Authorization for Health Insurance” is used to confirm your income category. You must apply to the Health Insurance Society in advance for this Certificate.

When you use a Myna health insurance card, you will be exempt from payment in excess of the maximum copayment amount under the High-Cost Medical Care Benefits system without any prior procedures.
We recommend using a Myna health insurance card. Using this card will eliminate the need to apply in advance for a Certificate of Application of Maximum Copayment Amount.

Reference link
When you incur high medical care costs「When you want to reduce the amount of medical care costs you pay at the medical care institution」
Reference link
You can use your My Number Card as a health insurance card

Caution：

Note that those aged 70 and older falling in the category of the same income level as active workers II or active workers I will also need to submit a Certificate of Application of Maximum Copayment Amount to avoid paying more than the cost-sharing maximum amount.

How High-Cost Medical Care Benefits are calculated

Additional benefits/Patient Cost-Sharing Reimbursements and Additional Benefits, etc. from the Society

If the copayment you made at an Insurance Medical Care Facility exceeded the “Final copayment” in Appendix 1, the Health Insurance Society will reimburse the amount by which it exceeded the final copayment amount minus the amount of High-Cost Medical Care Benefits (rounded down to the nearest 10 yen), as Patient Cost-Sharing Reimbursements and Additional Benefits, etc., an additional benefit from the Society. (This benefit will not be paid if the amount calculated is less than 100 yen.) In addition, even if the case does not qualify for High-Cost Medical Care Benefits, if the copayment you made at the medical care facility exceeded the “Final copayment” in Appendix 1, the Society will reimburse the amount by which it exceeded the final copayment amount as Patient Cost-Sharing Reimbursements and Additional Benefits, etc. Note that in both cases, benefits are calculated for each month from the first through the last day of the month on a per-person and per-hospital basis (but separately for outpatient/inpatient and medical/dental care).

Appendix 1: Final copayment amounts for Patient Cost-Sharing Reimbursements and Additional Benefits, etc.
Category Standard monthly remuneration Final copayment
Persons with high income A 830,000 yen or more 60,000 yen
Persons with high income B 530,000–790,000 yen 30,000 yen
Persons with general income Up to 500,000 yen 20,000 yen

Cost-Sharing Maximum Amounts for Total High-cost Medical Care Benefits

Insured persons and dependents under 70 years of age
Category Individual cost-sharing maximum amounts
830,000 yen or more
of standard monthly remuneration		 60,000 yen
530,000 yen - 790,000 yen
of standard monthly remuneration		 30,000 yen
280,000 yen - 500,000 yen
of standard monthly remuneration		 20,000 yen
Insured persons and dependents aged 70 and older
Category Individual cost-sharing maximum amounts
830,000 yen or more
of standard monthly remuneration		 60,000 yen
530,000 yen - 790,000 yen
of standard monthly remuneration		 30,000 yen
280,000 yen - 500,000 yen
of standard monthly remuneration		 20,000 yen

If actual copayment is less than the amount corresponding to the patient cost-sharing, the actual copayment will be deducted.

When your copayment is reduced still further

You can combine copayments for an entire household (Total High-cost Medical Care Benefits)

Even when the copayment for one case for one month is less than the maximum, if members of the same household have made copayments of 21,000 yen or more multiple times in the same month, they can combine those amounts for the purposes of the Cost-Sharing Maximum Amount.
If the total amount exceeds the Cost-Sharing Maximum Amount, then the excess amount is paid by the Health Insurance Society as “Total High-cost Medical Care Benefits”.

Using its own independent benefits (additional benefits), the Health Insurance Society can reduce copayments still further (Additional Total High-cost Medical Care Benefits).

Additional Total High-cost Medical Care Benefits
(insured persons, family members)

If you receive Total High-cost Medical Care Benefits, you will also be reimbursed for the total amount of your copayment for high-cost medical care (excluding Total High-cost Medical Care Benefits and the standard amounts for impatient meal and living expenses), minus the amount corresponding to your insured category in Appendix 1 above per person (rounded down to the nearest 10 yen). (This benefit will not be paid if the amount calculated is less than 100 yen.)
This payment is calculated and made automatically based on the medical cost details sent by the hospital to the Health Insurance Society. Note that payment will occur roughly three months after the month of the medical care.

  • ** If public expenditures are considered to be used for medical care, payment of these additional benefits will be suspended. In such cases, notify the Health Insurance Society if you are unable to receive benefits from your municipal government. The benefits will be paid after reviewing copies of your receipts and other documentation.

The Cost-Sharing Maximum Amount will be reduced for frequent qualification of expenditures.

If a single household qualifies for High-Cost Medical Care Benefits three or more months in a single year (the most recent 12 months), the Cost-Sharing Maximum Amount will be reduced to the amount of the table below starting with the fourth month.

Standard monthly remuneration Individual cost-sharing maximum amounts
830,000 yen or more 140,100 yen
530,000 yen - 790,000 yen 93,000 yen
280,000 yen - 500,000 yen 44,400 yen
260,000 yen or less 44,400 yen

Those receiving treatment for specified diseases and disorders

The amount paid to the medical care institution will not exceed 10,000 yen per month for patients with haemophilia, patients with AIDS receiving antiviral drugs, and patients with chronic nephritis who require artificial dialysis for an extended period, if they have been certified as having specified diseases and disorders.
However, if a patient requiring artificial dialysis and under 70 years of age qualifies as a person with 530,000 yen or more of standard monthly remuneration, his or her copayment will be 20,000 yen/month.
If you are eligible, apply for issue of Certificates Issued for Specific Disease Treatment.

If copayments for medical care and long-term care are high

When people in the same household pay copayments for both medical care and long-term care and the total copayment amount paid by the household over a one-year period (August 1 of the previous year to July 31) exceeds the maximum amount below, the excess amount is paid by health insurance and by long-term care insurance as “High Aggregate Cost for Long-term Care Services”.

  • ** The benefit will not be paid when the amount in excess of the maximum is 500 yen or less.
  • ** For persons less than 70 years of age, this applies if each copayment for medical care costs is 21,000 yen or more.

Cost-Sharing Maximum Amount

Category Private households
with household members
aged under 70		 Private households
with household members
aged 70-74
830,000 yen or more
of standard monthly remuneration		 2,120,000 yen
530,000 yen - 790,000 yen
of standard monthly remuneration		 1,410,000 yen
280,000 yen - 500,000 yen
of standard monthly remuneration 		670,000 yen
260,000 yen or less
of standard monthly remuneration		 600,000 yen 560,000 yen

Caution

The right to claim health insurance benefits expires in two years.

There is no frequently asked questions and answers that have been registered.

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