High-Cost Medical Care Benefits (for dependents, “Dependents' High-Cost Medical Care Benefits”)

• ** 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 Society 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 automatically calculated at the Society based on rezepts (health insurance claims/details) issued by medical care institutions. You do not need to apply for these benefits. Insured persons eligible for High-Cost Medical Care Benefits will be notified at a later date. Check the notice for more information such as on amounts paid. High-Cost Medical Care Benefits are typically paid three to four months after the month of the examination or treatment.

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).

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 Society in advance for this Certificate.

Reference link

• When you incur high medical care costs「When you want to reduce the amount of medical care costs you pay at the medical care institution」

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.

Reference link

• You can use your Individual Number Card as a health insurance card

How High-Cost Medical Care Benefits are calculated

• * The Recruit Health Insurance Society provided its own benefits (through an additional benefits system) for examinations and treatment through March 2019. This system was discontinued starting from examinations and treatment provided in April 2019. See here concerning the additional benefits system for examinations and treatment through March 2019.

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 Society as “Total High-cost Medical Care Benefits”.

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.

• ** See here for persons aged 70-74.
• ** See here concerning persons with low income.

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.