When you incur high medical care costs

The copayment for medical care costs you can be required to pay is capped. If your copayment calculated based on a certain standards exceeds this maximum, the excess amount will be paid as “High-Cost Medical Care Benefits”.
Since the Health Insurance Society automatically calculates these benefits together with its additional benefits (Patient Cost-Sharing Reimbursements and Additional Benefits), no special application is required.
Payment of High-Cost Medical Care Benefits and additional benefits is remitted through your employer.

Tips

By using a Myna health insurance card and giving consent to provide your cost-sharing maximum amount information, you will be exempt from payments beyond the maximum copayment amount under the High-Cost Medical Care Benefits system 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”)

** 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 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

By using a Myna health insurance card and consenting to provide your cost-sharing maximum amount information, you can ensure that the amount of medical care costs the hospital bills you (per month) will not exceed the individual cost-sharing maximum amount and thus reduce the amount you must pay at the hospital counter.
(Available for both inpatient and outpatient care)

See here for more information.

Reference link

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

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
If you are in the low income category (certificate of application of maximum copayment/reduced standard copayment)

Reference link

How High-Cost Medical Care Benefits are calculated

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”.

Using its own independent benefits (additional benefits), the Health Insurance Society can reduce copayments still further (Additional Total High-cost Medical Care Benefits).

If the Health Insurance Society has paid Total High-cost Medical Care Benefits, it later pays the amount of the subject total copayment minus 20,000 yen, as “Additional Total High-cost Medical Care Benefits”. This payment is automatically calculated and made based on “the Rezept (medical cost details)” the hospital sends to the Health Insurance Society. Payments will be made roughly three months after the month in which the medical care was provided.

** Amounts paid as Total High-cost Medical Care Benefits, as well as costs such as meal expenses, accommodation expenses, and premium bed expenses during hospitalization, are not included in the copayment amount for the purposes of this benefit.
** The benefits will not be paid if the calculated amount is less than 1,000 yen. The calculated amount will be rounded down to the nearest 100 yen.
** See “How High-Cost Medical Care Benefits are calculated” for a specific calculation example.

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.

Required documents:	Application Form for issue of Certificates Issued for Specific Disease Treatment (A4) Example

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

** See here concerning persons with low income.

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