Medical Care Benefits (for dependents, “Dependents' Medical Care Expenses”)

• ** The co-payment ratio for those 70 to 74 years of age (excluding those earning an income with the same level as active workers) had been kept at 10% from April 2008 to March 2014.For those who will reach 70 years of age on or after April 1, 2014 (born on or after April 2, 1944), the co-payment ratio will be 20% for medical treatment they receive in or after the month following the month in which they turn 70 years of age.
• ** For those who have reached 70 years of age on or before March 31, 2014 (born between April 2, 1939, and April 1, 1944), the co-payment ratio will remain 10% (or 20% for injuries and sickness caused by an act of a third party).
• ** See here for information on measures for reducing cost burdens for persons aged 70-74.
• **Persons earning income at the same levels as active workers: This refers to elderly persons aged 70-74 whose standard monthly remuneration is 280,000 yen or more. See here for more information.

Using health insurance, you can get necessary medical care for treatment of nonoccupational sickness and injury by making a copayment of 30%. This is referred to as "Medical Care Benefits" (for dependents, "Dependents' Medical Care Expenses"). You pay only 30% of medical care costs at the medical care institution because the Health Insurance Society covers the remaining 70%.

The Health Insurance Society later pays the amount of medical care costs paid at the hospital over one month minus 20,000 yen, as “Patient Cost-Sharing Reimbursements” (for dependents, “Dependents' Medical Care Additional Sum”). This payment is calculated and made automatically based on “the Rezept (medical cost details)” sent by the hospital to the Health Insurance Society. Payment will occur roughly four or five months after the month of the medical care.
See “When you incur high medical care costs: How High-Cost Medical Care Benefits are calculated” for a specific calculation example.

Payment of additional sums to eligible recipients of subsidy systems for medical expenses

The Health Insurance Society pays additional sums (patient cost-sharing reimbursements and additional benefits or dependents' medical care additional sum) to eligible recipients of their local government's (municipality's) subsidy systems for medical expenses on a reimbursement basis (payment on demand) to avoid duplicate payments. Do not forget to claim medical expenses you have incurred that are covered under those systems, as described below.

Eligible persons (eligible recipients of subsidy systems for medical expenses)

Persons who have been issued a certificate of an eligible recipient of medical expenses by their local government under any of the following subsidy systems for medical expenses

• 1) Subsidy for Medical Expenses of Infants and Children
• 2) Subsidy for Medical Expenses of Single-parent Families, etc.
• 3) Subsidy for Medical Expenses of Severe Mental or Physical Disabilities
• 4) Other subsidy systems for medical expenses independently implemented by each local government under which the co-payment amount of an eligible person will be zero or reduced (Subsidy for Medical Expenses of Expectant and Nursing Mothers, etc.)
  *Some local governments may have systems that are named differently.

Cases where you are required to claim additional sums

• 1) When an eligible recipient of a subsidy system for medical expenses receives treatment at a medical care institution and pays his/her co-payment amount and then claims a medical expense subsidy from his/her local government, and there remains a co-payment amount of 21,000 yen or more (*1)
• 2) When a child of high school age or younger receives treatment at a medical care institution outside of the relevant subsidy system for medical expenses, as his/her guardian (insured person) has income above a certain level and thus is not eligible for the system, and there remains a co-payment amount of 21,000 yen or more (*1)
  *1 Per patient, per month (calendar month), per medical care institution (inpatient/outpatient)

How to apply for additional sums

If you paid a co-payment amount of your medical expenses at a medical care institution, you should first claim a subsidy from your local government. If the calculation of the amount of your medical expense subsidy received from your local government excludes the additional sums from the Health Insurance Society, please send a claim form to the Health Insurance Society together with the following documents (the statute of limitation for a claim is two years).

(Claim forms)

• Claim for Patient Cost-Sharing Reimbursements and Additional Benefits (for insured persons)
  Claim for Patient Cost-Sharing Reimbursements and Additional Benefits (131KB)
  Claim for Patient Cost-Sharing Reimbursements and Additional Benefits (53KB)
• Claim for Dependents' Medical Care Additional Sum (for dependents)
  Claim for Dependents' Medical Care Additional Sum (138KB)
  Claim for Dependents' Medical Care Additional Sum (54KB)

(Attachments)

• A copy of the receipt of your co-payment medical expenses
• A copy of the notification of determination of eligible medical expense recipient issued by your local government or a similar document

Notes:

The Health Insurance Society does not require insured persons to submit a certificate of an eligible recipient of medical expenses (copy) for children of high school age or younger as they are covered under subsidy systems for medical expenses in most local governments, except when you are not eligible because of the income limit, or your child is high school age or older and is still eligible for subsidy systems for medical expenses, and in which case, you should notify the Health Insurance Society of such a situation. If you are eligible for a subsidy for medical expenses of single-parents, or serious mental or physical disabilities, please submit a copy of your certificate of an eligible recipient of medical expenses (copy) to the Health Insurance Society.