Insurance benefits
When you incur high medical
care costs
Your copayment for medical care costs is capped. When your copayment calculated
based on certain standards exceeds the maximum, the excess amount will be paid as
“High-Cost Medical Care Benefits”.
A cap on
copayments
Health insurance defrays a significant portion of
medical care costs. Nevertheless, in the event of a
major illness or long-term hospitalization, you may
still face high medical care costs. To lessen the
burden in such cases, your copayments for medical
care costs are capped at a certain amount.
The limit applies
on a monthly basis
Not all medical care costs are used to calculate
this cap. You are eligible to be reimbursed for the
amount beyond this cap for medical care costs
during the one-month period from the first through
the last day of the month, calculated based on the
following criteria:
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●
●
Criteria for calculating your copayment for
medical care costs
● (1) Calculated separately by hospital or clinic
When you visit multiple hospitals or clinics concurrently, the copayment will be calculated separately for
●
each one.
● ◦ When you are discharged and then hospitalized once again at the same hospital during the course of
one calendar month, both stays will be regarded as a single case for the purposes of calculation.
●
●
(2) Dental costs calculated separately
When you receive dental care at the same time at the same hospital or clinic, your copayment for
● dental costs will be calculated separately from your copayment for medical care costs.
● (3) Calculated separately for inpatient and outpatient care
Your copayments will be calculated separately for inpatient and outpatient care, even if inpatient and
●
outpatient care are provided by the same hospital or clinic.
●
(4) Standard copayment when hospitalized is not included
● These calculations exclude the cost of meals and residential costs paid by the patient during
hospitalization.
●
● (5) The cost of premium beds and other premium services is not covered
These calculations exclude the cost of premium beds, special individual nursing costs, and other special
● services that may be provided during hospitalization but are not covered by insurance.
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The excess amount will be paid as
“High-Cost Medical Care Benefits”
When your copayment calculated based on certain standards exceeds the maximum, the excess amount
will be paid as “High-Cost Medical Care Benefits”.
◦ Cost-Sharing Maximum Amounts vary with age and income
Cost-Sharing Maximum Amounts vary by income. Cost-Sharing Maximum Amounts also differ for those
69 or younger and those aged 70 or older.
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High-Cost Medical Care Benefits
■ Conditions for payment
When your copayment incurred over a one-month
period and calculated on a per-person, per-hospital
basis exceeds the Cost-Sharing Maximum Amounts.
■ Amounts paid
The amount in excess of Cost-Sharing Maximum
Amounts
To further reduce copayments when copayments exceed 20,000 yen, the Society provides
reimbursements in the form of Patient Cost-Sharing Reimbursements and Additional Benefits and the
Dependents’ Medical Care Additional Sum. (See page 25.)
Cost-Sharing Maximum Amounts for persons aged under 70
There are five income-based categories:
Standard monthly remuneration:
830,000 yen or more
252,600 yen + (Medical care costs incurred − 842,000 yen) ×1%
Standard monthly remuneration:
530,000-790,000 yen
167,400 yen + (Medical care costs incurred − 558,000 yen) ×1%
Standard monthly remuneration:
280,000-500,000 yen
80,100 yen + (Medical care costs incurred − 267,000 yen) ×1%
Standard monthly remuneration:
260,000 yen or less
57,600 yen
Persons with low income
35,400 yen
※ Persons with low income refers to insured persons and dependents exempted from municipal tax or insured persons and dependents who
do not require national assistance as a result of application of the treatment for persons with low income.
You can ensure that the amount you pay at each medical institution will not
exceed the Cost-Sharing Maximum Amounts
——— “a Certificate of Application of Maximum Copayment Amount”
When the cost of hospitalization at a single medical care institution over the course of a single calendar month exceeds
the Cost-Sharing Maximum Amount, you can cap the amount you pay at the medical care institution to the CostSharing Maximum Amount by presenting a Certificate of Application of Maximum Copayment Amount.
◦ Apply in advance
The Certificate of Application of Maximum Copayment Amount is used to confirm your income category. You must
apply to the Health Insurance Societies for this in advance and have the Certificate with you when you go to receive
treatment.
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Insurance benefits
When your copayment is reduced
still further
◦ When you incur high medical care costs every household
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 Society as “Total High-cost Medical Care Benefits”.
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Total High-cost Medical Care Benefits
■ Conditions for payment
When members of the same
household have made copayments
of 21,000 yen or more multiple times
in the same month, and the total
amount exceeds the Cost-Sharing
Maximum Amounts.
The Society's
additional benefits
To further reduce your copayment, the Society also
provides additional benefits.
Additional Total High-cost Medical
Care Benefits
Health Insurance Society provides insured persons
and their dependents, with amounts calculated by
deducting Total High-cost Medical Care Benefits
and 20,000 yen for one sickness/injury from total
personal cost-sharing amount. This benefit is not
available in cases where calculated amounts total
less than 500 yen.
This payment is calculated and made automatically
based on “the Rezept” sent by the hospital to the Health
Insurance Society. Payment will occur roughly three
months after the month of the medical care.
◦ When you incur high medical care
costs for frequent qualification of
expenditures
When 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 starting with the
fourth month.
