IBM Japan Health Insurance Association

IBM Japan Health Insurance Association

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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”.

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 Association 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 less than 70 years of age expects to incur high medical care costs, it can be more convenient to obtain “a Certificate of Application of Maximum Copayment Amount” in advance. By showing this “Certificate of Application of Maximum Copayment Amount” 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).

Caution

You can use the Certificate of Application of Maximum Copayment Amount to reduce the copayment amount paid at hospitals for high-cost medical care included in the amount of the copayment for treatment covered by insurance.


Prior application required

“The Certificate of Application of Maximum Copayment Amount” is used to confirm your income category. You must apply to the Health Insurance Association in advance for this Certificate.

How High-Cost Medical Care Benefits are calculated

If 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 Association as “Total High-cost Medical Care Benefits”.

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

If the Health Insurance Association has paid Total High-cost Medical Care Benefits, it later pays the amount of the subject total copayment minus 25,000 yen (dependents:50,000 yen), as “Additional Total High-cost Medical Care Benefits”. This payment is automatically calculated and made based on “the Rezept (medical cost details)” the hospital sends to the Health Insurance Association. Payments will be made roughly three months after the month in which the medical care was provided.

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

If you receive medical care for specified diseases and disorders

Patients suffering from haemophilia, AIDS for which they are administered antiviral drugs, or chronic nephritics requiring artificial dialysis for an extended period may be eligible to pay only 10,000 yen/month to the medical care institution if they obtain certification for specified diseases and disorders.
However, if a patient requiring artificial dialysis qualifies as a person with530,000 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 to July 31 the following year) 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

(Computation period: August 2015 - July 2016)
Classification Under 70 years 70-74 years
830,000 yen or more
of standard monthly remuneration
2,120,000 yen 670,000 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

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