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".
* Calculation standards:
High-Cost Medical Care Benefits and additional benefits are calculated for each Rezept (medical cost details).
- Per month of examination or treatment (from the start through the end of the month)
- Per person
- Per medical care institution (outpatient/inpatient, medical/dental, etc.)
High-Cost Medical Care Benefits (for dependents, “Dependents' High-Cost Medical Care Benefits”)
|Cost-Sharing Maximum Amounts||Reimbursement as High-Cost Medical Care Benefits|
Individual cost-sharing maximum amounts
|Category||Individual cost-sharing maximum amounts|
|Standard monthly remuneration|
|830,000 yen or more||252,600 yen ＋ (medical care costs - 842,000 yen) *1%|
|530,000 yen - 790,000 yen||167,400 yen ＋ (medical care costs - 558,000 yen) *1%|
|280,000 yen - 500,000 yen||80,100 yen ＋ (medical care costs - 267,000 yen) *1%|
|260,000 yen or less||57,600 yen|
- * Meal expenses, accommodation expenses, and charges of beds incurring an extra charge during hospitalization are not eligible for High-Cost Medical Care Benefits.
- * See here for Cost-Sharing Maximum Amounts for persons aged 70-74.
- * See here for Cost-Sharing Maximum Amounts for persons with low income. Those in the categories of 830,000 yen or more and 530,000 - 790,000 yen will remain in those categories, even if they are exempt from paying municipal tax.
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 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).
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.
- Reference link
Note that those aged 70 or older in the category of same income level as active workers I or II must submit a Certificate of Application of Maximum Copayment Amount if they wish to pay no more than their maximum copayment amount.
Cases in which no Certificate of Application of Maximum Copayment Amount is needed
At medical care institutions and other facilities that have adopted the online eligibility verification system, simply present either your health insurance card or Individual Number Card in order to limit the amount you pay at the counter to no more than the Cost-Sharing Maximum, even if you do not have a Certificate of Application of Maximum Copayment Amount.
- * Note that you must register in advance at Mynaportal etc. to use your Individual Number Card as a health insurance card.
- * You must still submit a Certificate of Application of Maximum Copayment Amount at medical care institutions and other facilities that have yet to adopt the online eligibility verification system.
See here for more information.
How High-Cost Medical Care Benefits are calculated
Calculation example: If the copayment for one months' medical care costs is 300,000 yen (for an insured person with 280,000 yen - 500,000 yen of standard monthly remuneration)
|Total amount of medical care costs 1 million yen|
|Medical Care Benefits 70%
The amount in excess of the Cost-Sharing Maximum Amount is paid as High-Cost Medical Care Benefits.
80,100 yen＋1,000,000 - 267,000 yen)*1%
The Health Insurance Association also pays additional benefits.
- *Figures rounded down to the 100 yen
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”.
The association's additional benefits
Total High-cost Medical Care Benefits
When the Association pays Total High-Cost Medical Care Benefits, it also pays Additional Total High-Cost Medical Care Benefits in the amount calculated by subtracting from the total copayment amount the amount corresponding to Total High-Cost Medical Care Benefits and 25,000 yen (if an insured person) or 50,000 yen (if a dependent). 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.
- * Amounts paid as Total High-cost Medical Care Benefits, as well as costs such as meal expenses, accommodation expenses, and premium bed expenses during hospitalization, are not included in the copayment amount for the purposes of this benefit.
- * The calculated amount will be rounded down to the nearest 100 yen.
- * See “How High-Cost Medical Care Benefits are calculated” for a specific calculation example.
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.
|Category||Individual cost-sharing maximum amounts|
|Standard monthly remuneration|
|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|
Notify the IBM Japan Health Insurance Association if you were not charged a copayment because you presented a disability medical care card or a medical care identification card for infants at the medical care institution. The Association will take the steps necessary to ensure aid is not duplicated.
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.
- * This is not paid when no copayment has been paid for either health insurance or long-term care insurance.
Cost-Sharing Maximum Amount
|Category||Under 70 years||70-74 years|
|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|
The right to claim health insurance benefits expires in two years.