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HOME > When you become sick or injured? > Other benefits > When you receive medical treatment which require patient's pay on the difference
When you receive medical treatment which require patient's pay on the difference Benefits in kind

When an insured person undergoes treatment not covered by insurance, he or she must pay the entire amount of medical costs including those for treatment covered by insurance.
However, in response to the advancement of medical technologies and diversifying patient needs, even when the patient is undergoing treatment not covered by insurance, health insurance may be used for treatment under evaluation and elective treatment that meets certain conditions. Although the patient must pay any amounts exceeding the limits of insurance coverage, insurance benefits will be provided for medical costs to which insurance applies.
Individual cost-sharing for this portion covered by insurance is 30 percent (20 percent in the event patients are 2 years old or younger) as it is with general insurance treatment. The remaining amount is covered by insurance as "Additional Medical Costs not covered by insurance."

Treatment partly at their own expense - Illustration


Dependents receive benefits for Additional Medical Costs not covered by insurance as Dependents' Medical Care Expenses.


High-cost medical care or additional benefits are available in cases where cost-sharing by insured persons and dependents fall within the scope of health insurance.


The insured persons and the dependents also cover inpatient meals (meal and accommodation expenses in the event an elderly person 70 years old or older is hospitalized in a medical treatments facility).

Treatment under evaluation, Patient-requested care, and elective treatment

<Treatment under evaluation>


This refers to treatment being evaluated for possible insurance coverage in the future, such as new treatment methods and medicines whose medical value has yet to be established.


Advanced treatment

Cases involving clinical trials of pharmaceuticals, medical equipment, and regenerative medicine products

Use of pharmaceuticals, medical equipment, and regenerative medicine products approved by the Pharmaceutical Affairs Act prior to application of insurance to such equipment

Use of pharmaceuticals for which drug price standards have been published, for uses other than those covered in such standards
(Those for which application has been made for approval of partial changes to usage, doses, efficacy, or effects)

Use of medical equipment and regenerative medicine products for the purpose outside of insurance coverage
(Those for which application has been made for approval of partial changes to purpose of use, efficacy, effects, etc.)


<Patient-requested care>


Care such as use of pharmaceuticals not yet approved for use in Japan or use of those approved for use in Japan but for other than their approved uses, subject to accelerated approval as non-insured associated medical care requested by the patient


[Flow from request through care]


A patient who, following consultation with his or her family doctor or other healthcare provider, would like to use advanced medical care technologies not covered by insurance together with insured medical care, requests such care from the Core Clinical Research Hospital or from a special functioning hospital. After issues like treatment efficacy and safety are explained to the patient, he or she applies to the Japanese government for patient-requested care, attaching a written opinion prepared by the Core Clinical Research Hospital or other facility.
While screening of advanced medical care by the Japanese government traditionally took about six months, in the case of patient-requested care, this time in principle is shortened to six weeks (two weeks in principle for treatment administered in previous cases).
If the application is approved following the screening process, the patient will receive treatment at the Core Clinical Research Hospital or other facility receiving the request. However, depending on the results of the screening, the treatment may be provided at a medical care institution located near where the patient lives.


<Elective treatment>


This refers to treatment chosen by the patient him or herself that it is assumed not to be covered by insurance, such as special treatment environments.


Provision of special treatment environments (hospitalization in higher-cost beds)

Examination and treatment by reservation

Examination and treatment outside regular hours

Use of higher-priced materials for front teeth

Metallic false teeth

First examination and subsequent examinations at a hospital of 200 or more beds of a patient not referred to that hospital

Treatment conducted more than the designated maximum number of times

Hospitalization for more than 180 days

Continued maintenance after completion of treatment of childhood cavities

First examination and subsequent examinations of a patient not referred to that hospital or facility at a special functioning hospital or similar facility

Lens reconstruction using multifocal intraocular lens

Advanced medical care

Under the system for the "advanced medical treatment", use of uninsured treatment together with insurance treatment is permitted in special cases. The "advanced medical treatment", assuming certain standards are met in areas such as safety and efficacy, allows you to receive health insurance benefits for the portion of the costs corresponding to ordinary treatment, such as medical consultations. Note that you must still pay the full amount of costs for the advanced medical technology itself. This can reduce the amount you need to pay yourself.
Advanced medical treatment technologies are available only at medical care institutions that satisfy standards established by the Ministry of Health, Labour and Welfare of Japan.

Room charges for hospitalization

Health insurance covers charges for hospital rooms. However, you must pay the balance in the event you occupy a private room or a "deluxe room" whose cost exceeds the maximum amount of insurance benefits. Such accommodations are often referred to as "amenity beds," although they are officially designated "rooms offering special treatment environments." A hospitalized patient pays the balance only when he or she has requested a "room offering a special environment."
Although opinions may vary when it comes to defining what constitutes a room with good conditions, an extra charge may be sought not only for a private or twin room, but also for a three- or four-person room if the following conditions are met.


There are four or fewer beds in a single room


The room floor space is equivalent to 6.4 square meters or more per person


Facilities are in place affording some degree of privacy around each bed


Private storage facilities, tables, chairs, and lighting have been installed

A large ward transformed into private rooms by erecting veneer partitioning, a new building, or a sunny building do not constitute reasons for demanding an extra charge.

Dental treatment

Health insurance covers all types of normal dental treatment. Insured persons and dependents are required to pay remaining balances in excess of maximum benefit amounts when they wish to have a full set of dentures made using a metal base or other treatments using materials not covered by health insurance.

Index Top
Other benefits
@ Cases in which medical treatment is provided at home
@ When you receive medical treatment which require patient's pay on the difference
@ When you are unable to walk and require transport for hospitalization
@ Medical care at public expense

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