When you incur high medical care costs | Procedures | Works Applications Group Health Insurance Society

When the self-pay amount of medical expenses exceeds a certain amount, the health insurance association automatically calculates it based on the medical treatment statement (receipt) sent from the medical institution, and at a later date, "high medical expenses" and the total amount of "additional benefit expenses" will be paid.
(Expenses not covered by insurance, such as bed charges, and meals when hospitalized are not covered)

High medical expenses

If you are hospitalized due to illness or injury, a large amount of medical expenses may be incurred. If the self-pay amount exceeds a certain amount, the excess amount will be provided by the health insurance association as "high medical expenses".
High medical expenses are usually paid once at a medical institution, etc., and then refunded at a later date. It is not necessary for insured persons and dependents to submit applications.
In addition, the Health Insurance Society will pay the amount after deducting ¥20,000 from the self-pay limit at a later date (less than ¥1,000 will not be paid, rounded down to the nearest ¥100). This is called "Partial contribution reduction (family medical treatment surcharge)." Payment will be calculated automatically based on the “medical treatment statement” sent from the medical institution to the health insurance association, but the payment will be made approximately 3 to 4 months after the medical treatment month.

* There is also a high-priced medical treatment / high-value nursing care complex system that refunds the total amount of self-paid medical insurance and long-term care insurance if the total amount exceeds a certain amount.

Payment and additional benefits

Payment	When the self-pay amount of medical expenses per month exceeds the limit, the amount exceeded (Low-income people, 70-74 years old have different limits)
Health insurance association additional benefits	Partial refund, family medical treatment surcharge ：Pay the amount of ¥20,000 deducted from the self-pay amount (less than ¥1,000 will not be paid, rounded down to the nearest ¥100) * Excludes high-cost medical treatment, standard medical expenses for hospital meals, and standard medical expenses for daily living at hospitals.

Cost-Sharing maximum amount of medical expenses(maximum amount for one month)

＜For those under age 70＞

Income Category	Up to 3 times	From the 4th time
Standard monthly remuneration is ¥830,000 or more	¥252,600 + (medical care costs − ¥842,000) × 1%	¥141,100
Standard monthly remuneration is between ¥530,000 and ¥790,000	¥167,400 + (medical care costs − ¥558,000) × 1%	¥93,000
Standard monthly remuneration is between ¥280,000 and ¥500,000	¥80,100 + (medical care costs − ¥267,000) × 1%	¥44,000
Standard monthly remuneration is ¥260,000 or less	¥57,600	¥44,000
Low income※	¥35,400	¥24,600

* Insured persons and dependents who are exempt from municipal tax, or insured persons and dependents who do not require welfare due to the application of low-income persons.

＜For those between the ages of 70 and 75＞

Income Category		outpatient (Per-person)	outpatient + inpatient (Per household)
Active income earners	level similar to active workersⅢ Standard monthly remuneration is ¥830,000 or more	Active income earners level similar to active workersⅢ(Standard monthly remuneration is ¥830,000 or more)	¥252,000 + (medical care costs − ¥842,000 ) ×1% [¥140,100]
	level similar to active workersⅡ Standard monthly remuneration is ¥530,000- ¥790,000	Active income earners level similar to active workersⅡ(Standard monthly remuneration is ¥530,000- ¥790,000)	¥167,400 + (medical care costs − ¥558,000 ) ×1% [¥93,000]
	level similar to active workersⅠ Standard monthly remuneration is ¥280,000 -¥500,000	Active income earners level similar to active workersⅠ(Standard monthly remuneration is ¥280,000 -¥500,000)	¥80,100 + (medical care costs − ¥267,000) ×1% [¥44,000]
General	Standard monthly remuneration is ¥260,000 or less	General (Standard monthly remuneration is ¥260,000 or less)	¥18,000 (Annual limit ¥144,000)	¥57,600 [¥44,400]
Low income (Resident tax exemption)	Ⅱ	Low income (Resident tax exemption)Ⅱ	¥8,000	¥8,000	¥24,600
Low income (Resident tax exemption)	Ⅰ(Pension income of ¥800,000 or less)	Low income (Resident tax exemption)Ⅰ (Pension income of ¥800,000 or less)	¥8,000	¥8,000	¥15,000

* The amount in [] is the limit after the 4th time.

