When you incur high medical care costs
Your copayment for medical care costs is capped. If your copayment calculated based on certain standards exceeds the maximum, the excess amount will be paid as "High-Cost Medical Care Benefits".
- By using a Myna health insurance card, you will be exempt from payments beyond the maximum copayment amount under the High-Cost Medical Care Benefits system, because your cost-sharing maximum amount information will be provided with no need to give your consent and 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")
Amount paid
| Copayment: 30% | |
|---|---|
| Cost-Sharing Maximum Amounts | Reimbursement as High-Cost Medical Care Benefits |
Individual cost-sharing maximum amounts
| Category | Individual cost-sharing maximum amounts | |
|---|---|---|
| Standard monthly remuneration | ||
| ア | 830,000 yen or more | 252,600 yen ＋ (medical care costs - 842,000 yen) *1% |
| イ | 530,000 yen - 790,000 yen | 167,400 yen ＋ (medical care costs - 558,000 yen) *1% |
| ウ | 280,000 yen - 500,000 yen | 80,100 yen ＋ (medical care costs - 267,000 yen) *1% |
| エ | 260,000 yen or less | 57,600 yen |
- ** 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 on a case by case basis.
- * A single case refers to one set of medical cost details. Medical cost details are prepared monthly for each patient by each medical care institution. (Note that inpatient medical care, outpatient medical care, inpatient dental care, and outpatient dental care are handled separately, even if provided by the same medical care institution.) External prescriptions for which the dates of visiting the pharmacy and the dates of visiting the medical care institution issuing the prescriptions fall in the same month are considered to belong to the same single case.
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
①Using a Myna health insurance card
By scanning your Myna health insurance card with a card reader at the reception desk and consenting to provide your cost-sharing maximum amount information, the medical care institution can verify your cost-sharing maximum amount online. This eliminates the need for a Certificate of Application of Maximum Copayment Amount, which previously required an application and was issued in paper form.
* See ② if you would like to be treated as being in the low income category because the insured person is tax-exempt.
②Using a Certificate of Application of Maximum Copayment Amount
If you are unable to use a Myna health insurance card, submit a Request for Issuance of Certificate of Application of Maximum Copayment Amount to the Health Insurance Society beforehand. It will typically take about one week after you apply for the certificate to be issued. Given the potential for postal delays, we recommend applying well in advance.
If you would like to be treated as being in the low income category because the insured person is tax-exempt, attach a certificate of exemption from resident tax. Contact the Health Insurance Society in advance, since the relevant tax year may vary depending on the applicable month.
How High-Cost Medical Care Benefits are calculated
Calculation example: If the copayment for one months' medical care costs is 300,000 yen (for an insured person with 280,000 yen - 500,000 yen of standard monthly remuneration)
| Total amount of medical care costs 1 million yen | |
|---|---|
| Copayment 30% 300,000 yen |
Medical Care Benefits 70% 700,000 yen |
The amount in excess of the Cost-Sharing Maximum Amount is paid as High-Cost Medical Care Benefits.
80,100 yen＋1,000,000 - 267,000 yen)*1%
＝87,430 yen
212,570 yen
The Health Insurance Society also pays additional benefits.
20,030 yen
67,400 yen**
- * Patient Cost-Sharing Reimbursements and Additional Benefits, Additional Total High-cost Medical Care Benefits, Home-Visit Nursing Care Additional Sum
- ** Figures rounded down to the nearest 100 yen
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".
- * A single case refers to one set of medical cost details. Medical cost details are prepared monthly for each patient by each medical care institution. (Note that inpatient medical care, outpatient medical care, inpatient dental care, and outpatient dental care are handled separately, even if provided by the same medical care institution.) External prescriptions for which the dates of visiting the pharmacy and the dates of visiting the medical care institution issuing the prescriptions fall in the same month are considered to belong to the same single case.
The society's additional benefits
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 500 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.
| Category | Individual cost-sharing maximum amounts | |
|---|---|---|
| Standard monthly remuneration | ||
| ア | 830,000 yen or more | 140,100 yen |
| イ | 530,000 yen - 790,000 yen | 93,000 yen |
| ウ | 280,000 yen - 500,000 yen | 44,400 yen |
| エ | 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.
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 |
Caution
The right to claim health insurance benefits expires in two years.
Our Health Insurance Society offers loans to cover high-cost medical care expenses
Although the Health Insurance Society pays benefits for high-cost medical care such as those incurred for hospitalization, since these benefits are actually paid to the insured approximately three months following examination and treatment, not a few insured households would find it difficult to make ends meet over this period.
For this reason, a system has been developed to provide interest-free loans for covering current-account payments over the period until payment of benefits for "high-cost medical care." As part of its operations, the Tokyo General Health Insurance Society Promotion Association handles this system, known as “short-term loans program for benefits for high-cost medical care.”
Since the Health Insurance Society is a member of this association, this system is available for use by any insured persons. Please feel free to apply to take advantage of this system.
1.Borrower requirements
This system is available for use only by persons expected to receive payment of benefits from the Health Insurance Society for high-cost medical care (not including costs not eligible for insurance coverage, such as those for higher-cost beds, which will not be included in calculation of benefits for high-cost medical care).
2.Application method
Attach to the “Application for Short-Term Loans for Benefits for High-Cost Medical Care” a certificate or a copy of a bill issued by the medical institution that shows the insurance coverage score for the subject medical expenses, have these certified by your employer, and submit them to the Health Insurance Society’s Benefits Section.
3.Loan amount
90% of the amount corresponding to the subject high-cost medical care expenses (rounded down to the nearest 1,000 yen)
4.Remittance of loan funds
The loan funds will be remitted to your designated bank account. (No fees are required.)
5.Repayment and settlement of loan funds
When the Health Insurance Society has determined the amount of high-cost medical care expenses, it will repay the loan to the Tokyo General Health Insurance Society Promotion Association directly.
The approximately 10% of the amount of high-cost medical care expenses remaining after repayment of the loan will be paid by the Health Insurance Society.