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Other medical payment services

High-cost medical care benefit
What is the high-cost medical care benefit?
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?
As illustrated in tables 1 and 2 below, the figures for medical costs pertaining to high-cost medical care (high medical care cost) differ for persons under 70 and those 70 and older. These changes were part of the heath insurance reform effective as of October 1, 2006.
1. Persons under 70

[table 1] Medical fees applicable to high-cost medical care benefit (monthly)

Household
status
Before
October 1, 2006
From
October 1, 2006
Common
household
72,300 yen or higher 80,100 yen or higher
High-income
bracket
Regular monthly income per household: higher than 560,000 yen 139,800 yen or higher Regular monthly income per household: higher than 530,000 yen 150,000 yen or higher
Municipal
tax-exempt
household
35,400 yen or higher 35,400 yen or higher
(changes made later than October 2006 are in red)
2. Persons over 70

[table 2] Medical fees applicable to high-cost medical care benefit (monthly)

Household
status
Before
October 1, 2006
From
October 1, 2006
Outpatient Inpatient and other Outpatient Inpatient and other
Common
household
12,000 yen or higher 40,200 yen or higher 12,000 yen or higher 44,400 yen or higher
Persons earning
full salaries
40,200 yen or higher 72,300 yen or higher 44,400 yen or higher 80,100 yen or higher
Low-income II 8,000 yen or higher 24,600 yen or higher 8,000 yen or higher 24,600 yen or higher
Low-income I 8,000 yen or higher 15,000 yen or higher 8,000 yen or higher 15,000 yen or higher
(changes made later than October 2006 are in red)
[table 3] Income brackets for persons 70 and over
Persons earning
full salaries
Insured persons or dependents 70 and over, whose regular monthly income is 280,000 yen or higher
Low-income II Head of household or all household members are municipal tax-exempt
Low-income I Members of a household who have no taxable income.
General Persons who do not fall under "Persons earning full salaries", "Low-income II", or "Low-income I"
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 4] Monthly cost-bearing limit on high-cost medical care (persons under 70)

[Common household] Cost-bearing limit (outpatient, inpatient)
Before October
1, 2006
  • 72,300 yen + (total medical charges - 241,000 yen) x 1%
  • If the total medical charges do not exceed 241,000 yen, the cost-bearing limit is 72,300 yen.
From October
1, 2006
  • 80,100 yen + (total medical charges - 267,000 yen) x 1%
  • If the total medical charges do not exceed 267,000 yen, the cost-bearing limit is 80,100 yen.
[High income bracket]  Cost-bearing limit (outpatient, inpatient)
Before October
1, 2006

Regular monthly income per household: higher than 560,000 yen

  • 139,800 yen + (total medical charges - 466,000 yen) x 1%
  • If the total medical charges do not exceed 466,000 yen, the cost-bearing limit is 139,800 yen.
From October
1, 2006

Regular monthly income per household: higher than 530,000 yen

  • 150,000 yen + (total medical charges - 500,000 yen) x 1%
  • If the total medical charges do not exceed 500,000 yen, the cost-bearing limit is 150,000 yen
[Tax-exempt household]  Cost-bearing limit (outpatient, inpatient)
Before October 1, 2006 35,400 yen
From October 1, 2006 35,400 yen
(changes made later than October 2006 are in red)
2. Persons over 70

[table 5] Monthly cost-bearing limit on high-cost medical care (persons 70 and older)

[Common household] (10% copayment at outpatient reception)
Before October
1, 2006
Outpatient (per individual) 12,000 yen
Inpatient and other (per household) 40,200 yen
From October
1, 2006
Outpatient (per individual) 12,000 yen
Inpatient and other (per household) 44,400 yen
[Persons earning full salaries] (30% copayment at outpatient reception)
Before
October
1, 2006
Outpatient
(per individual)
40,200 yen
Inpatient
and other
(per household)
  • 72,300 yen + (total medical charges - 361,500 yen) x 1%
  • If the total medical charges do not exceed 361,500 yen, the cost-bearing limit is 72,300 yen
From
October
1, 2006
Outpatient
(per individual)
44,400 yen
Inpatient
and other
(per household)
  • 80,100 yen + (total medical charges - 267,000 yen) x 1%
  • If the total medical charges do not exceed 267,000 yen, the cost-bearing limit is 80,100 yen
[Low-income II] (10% copayment at outpatient reception)
Before October
1, 2006
Outpatient
(per individual)
8,000 yen
Inpatient and other
(per household)
24,600 yen
From October
1, 2006
Outpatient
(per individual)
8,000 yen
Inpatient and other
(per household)
24,600 yen
[Low-income I] (10% copayment at outpatient reception)
Before October
1, 2006
Outpatient
(per individual)
8,000 yen
Inpatient and other
(per household)
15,000 yen
From October
1, 2006
Outpatient
(per individual)
8,000 yen
Inpatient and other
(per household)
15,000 yen
(changes made later than October 2006 are in red)
*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?
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 6 below, to your insurance provider. It usually takes about two to three months for the refund to come through.

[table 6] 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 (other than postal account) 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 7] 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 applicants 70 and over, the maximum cost-bearing limit for multiple application will apply only to those who fall under the category of "persons earning full salaries".
[table 8] Maximum cost-bearing limit under "multiple application" for persons under 70:
Income status Before October 1, 2006 From October 1, 2006
Common household 40,200 yen 44,400 yen
High-income bracket 77,700 yen 83,400 yen
Tax-exempt household 24,600 yen 24,600 yen
[table 9] Maximum cost-bearing limit under "multiple application" for persons 70 and older:
Income status Before October 1, 2006 From October 1, 2006
Persons earning full salaries 40,200 yen 44,400 yen
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