* “Active income earners” are those who receive a standard monthly salary of ¥280,000 or more and their dependents. However, if the amount of income is re-determined and there are no dependents over 70 years old and annual income is less than ¥3,830,000, dependents over 70 years old / former dependents Those who are no longer dependent because of becoming a person.If the total annual income is less than ¥5,200,000 for those who have less than 5 years after the month in which they are no longer dependent, the application will be classified as “general”.

Those who receive infants and children medical expenses subsidy system, etc.

Regarding medical expenses (high-cost medical treatment expenses and family medical treatment surcharges) during compulsory education, local governments (prefectures and municipalities) have also implemented a "medical expense subsidy system" to subsidize medical expenses.
In order to prevent double payment of benefits with the subsidy of the local government, the Health Insurance Society does not automatically provide high-cost medical treatment expenses and family medical treatment surcharges for persons during the compulsory education period.
If the medical expenses become high and four months after the medical treatment month and there is no benefit from the local government or the health insurance association, please contact the health insurance association.

Limit application certificate.

If the self-pay amount exceeds the limit, if you apply to the health insurance association in advance and receive a certificate, you can show it to a medical institution and pay at the counter up to the self-pay limit.
If you use your Individual Number Card (My Number Card) as your health insurance card, you will be exempt from paying any out-of-pocket expenses that exceed the maximum amount under the High-Cost Medical Expenses System without undertaking any prior procedures.
There is no need to apply for a Eligibility Certificate for Ceiling-Amount Application in advance.

* To use your Individual Number Card as a health insurance card, you must register on the "Myna Portal site", etc.
For more information, please see here.

* Medical institutions that do not support the use of the Individual Number Card as your health insurance card are not exempt.
In addition, if the medical institution cannot confirm your eligibility using your Individual Number Card, you may not be able to receive an exemption.
Please check with the medical institution you will be visiting in advance regarding the status of Individual Number Card compatibility.

Procedure

Required documents

Health insurance limit application certificate application form
EXCEL

How to calculate high medical expenses.

Calculation for each consultation month (1st to last day of the month)
Calculated for each examinee
Calculation for each medical institution (Inpatient / outpatient / dentistry is calculated separately. For old general hospital, each department is calculated)

How to pay at the hospital window when a large amount of medical expenses are required for hospitalization

(Ex) If the standard remuneration monthly fee is ¥280,000 to ¥500,000 and the total medical expenses are ¥1,000,000

Regardless of whether or not a limit application certificate is used, the amount of medical expenses paid at the hospital window minus ¥20,000 will be paid approximately 3 months after the medical treatment month (less than ¥1,000 is not paid. Less than ¥100 Rounded down).

* Application is not required as it will be calculated automatically.

In either case, the final copayment remains the same.

In case of household total

If there are two or more self-payments of ¥21,000 or more per month in the same household, if the sum of those amounts exceeds the self-pay limit, the amount exceeding that amount will be paid as "total high medical treatment expenses".

When high-cost medical expenses apply for the fourth time or more (many apply)

If the same household receives high-cost medical treatment three or more times in the last 12 months, the self-pay limit will be as follows after the fourth time.

[In case of many cases]

Standard monthly fee	Self-pay ceiling
¥830,000 or more	¥140,100
More than ¥530,000 and less than ¥790,000	¥93,000
More than ¥280,000 and less than ¥500,000	¥44,400
¥260,000 or less	¥44,400
Low income (Exemption from residence tax)	¥24,600

Special cases of specific diseases.

Long-term patients with "hemophilia", "acquired immunodeficiency syndrome with antiviral agents", and "chronic renal failure requiring artificial dialysis" will be admitted to a medical institution when certified for a specific disease. The payment is ¥10,000 per month. However, if a patient who needs artificial dialysis has a standard monthly salary of ¥530,000 or more, the self-pay will be ¥20,000 per month. (Same for dependents)

Procedure

Those who receive treatment for a specific illness will receive the "Specific illness medical treatment medical treatment certificate" after submitting it to the Health Insurance Society with the proof of the doctor in the "Specific medical treatment medical treatment certificate application". The "specific medical treatment medical treatment certificate" issued by the Health Insurance Society will be submitted together with the insurance card to the medical institution counter.

* Since the amount received by the Health Insurance Society until the end of the month will be applied this month, if you are to be treated for a specific disease, please submit the application form immediately.

Required documents

Application form for specific medical treatment certificate　
EXCEL