If you use the National Health Insurance when you receive medical treatment at a hospital etc., you are supposed to pay 30% of the total medical fees. If you use the Employee’s Health Insurance, payment by the insured individual is 20% and that of a dependent is 20% (inpatient) or 30% (outpatient). This is called “co-payment”. Some medical treatment such as long-term inpatient or special medical treatment may make your co-payment unaffordable. Official support is available to anyone whose co-payment to a medical institution exceeds the limit of maximum co-payment set by the government.
(1) In the case where your co-payment to the same medical institution exceeds the limit (¥63,000 per month) the excess is subsidized by the government. (If the total medical fee is more than ¥318,000, 1% of the excess is added to the limit of ¥63,000).
Example A: For an inpatient whose total medical fee per month is ¥250,000. If the National Health Insurance is applied to the case, you pay 30% of the total cost (¥250,000 x 0.3 = ¥75,000(your co-payment). If you claim for the subsidy for expensive medical fees, the excess of ¥11,400 is refunded (calculated as follows - ¥75,000 (your co-payment) - ¥63,000 (the government limit) = ¥11,400).
Example B: Total medical fee for one month per month is ¥500,000.
If you use the National Health Insurance, your co-payment (30%) is ¥500,000 x 0.3 = ¥150,000. The maximum limit of co-payment varies as follows: initial limit (¥63,600) + additional limit (¥500,000 - ¥318,000) x 1% = new limit (¥65,420). The amount to be refunded is calculated as follows: ¥150,000 - ¥65,420 = ¥84,580.
If a family is exempt from resident taxes, the limit is constant at ¥35,400 irrespective of the medical fee. So, in Example A the calculation is ¥75,000 - ¥35,400 = ¥39,600. In Example B the calculation is ¥150,000 - ¥35,400 = ¥114,600. These would be the sums reimbursed respectively.
(2) In the case where a family makes a co-payment of more than ¥30,000 more than twice a month (¥21,000 for a tax-exempt family) and the total amount paid by the family exceeds the limit stated in (1), the excess is subsidized as expensive medical fees.
Example: Supposing monthly medical fees of a father and child are ¥200,000 and ¥100,000 respectively, the father’s co-payment is ¥60,000 and the child’s ¥30,000. The subsidy is not applicable to each of them unless their separate payments are more than the limit. In this case the co-payments exceed the limit of ¥30,000. According to rule (2) ¥26,400 is refunded – calculated as follows (¥60,000 + ¥30,000) - ¥63,600 = ¥26,400. In the case of a tax-exempt family ¥54,600 is refunded – (\¥60,000 + ¥30,000) - ¥35,400 = ¥54,600.
(3) In the case where the subsidy is granted more than three times a year due to long-term inpatient stay etc., the maximum limit of co-payment is reduced to ¥24,600 for a tax-exempt family and ¥37,200 for an ordinary family.
(4) In the case where the annual income of the family is above ¥6.7 million (average monthly salary is above ¥560,000 for someone in the Employee’s Health Insurance), the limits explaining in (1) rise to ¥121,800 from ¥63,600 and to ¥609,000 from ¥318,000.
Notes:
The subsidy for expensive medical fees is provided for medical treatment covered by health insurance (co-payment is 20% or 30%). It does not include items not covered by health insurance (i.e. special dental treatment (gold fillings etc.), meals during impatient care, special bed fees, etc.).
Application procedures require all co-payments to be paid first then claim for the subsidy and a refund later. If one is unable make the co-payments prior to an application, an official scheme to pay for the excess is available. This means that one will pay only for the amount of the maximum limit to the medical institution. There is a similar scheme for users of the Employee’s Health Insurance. However, the procedures and the contents of the assistance vary depending on the locality.
For details of the subsidy or official support scheme, contact your nearest welfare office or a consulting office at a hospital or a medical social worker. Remember to keep receipts for medical services.