To provide relief in cases where the amount to be paid at the reception desk of the hospital as the individual cost-sharing of medical care costs grow large, health insurance provides for a cash payment at a later date equivalent to the amount in excess of a fixed amount (individual cost-sharing maximum amounts). This is called "High-cost Medical Care Benefits (Dependents' High-cost Medical Care Benefits)."

See here concerning the personal cost burden for elderly persons aged 70-74 covered by health insurance. >> "Elderly persons aged 70-74 pay 20% or 30% of medical costs, depending on their income #High-cost Medical Care Benefits"

When your payment at the reception desk of the hospital keeps the expenses below individual cost-sharing maximum amounts

For persons aged under 70, by presenting your co-payment maximum certificate together with your insurance card at the reception desk of the hospital, you can ensure that the amount you pay at each medical institution will not exceed your individual costsharing maximum amount. To receive a co-payment maximum certificate, you need to apply to the Health Insurance Society in advance.
*The same applies to those aged 70 and older who present their elderly benefits cards. However, note that those falling in the category of the same income level as active workers I or II must submit a certificate if they wish to avoid paying more than the cost-sharing maximum amount.

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If you have already received a co-payment maximum certificate, the amount you pay at each medical institution will not exceed your individual cost-sharing maximum amount.(You can use this certificate for both inpatient and outpatient care)

At our Health Insurance Society, in cases where Medical Care Benefits (Dependents' Medical Care Expenses) or High-cost Medical Care Benefit (Dependents' High-cost Medical Care Benefit) are paid for treatment, we also provide a benefit of our own (additional benefit), and so the ultimate cost-sharing amount made by an insured person or dependent is 20,000 yen (+ fractions). See here for more details. >> "Thirty percent of the total medical care costs are due at the hospital upon receipt of treatment"

Cases in which no Certificate of Application of Maximum Copayment Amount is needed

Measures associated with High-cost Medical Care Benefits aimed at reducing individual cost-sharing

Measures for reducing personal cost-sharing associated with High-cost Medical Care Benefits are available in the special cases described below.

(1) Special cases in which aggregation of expenses by household is permitted

Aggregation of expenses by households is permitted in cases where two or more members of the same household have individually paid medical care costs totaling 21,000 yen or more in a given month (the amount is the same for persons with low income ). Health Insurance Societies will provide reimbursement for the balance in the event "Total High-cost Medical Care Benefits" exceed individual cost-sharing maximum amounts.

At our Health Insurance Society, in cases where Total High-cost Medical Care Benefits are paid for treatment, we also provide a benefit of our own (additional benefit), and so the ultimate cost-sharing amount made by an insured person or dependent is 20,000 yen (+ fractions) per person.

Health Insurance Society provides insured persons and their dependents, at a later date, with amounts calculated by deducting 20,000 yen from total personal cost-sharing amount (excluding amounts for Total High-cost Medical Care Benefits, standard inpatient meal expenses, and standard inpatient living expenses) per person. Amounts less than 100 yen are rounded down. This benefit is not available in cases where calculated amounts total less than500 yen. This is called "Additional Total High-cost Medical Care Benefits."

(2) Special cases of frequent qualification of expenditures as High-cost Medical Care Benefits

Health Insurance Societies offer special treatment for households whose medical care costs have qualified as High-cost Medical Care Benefits three or more months within the nearest given 12-month period. Health Insurance Societies reimburse the balance of household expenditures in excess of the amount of the table below for the fourth and succeeding periods.

* Persons with low income refer to insured persons and dependents exempted from municipal tax or to insured persons and dependents who do not require public assistance if they are approved as eligible for measures for reducing cost burdens for persons with low income.

(3) Special cases involving 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.

Exception for the cost-sharing maximum amounts of a family member of an insured person who has turned 75

Half of the corresponding amount will be exceptionally applied, for the month that an insured person's 75th birthday belongs, as the cost-sharing maximum amounts for a dependent under 70 years old who will be disqualified since the insured person he or she has been depended on will turn 75 and become an insured person under the long life medical care system. (Not including cases in which the insured person's 75th birthday will be the first day of that month).
(The cost-sharing maximum amounts under the National Health Insurance or other plans that he or she will join after disqualification will also be half of the corresponding amount.)

Annual High-Cost Medical Care Benefits for outpatient care (annual total of outpatient costs) for those aged 70 or older

Insured persons and dependents aged 70 or older whose total copayments for outpatient care during the one year period (from August 1 of the previous year to July 31) exceeded 144,000 yen are eligible to be reimbursed for the excess amount as High-Cost Medical Care Benefits.

* This benefit is available only to those whose income category is "general" or "low income" as of the basis date (July 31, or the day before the date of death in the event of the death of the insured person).

* Calculations of High-Cost Medical Care Benefits exclude copayments paid during a period in which the insured person belonged to the "same income level as active workers" category.

Payment of high aggregate cost for long-term care service

To reduce high co-payments, a system will be established whereby the co-payments for health insurance and long-term care insurance are aggregated annually and benefits paid to cover high aggregate cost for long-term care service if this annual aggregate is remarkably high.