The high-cost medical care benefit ("high medical care cost" for persons 70 and over) can be claimed if the cost-bearing limit of medical expenses exceeds the specified amount for the month (please refer to the question: "How much would my total medical costs be with the high-cost medical care benefit?"). The full amount (30% of medical costs) is paid first and a refund later received.
Only medical fees covered by national health insurance are covered under this system. Hospital meals and other items not covered by the policy (private room, medical certificate, diapers, certain medications) are exempt.
Medical costs are calculated by month, by days of hospitalization or as an outpatient, and by medical institution. Applications can be made up to two years after payment.
As of April 1, 2007, persons under 70 are only required to pay their maximum copayment of high-cost medical expenses incurred during hospitalization at the hospital (this is already in effect with persons 70 and over). Because of this, it is no longer necessary to pay the initial 30% and apply for remuneration, thus greatly reducing payment at the hospital. To be eligible however, a claimant's certificate must first be obtained at a national health insurance office.
The figures for medical costs pertaining to high-cost medical care (or high medical care cost) differ for persons under 70 and those 70 and older.
If the amount paid to a single medical institution is more than 21,000 yen per month, it is regarded as high-cost medical care. In this case, medical and dental care are treated separately, and so are inpatient and outpatient care.
All of your copayments can be combined.
| Persons earning full salaries III |
(Health Insurance) Those whose standard monthly remuneration is 830,000 yen or higher and a copayment ratio of the Elderly Recipient Certificate is 30%. (National Insurance) Those whose taxable income is 6,900,000 yen or higher. |
|---|---|
| Persons earning full salaries II |
(Health Insurance) Those whose standard monthly remuneration is between 530,000 and 790,000 yen and a copayment ratio of the Elderly Recipient Certificate is 30%. (National Insurance) Those whose taxable income is 3,800,000 yen or higher. |
| Persons earning full salaries I |
(Health Insurance) Those whose standard monthly remuneration is between 280,000 and 500,000 yen and a copayment ratio of the Elderly Recipient Certificate is 30%. (National Insurance) Those whose taxable income is 1,450,000 yen or higher. |
| General income earner | Those who do not fall under the category of “Persons earning full salaries” or “Low-income II”, or “Low-income I”. |
| Low-income II | A head and other members of the household are exempted from inhabitant tax. |
| Low-income I | A head and all other members of the household have no income after necessary deductions are made. |
Calculations for high-cost medical care benefits (high medical care cost for persons aged 70 and over) vary depending on age (under 70 or 70 and older) and household income. As part of the heath insurance reform effective October 1, 2006, cost-bearing limits and calculation methods have been changed.
Your copayment will be the remainder of your calculated high-cost medical care benefit subtracted from the medical facility's invoice (30% of to total medical charges).
| Income level | Monthly cost-bearing limit for medical expenses |
|---|---|
Annual income is about 11,600,000 yen or higher
|
252,600 yen + (Total medical charges - 842,000 yen) x 1% 〈Multiple application: 140,100 yen〉 |
Annual income is approximately more than 7,700,000 yen but less than 11,600,000 yen
|
167,400 yen + (Total medical charges - 558,000 yen) x 1% 〈Multiple application: 93,000 yen〉 |
Annual income is approximately more than 3,700,000 yen but less than 7,700,000 yen
|
80,100 yen + (Total medical charges - 267,000 yen) x 1% 〈Multiple application: 44,400 yen〉 |
Annual income is approximately less than 3,700,000 yen
|
57,600yen 〈Multiple application: 44,400 yen〉 |
| Persons who are exempted from inhabitant tax |
35,400yen 〈Multiple application: 24,600 yen〉 |
[Note] When your payments to a single medical institution (including the cost of external prescription) do not exceed the monthly cost-bearing limit, you can add up your medical charges paid to other institutions in the same month. If the combined amount exceeds the monthly cost-bearing limit, you are eligible for the high-cost medical care benefit. (The total medical expense must be at least 21,000 yen for persons under the age of 70.)
Source: Ministry of Health, Labour and Welfare
| Income level | Monthly maximum copayment limit (per household) |
|---|---|
| III: Annual income is about 11,600,000 yen or higher Standard monthly remuneration is more than 830,000 yen / Taxable income is 6,900,000 yen or higher |
252,600 yen + (Total medical charges - 842,000 yen) x 1% 〈Multiple application: 140,100 yen〉 |
| II: Annual income is approximately more than 7,700,000 yen but less than 11,600,000 yen Standard monthly remuneration is more than 530,000 yen / Taxable income is more than 3,800,000 yen |
167,400 yen + (Total medical charges - 558,000 yen) x 1% 〈Multiple application: 93,000 yen〉 |
| I: Annual income is approximately more than 3,700,000 yen but less than 7,700,000 yen Standard monthly remuneration is more than 280,000 yen / Taxable income is more than 1,450,000 yen |
80,100 yen + (Total medical charges - 267,000 yen) x 1% 〈Multiple application: 44,400円 yen〉 |
| Income level | Outpatient (per individual) | Monthly maximum copayment limit (per household) |
|---|---|---|
| Annual income is approximately between 1,560,000 and 3,700,000 yen Standard monthly remuneration is less than 260,000 yen / Taxable income is less than 1,450,000 yen |
18,000 yen （144,000 yen per year） |
57,600 yen 〈Multiple application: 44,400 yen〉 |
| Income level | Outpatient (per individual) | Monthly maximum copayment limit (per household) |
|---|---|---|
| II. Exempted from Inhabitant tax | Outpatient (per individual)／
8,000 yen |
Monthly maximum copayment limit (per household)／
24,600 yen〈Multiple application not applied〉 |
| I. Exempted from Inhabitant tax (If the only income is pension, 800,000 yen or less.) |
Outpatient (per individual)／
8,000 yen |
Monthly maximum copayment limit (per household)／
15,000 yen〈Multiple application not applied〉 |
[Note] When your payments to a single medical institution (including the cost of external prescription) do not exceed the monthly cost-bearing limit, you can add up your medical charges paid to other institutions in the same month. If the combined amount exceeds the monthly cost-bearing limit, you are eligible for the high-cost medical care benefit.
