High-Cost Medical Care Benefits (for dependents, “Dependents' 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 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 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.

When the co-pay amount is high

When the amount that you paid at medical care institutions for (1) each month of medical care, (2) each person, and (3) each hospital (specification of inpatient/outpatient, medical/dental) exceeds the maximum amounts on the following table, you are eligible for reimbursement of the amount in excess.
When high-cost medical care benefits and patient cost-sharing reimbursements and additional benefits and other additional benefits are paid for pharmaceutical drugs from pharmacies based on prescriptions from medical care institutions, itemized statements of medical expenses and itemized statements of pharmaceutical prescription expenses are combined and calculated as a single case.

Method of reimbursement

At YHIS, procedures (including for additional benefits) are automatic; applications are generally not required.

•  Automatic payment (in principle)
  Benefits are automatically calculated based on bills from medical care institutions, and, in principle, are paid together with wages three months after the month in which the care was received.
  (Insured persons’ addresses are used to determine whether municipal subsidies for medical care costs exist. If subsidies exist, payment of benefits is suspended.)

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

By using a Myna health insurance card, you can ensure that the amount of medical care costs the hospital bills you (per month) will not exceed the individual cost-sharing maximum amount and thus reduce the amount you must pay at the reception desk of the hospital, because your cost-sharing maximum amount information will be provided with no need to give your consent.
(Available for both inpatient and outpatient care)

See here for more information.

Reference link

• You can use your Individual Number Card as a health insurance card

Note that you will need a Certificate of Application of Maximum Copayment Amount in the following cases. If you need this certificate, apply in advance.

• Examinations and treatment received at a medical care institution or other facility that has not adopted the online eligibility verification system
• When not using a Myna health insurance card
• When not using a Myna health insurance card and you are 70 or older and in the same income category as active workers Ⅰ or Ⅱ

• * Even when using a Myna health insurance card, those in the low income category must apply in advance for a Maximum Copayment/Reduced Standard Copayment Certificate to be treated as falling in the low income category.

Reference link

• When you incur high medical care costs「When you want to reduce the amount of medical care costs you pay at the medical care institution」

How High-Cost Medical Care Benefits are calculated

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”.

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.

• ** See here for persons aged 70-74.
• ** See here concerning persons with low income.

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.