If the medical expenses paid (out-of-pocket amount) exceed a certain amount (out-of-pocket maximum amount), it will be paid as high-cost medical expenses.
Applicable households will receive a "Notification of High-Cost Medical Care Benefits" three to four months after the month of medical treatment. The “Application for Payment” is enclosed, so please apply by mail.
The limit and calculation method are as follows.
Please note that if two years have passed since the 1st of the month following the month of medical treatment, it will expire and will not be paid.
From November 2022, the simplification of the application procedure for high-cost medical care expenses began. Click here for details.
Simplification of high-cost medical expenses payment application procedures has begun
Method of calculation
Meal expenses during hospitalization, bed charges not covered by health insurance, etc. are not covered.
The calculation method is different for those under 70 and those over 70.
Click here for high-cost medical care costs for those under the age of 70
70-74 years old
For those aged 70 to 74, all insurance medical treatment costs are covered by high-cost medical care benefits.
We will pay the sum of the amounts calculated in A and B below.
Individual unit (outpatient portion) A
If all outpatient co-payments are added up on an individual basis, the amount exceeding the individual unit limit (A in the table below) will be the high-cost medical care expense.
Household unit (including hospitalization) B
High-cost medical care expenses are the amount that exceeds the household unit limit (Table B below) by adding up the copayment for each individual (hospitalization and A limit).
・Until July 2018
| income category |
Individual unit limit (outpatient only, monthly) |
Household unit limit (monthly amount including hospitalization) |
|---|---|---|
| Income households above a certain level (those who pay 30%) | 57,600 yen | 80,100 yen + (total medical expenses - 267,000 yen) x 1% (44,400 yen if payment has been made 4 or more times in the past 12 months) |
| General household |
14,000 yen (annual upper limit of 144,000 yen) Note 1 |
57,600 yen (44,400 yen if paid more than 4 times in the past 12 months) |
| Resident tax exempt 2 Note 2 | 8,000 yen | 24,600 yen |
| Resident tax exempt 1 Note 3 | 8,000 yen | 15,000 yen |
Note 1: The annual upper limit applies to the total outpatient copayment for one year (August 2017 to July 2018).
Note 2: Households where the head of the household and all members of the National Health Insurance are exempt from inhabitant tax.
Note 3 Households where the head of the household and all members of the National Health Insurance are tax-exempt, and the income of each household member is 0 yen.
・Since the above income determination is performed every year, the income classification may change if the income changes. Also, the fiscal year for judging will change to August.
・For those who are receiving reduction measures for insurance premiums for involuntary unemployed people, the application category will be determined based on income that is 70% less than employment income.
・From August 2018
| income category |
Individual unit limit (outpatient only, monthly) |
Household unit limit (monthly amount including hospitalization) |
|---|---|---|
|
active duty 3 (tax base amount of 6.9 million yen or more) |
252,600 yen + (total medical expenses - 842,000 yen) x 1% (140,100 yen if paid more than 4 times in the past 12 months) |
|
| active duty 2 (tax base amount of 3.8 million yen or more) |
167,400 yen + (total medical expenses - 558,000 yen) x 1% (93,000 yen if paid more than 4 times in the past 12 months) |
|
|
active duty 1 (tax base amount of 1,450,000 yen or more) |
80,100 yen + (total medical expenses - 267,000 yen) x 1% (44,400 yen if paid more than 4 times in the past 12 months) |
|
| General household |
18,000 yen (annual upper limit of 144,000 yen) Note 1 |
57,600 yen (44,400 yen if paid more than 4 times in the past 12 months) |
| Resident tax exempt 2 Note 2 | 8,000 yen | 24,600 yen |
| Resident tax exempt 1 Note 3 | 8,000 yen | 15,000 yen |
Note 1: The annual upper limit is applied to the total outpatient copayment for one year (August 2018 to July 2019).
Note 2: Households where the head of the household and all members of the National Health Insurance are exempt from inhabitant tax.
Note 3 Households where the head of the household and all members of the National Health Insurance are tax-exempt, and the income of each household member is 0 yen.
・Since the above income determination is performed every year, the income classification may change if the income changes. Also, the fiscal year for judging will change to August.
・For those who are receiving reduction measures for insurance premiums for involuntary unemployed people, the application category will be determined based on income that is 70% less than employment income.
About ceiling application certificate
If you are 70 years old or older and all members of the National Health Insurance (including the fictitious head of the household) are exempt from residence tax, the meal charges for hospitalization and the payment at the hospital counter will be up to the maximum copayment amount. A Certificate of Application of Maximum Amount/Standard Contribution Reduction will be issued. In addition, if you are 70 years old or older and have an income category of 1 or 2 households, you will be issued a "Ceiling Amount Application Certificate".
A prior application is required for the issuance of a Certificate of Eligibility for Maximum Amount Application. Please bring your insurance card, etc., and apply for the issuance of a certificate. A valid certificate will be issued from the first day of the month to which the application date belongs.
In addition, if you pay the co-payment without presenting your certificate and fall under high-cost medical care, please submit the "Notice of High-Cost Medical Care" and "Payment Application" three to four months after the month of medical treatment. I will send it to you.
Details of National Health Insurance Benefits
About specific illness medical treatment certificate
For diseases that require high medical costs over the long term and are designated by the Minister of Health, Labor and Welfare (hemophilia, chronic renal failure requiring dialysis, HIV infection caused by administration of blood coagulation factor preparations), monthly You will be issued a certificate of medical treatment for a specific disease, with a copayment limit of up to 10,000 yen.
When applying, you will need your health insurance card and a doctor's opinion or a document proving that you are suffering from the disease.
Please apply at Ward Office 2F No. 1 (National Health Insurance Payment Section).
Please
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Related information
- Benefits of National Health Insurance Payment of high-cost medical expenses (under 70)
- Simplification of high-cost medical expenses payment application procedures has begun
- Benefits of National Health Insurance About the maximum amount of self-pay and the maximum amount application certificate, etc.
- Applying for National Health Insurance Maximum Amount/Standard Contribution Reduction Certificate (For those aged 70 to 74)
- Application for reissuance of National Health Insurance limit application/standard burden reduction certificate (persons aged 70 to 74)
Inquiries about this page
Citizens Department Insurance and Medical Care Division National Health Insurance Benefit Section
Ward Office 2nd Floor Window 1
telephone number 03-3228-5508 ｜ fax number 03-3228-5655 ｜ Mail form
Reception time 8:30 a.m. to 5:00 p.m. Monday through Friday (excluding public holidays)