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".
- By using a Myna health insurance card, you will be exempt from payments beyond the maximum copayment amount under the High-Cost Medical Care Benefits system, because your cost-sharing maximum amount information will be provided with no need to give your consent and without any prior procedures.
We recommend using a Myna health insurance card. Using this card will eliminate the need to apply in advance for a Certificate of Application of Maximum Copayment Amount.
High-Cost Medical Care Benefits (for dependents, "Dependents' High-Cost Medical Care Benefits")
Amount paid
| Copayment: 30% | |
|---|---|
| Cost-Sharing Maximum Amounts | Reimbursement as High-Cost Medical Care Benefits |
Individual cost-sharing maximum amounts
| 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.
The association's additional benefits
The Association provides its own benefits (additional benefits) in the amount of medical care costs* paid by the insured person and dependents at the medical care institution minus 25,000 yen.
These are called Patient Cost-Sharing Reimbursements (for dependents, Dependents’ Medical Care Additional Sum).
No application is required for these benefits, because the payment is automatically made after amounts are calculated based on rezepts (medical cost details) sent by hospitals to the Health Insurance Association.
The timing of payment is roughly three months after the month of examination or treatment. (Paid with the salary for current employees and paid separately for former employees)
* Only medical care costs covered by health insurance are eligible. Calculated monthly, per individual, and per hospital (separately for categories such as outpatient/inpatient and medical/dental).
Costs eligible for additional benefits do not include the amount equivalent to High-Cost Medical Care Benefits, inpatient meal expenses, accommodation expenses, and costs for beds with extra charge, etc.
High-Cost Medical Care Benefits will be paid separately if you pay the portion eligible for High-Cost Medical Care Benefits yourself.
[Notes]
If you visit multiple medical care institutions (hospitals, pharmacies, dental clinics, etc.) for examination or treatment, you must pay a copayment of roughly 25,000 yen to each institution.
If you receive both inpatient and outpatient treatment at the same medical care institution, you must pay a copayment of roughly 25,000 yen for each.
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 Association in advance for this Certificate.
See here for more information.
Note that you will need a Certificate of Application of Maximum Copayment Amount in the following cases. If you need this certificate, apply in advance.
- Examinations and treatment received at a medical care institution or other facility that has not adopted the online eligibility verification system
- When not using a Myna health insurance card
- When not using a Myna health insurance card and you are 70 or older and in the same income category as active workers Ⅰ or Ⅱ
- * Even when using a Myna health insurance card, those in the low income category must apply in advance for a Maximum Copayment/Reduced Standard Copayment Certificate to be treated as falling in the low income category.
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 | |
|---|---|
| Copayment 30% 300,000 yen |
Medical Care Benefits 70% 700,000 yen |
High-Cost Medical Care Benefits.
80,100 yen＋(1,000,000 - 267,000 yen)*1%
＝87,430 yen
212,570 yen
The Health Insurance Society also pays additional benefits.
25,030 yen
62,400 yen*
- * Figures rounded down to the nearest 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 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.
| Standard monthly remuneration | Individual cost-sharing maximum amounts |
|---|---|
| 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 |
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 |
Caution
The right to claim health insurance benefits expires in two years.