Chugoku-Shikoku Regional AIDS Center

3.Other medical payment services

High-cost medical care benefit

What is the high-cost medical care benefit? (As of August 2018)

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.

>>Ministry of Health, Labour and Welfare Issue in Kind of High-cost Medical Care Benefit for Persons Under 70 (pdf)

How much would my total medical costs be with the high-cost medical care benefit?

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.

1. Persons under 70

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.

2. Persons over 70

All of your copayments can be combined.

[table 1] Income brackets for persons 70 and over

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.

How much will my copayment be?

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).

1. Persons under 70

[table 2] Monthly cost-bearing limit on high-cost medical care (Persons under 70 years old)

Income level Monthly cost-bearing limit for medical expenses
Annual income is about 11,600,000 yen or higher
  • Health insurance: Standard monthly remuneration is 830,000 yen or higher
  • National insurance: Annual income (after deductions) exceeds 9,010,000 yen
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
  • Health insurance: Standard monthly remuneration is between 530,000 and 830,000 yen
  • National insurance: Annual income (after deductions) is between 6,000,000 and 9,010,000 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
  • Health insurance: Standard monthly remuneration is between 280,000 and 530,000 yen
  • National insurance: Annual income (after deductions) is between 2,100,000 and 6,000,000 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
  • Health insurance: Standard monthly remuneration is less than 280,000 yen
  • National insurance: Annual income (after deductions) is less than 2,100,000 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

2. Persons over 70

[table 3] Monthly cost-bearing limit on high medical care cost (Household with persons over 70 / Applies to medical treatment from August 2018)

Persons earning full salaries
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〉
General income earner
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〉
Tax-exempt household
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.

What is the "combined benefit" for high-cost medical care?

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.

[More specifically]

All of the below qualify for high-cost medical care benefit.

  • Within the same month, payments of at least 21,000 yen were made towards both outpatient and inpatient medical care.
  • Within the same month, payments of at least 21,000 yen were made towards medical care to two or more medical facilities.
  • Within the same month, two or more members covered by the same insurance policy were hospitalized at the same time, or were inpatients and outpatients at the same time, and that each payment for medical care was at least 21,000 yen.

*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?"

What procedures are necessary?

Applications are accepted at your place of insurance registration.

1. Applying for high-cost medical care benefit (normal conditions)

High-cost medical care benefit applies when:

  • Total payment of medical costs to a medical institution during a particular month is high
  • The payment was made to a medical institution prior to March 31, 2007
  • Total payment meets the conditions for combined benefit
  • Application for issue in kind towards hospitalization has not been made (persons under 70).
 

Procedures

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.

[table 4] Necessary documents for high-cost medical care benefit and place of application

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
  • National health insurance
    Your local government office
  • Government Managed Insurance
    Social insurance office
  • Health insurance society
    Union office printed on your insurance certificate or business administration within your company.
  • Mutual aid association
    Offices of each organization

2. Application for issue in kind towards hospitalization (persons under 70)

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.)

Eligibility

Persons under 70 and have been hospitalized since April 1, 2007 or plan to be hospitalized.

Procedures

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.

[table 5] Where to apply for hospital fees in kind

Place of application
  • National health insurance
    Your local government office
  • Government Managed Insurance
    Social insurance office
  • Health insurance society
    Union office printed on your insurance certificate or business administration within your company.
  • Mutual aid association
    Offices of each organization

What does it mean to have "multiple applications" for high-cost medical care benefits?

"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.

  • As of October 2006 the maximum limit of "multiple application" has been changed.
  • For persons 70 years of age and older, the maximum cost-bearing limit for multiple application will apply only to those who fall under the category of “Persons earning full salaries” and “General income earner”. As for the amount, please refer to [table 2] and [table 3].

What is Unitary High-Cost Medical / Long-Term Care Benefit System?

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.

Eligible 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.

Procedures

Submit the application with the receipts of medical care and long-term care services to the local municipality.

[table 6] Maximum copayment

  “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)
2,120,000 yen 2,120,000 yen 2,120,000 yen
1,410,000 yen 1,410,000 yen 1,410,000 yen
670,000 yen 670,000 yen 670,000 yen
General 560,000 yen 560,000 yen 600,000 yen
Low-income earner 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.


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