Source: Ministry of Health, Labour and Welfare
*High-cost medical care costs for outpatients are calculated individually. If the total payment for medical costs exceeds the cost-bearing limit, remunerations will be made upon application to each insurer.
*For inpatients, there is no payment for any amount that exceeds the monthly cost-bearing limit.
When persons using one insurance policy make several medical payments of 21,000 yen or more within one month, and if the grand total of all of these payments meet the requirements for high-cost medical care benefit, an application can be made for a refund.
All of the below qualify for high-cost medical care benefit.
*For persons 70 and over, total copayment of all insured under the same policy, for the same month, will be calculated.
*For procedures regarding the "combined benefit", please refer to Section 1, "Applying for high-cost medical care benefit (normal conditions)" below the question: "What procedures are necessary?"
Applications are accepted at your place of insurance registration.
Application for high-cost medical care benefit can be made after copayment is made in full (30% of medical costs) at a medical facility, by submitting the necessary documents stated in Table 4 below, to your insurance provider. It usually takes about two to three months for the refund to come through.
| What you need | 1. Receipt from medical institution (showing insurance points) 2. Medical insurance certificate 3. Personal seal 4. Bankbook in the name of the insured |
|---|---|
| Place of application |
|
As of April 1, 2007 patients under the age of 70 have the option of paying only their copayment after deduction of high cost medical care benefit, towards hospitalization (in-kind). (This system has previously been established for those 70 and older.)
Persons under 70 and have been hospitalized since April 1, 2007 or plan to be hospitalized.
You must first take your health insurance card to your insurance agency and request coverage for your benefit. After this procedure, you will receive "certification for cost-bearing limit on health insurance," which you must then submit, with your insurance card, to your hospital or other medical facility.
| Place of application |
|
|---|
"Multiple application" refers to situations where one family makes over four payments towards high cost medical care within one year. From the fourth payment, the cost-bearing limit is lowered. The final limit will depend on age, household and income.
When the total amount of copayment of medical insurance and long-term care insurance for one year (from August to July of the next year) exceeds the limit set for each income category in a household with medical insurance, an amount exceeding the limit is paid from the total amount. Copayment of the household members in the same healthcare system can be combined.
Limit amount is set according to the income and age of the insured of a household.
Unitary High-Cost Medical / Long-Term Care Benefit applies to a household under a healthcare insurance system (such as Employees’ Health Insurance, National Health Insurance or Medical Care System for the Elderly aged 75 and over) which has at least one long-term care insurance beneficiary and is eligible for the high-cost care benefit system on application by the insured. When the combined total amount of self-payments of medical insurance and the long-term care insurance for medical expenses exceeds the cost-bearing limit, an amount exceeding the limit is reimbursed.
Submit the application with the receipts of medical care and long-term care services to the local municipality.
| “Medical care system for the elderly aged 75 and over” plus “Long-term care insurance” | Employees’ Health Insurance” or “National Health Insurance” plus “Long-term care insurance (Household with a person who is 70 to 74 years old)” [1]* |
Employees’ Health Insurance” or “National Health Insurance” plus “Long-term care insurance (Household with a person who is under 70 years old)” [2]* |
||
|---|---|---|---|---|
| Persons earning full salaries (high-income earner) |
Ⅲ | 2,120,000 yen | 2,120,000 yen | 2,120,000 yen |
| Ⅱ | 1,410,000 yen | 1,410,000 yen | 1,410,000 yen | |
| Ⅰ | 670,000 yen | 670,000 yen | 670,000 yen | |
| General | 560,000 yen | 560,000 yen | 600,000 yen | |
| Low-income earner | Ⅱ | 310,000 yen | 310,000 yen | 340,000 yen |
| I | 190,000 yen | 190,000 yen | ||
[1]*[2]*: If eligible household is a mixture of a person who is 70 to 74 years old and those under 70, the maximum copayment listed in column [1]* is first applied to the total amount of the self-payment of a person aged 70 to 74. Then, add the remaining amount to the amount of self-payment of a person under 70. Maximum copayment listed in column [2]* is applied to the sum.