When you incur high medical care costs
Your copayment for medical care costs is capped by the insured person’s income category. If your copayment (30% of medical care costs) exceeds the maximum, the excess amount will be calculated by the Society and paid as “High-Cost Medical Care Benefits.” However, some procedures are required to ensure that the amount you pay at the reception desk of the hospital does not exceed the Cost-Sharing Maximum Amounts.
- High-Cost Medical Care Benefits
- 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（Application of Maximum Copayment Amount）
- Cases in which no Certificate of Application of Maximum Copayment Amount is needed
- How High-Cost Medical Care Benefits are calculated
- If your copayment is reduced still further
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.
If the copayment amount for medical care costs paid at the reception desk of the hospital becomes high, the Health Insurance Association will automatically pay the amount beyond a certain amount 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.”
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 that 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.
- Reference link
Note that, those aged 70 and older falling in the category of the same income level as active workers II or active workers I will also need to submit a Certificate of Application of Maximum Copayment Amount to avoid paying more than the cost-sharing maximum amount.
Cases in which no Certificate of Application of Maximum Copayment Amount is needed
If you visit a medical care institution or other facility adopting online eligibility verification, you can limit the amount you pay at the counter to the Cost-Sharing Maximum Amount using just your Individual Number Card or your health insurance card. You will not be required to present a Certificate of Application of Maximum Copayment Amount.
- ** Note that you must register in advance on a specific site such as Mynaportal to use your Individual Number Card as a health insurance card.
See here for more information.
- ** You will still need to present a Certificate of Application of Maximum Copayment Amount at medical care institutions or other facilities that have yet to adopt the online eligibility verification system.
How High-Cost Medical Care Benefits are calculated
- If you become sick or are injured
- ■ Medical Care Benefits
- ■ Additional benefits
- ■ Meals during hospitalization
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 and its payments are 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 SUNTORY HEALTH INSURANCE ASSOCIATION also pays as additional benefits the Cost-Sharing Maximum Amounts minus 25,000 yen per person.
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||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.
The right to claim health insurance benefits expires in two years.
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