■ The Cost-Sharing Maximum Amounts
(Frequent qualification of expenditures)
Standard monthly remuneration:
830,000 yen or more
Standard monthly remuneration:
530,000-790,000 yen
Standard monthly remuneration:
280,000-500,000 yen
140,100 yen
93,000 yen
44,400 yen
Standard monthly remuneration:
260,000 yen or less
44,400 yen
Persons with low income
24,600 yen
◦ If you receive medical care for specified diseases and disorders
Patients suffering from long-term high-cost diseases may be eligible to pay only 10,000 yen/month to the
medical care institution as long as they obtain certification for specified diseases and disorders. However,
when a patient requiring artificial dialysis earns standard monthly remuneration of 530,000 yen or more,
his or her copayment will be 20,000 yen/month.
◦ Long-term high-cost diseases
haemophilia, AIDS for which they are administered antiviral drugs, or chronic nephritics requiring artificial dialysis for
an extended period
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Cost-sharing maximum amounts for elderly persons aged 70 or older
Cost-sharing maximum amounts for elderly persons aged 70 or older are lower than for persons less than 70
years of age. There are a per-person cost-sharing maximum amount for outpatient care and a combined costsharing maximum amount for total outpatient and inpatient cost-sharing amounts per household.
■ A per-person cost-sharing
maximum amount
A per-person cost-sharing maximum
amount for outpatient care
Persons earning income
at levels comparable to
active workers
44,400 yen ＊1
Normal
12,000 yen ＊2
Persons exempt from
paying municipal tax
■ A combined cost-sharing maximum amount
A combined cost-sharing maximum amount for total outpatient and inpatient costsharing amounts per household applied in cases in which more than one member is
covered under the same medical insurance plan within one household
8,000 yen
Persons earning income at levels comparable to active workers
Frequent qualification of expenditures
80,100 yen＋（medical care costs−267,000 yen) ×1% ＊1
44,400 yen ＊1
Normal
44,400 yen ＊3
Persons with low income
24,600 yen
Persons with low income
15,000 yen
＊ Half of the corresponding amount in the table above will be exceptionally applied, for a new insured person under Medical Care System for the Advanced
Elderly, as the cost-sharing maximum amounts (per person) for the month in which he or she will turn 75 and become an insured person under the system (not
including cases in which the insured person’s 75th birthday will be the first day of that month).
※ Persons with low income II refers to those for whom all persons in the household are exempt from municipal tax; persons with low income I refers to those
for whom all persons in the household are exempt from municipal tax and earn less than a certain amount (e.g., pension income of less than 800,000 yen).
＊ 1 Starting from August 1, 2017, a per-person cost-sharing maximum amount will be raised from 44,400 yen to 57,600 yen, and then from August 1,
2018, a per-person cost-sharing maximum amount will be abolished and the classification by monthly remuneration will be divided same as those
under 70 years to raise the cost-sharing maximum amount.
＊ 2 Starting from August 1, 2017, the amount will be raised from 12,000 yen to 14,000 yen (annual maximum amount: 144,000 yen), and then from
August 1, 2018, to 18,000 yen (annual maximum amount: 144,000 yen).
＊ 3 Starting from August 1, 2017, the amount will be raised from 44,400 yen to 57,600 yen (frequent qualification of expenditures: 44,400 yen).
Persons earning income at the same levels as active workers
For health-insurance purposes, this refers to persons whose standard monthly remuneration is
280,000 yen or more. However, persons meeting either of the descriptions below may apply to the Health Insurance Society to
be treated as persons with normal income levels.
◦ Those in a household consisting of two or more elderly persons with a combined annual income of less than 5.2 million yen, or
elderly persons living alone whose annual income is less than 3.83 million yen.
◦ Those for which the judgment criteria for annual income have changed from those for a multi-person household to those
for a single-person household because a dependent becomes an insured person under the Medical Care System for the
Advanced Elderly and who are therefore judged to qualify as persons earning income at the same levels as active workers.
◦ If copayments for medical care and long-term care are high
In cases in which people in the same household pay copayments for both medical care and long-term care
and the total amount of copayments under health insurance and long-term care insurance over a period of
one year becomes high, annual cost-Sharing Maximum Amount is established to help ease the burden of
medical care costs. The amount in excess of that maximum will be reimbursed at a later date by the health
insurance provider as high aggregate cost for long-term care service, and by the long-term care insurance
provider as high aggregate cost for long-term care service.
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High Aggregate Cost for Long-term Care Service
■ Conditions for payment
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.
＊ 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.
◦ P lease apply to the insurer of
the medical insurance (Health
Insurance Society etc.) where you
join as of July 31.
◦ T h e r a t i o o f s u m t h a t e a c h
insurer of the medical insurance
pays follows a ratio of medical
care and long-term care in costsharing amounts.
■ Cost-Sharing Maximum Amount
(One-year period from August 1, 2016 through July 31, 2017)
▼ Under 70 years
▼ 70−74 years＊
2,120,000 yen
670,000 yen
Standard monthly remuneration:
530,000-790,000 yen
1,410,000 yen
670,000 yen
Standard monthly remuneration:
280,000-500,000 yen
670,000 yen
670,000 yen
Standard monthly remuneration:
260,000 yen or less
600,000 yen
560,000 yen
Standard monthly remuneration:
830,000 yen or more
※ Cost-sharing maximum amounts for persons with low income are set to a lower sum.
※ Elderly persons aged 75 or older receive insurance benefits from the Medical Care System
for the Advanced Elderly.
＊ Starting from October 1, 2017, for the standard personal cost burden for living expenses,
the accommodation expenses will be raised from 320 yen to 370 yen. If inpatient care
is highly required (except for patients with intractable diseases), the accommodation
expenses will be 200 yen (it will be raised to 370 yen starting from April 1, 2018).
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