Tokyo securities industry health insurance society privacy policy
Japanese sitemap
Links
Introduction to Kenpo Seach by life stage when you need long-term care when you become sick or injured List of application forms
Additional health insurance information Guide to recreation facilities Health examinations, disease prevention Guide to directly managed clinic Other activities
Pritection of personal information
HOME > When you become sick or injured? > When your medical costs grow large > When your medical costs grow large
When your medical costs grow large 現金給付
 

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"



What is the fixed amount (individual cost-sharing maximum amounts)?

Standard monthly remuneration

Individual cost-sharing maximum amounts

830,000 yen or more

252,600 yen +
(Medical care costs incurred- 842,000 yen) * 1%

530,000 yen - 790,000 yen

167,400 yen +
(Medical care costs incurred - 558,000 yen) * 1%

280,000 yen - 500,000 yen

80,100 yen +
(Medical care costs incurred - 267,000 yen) * 1%

260,000 yen or less

57,600 yen

Persons with low income*

35,400 yen

* 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.


High-cost Medical Care Benefits are calculated in terms of (1) months, (2) individuals, and (3) hospitals. Outpatient and inpatient expenses are calculated separately, as are dental care and other medical care expenses.



Individual cost-sharing upon treatment−Illustration

*

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)



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 starting in August 2018, those falling in the category of the same income level as active workers II or active workers I will also need to submit a certificate to avoid paying more than the cost-sharing maximum amount.



procedure

Fill in the form below and apply together with your insurance card for the Maximum Co-payment Certificate for Health Insurance.

Procedural
Documents:

1.

Request for issuance of Maximum Co-payment Certificate for Health Insurance

 

Without no application for issue of a co-payment maximum certificate or no presentation of your certificate at the reception desk of the hospital,the Health Insurance Society provides a cash payment as High-cost Medical Care Benefits at a later date.At the Health Insurance Society, this is carried out automatically, so there is no need to make an application. Note that because the calculation is made on the basis of the "detailed medical fee statement" sent to the Health Insurance Society by the hospital, the payment will be made around three months after the treatment.



In the case of our health insurance society

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"



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.



In the case of our health insurance society

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.


当組合の給付額
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.

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

Persons with low income*

24,600 yen

* 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.)

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.

See here for more information >>In cases in which the co-payment for medical care or long-term care is remarkably high.


Index Top
When your medical care costs grow large
  When your medical care costs grow large
  Our Health Insurance Society offers loans to cover high-cost medical care expenses
  In cases in which personal payments for medical and long-term care are remarkably high
Index



Copyright© 2004 Tokyo securities industry health insurance society All rights reserved.