EY Japan
Health Insurance Society

High-cost Medical Care Expenses

High-cost Medical Care Expenses and Co-payment Reductions (Additional Family Medical Expense Benefit)

The EY Japan Health Insurance Society reimburses insured persons and dependents for high-cost medical care expenses paid at the billing counter for inpatient or other medical care at a later date. A co-payment reduction (additional family medical expense benefit) is also offered as a unique benefit from the EY Japan Health Insurance Society.

Insured persons and dependents can limit payments at the billing counter of healthcare providers to the ceiling amount of out-of-pocket costs by applying for and presenting an Eligibility Certificate for Ceiling-Amount Application. See more details about the Eligibility Certificate for Ceiling-Amount Application here.

These payments are calculated automatically based on the "medical fee statement" sent from the medical institution to the Health Insurance Society (the insured person or dependent does not need to submit an application form). ) Payment is made approximately three to four months after the month of treatment.

*Insured persons and dependents can reduce the burden of co-payments when the total amount of out-of-pocket payments for medical insurance or long-term care exceeds a certain amount through programs such as the high-cost medical care expense and high-cost long-term care cooperation system for reimbursements of excess medical care costs or certificates issued for specified disease treatments to reduce the ceiling amount for specified diseases incurring high-cost medical care expenses.

*If there are two or more cases of out-of-pocket payments of 21,000 yen or more in the same household, and if the combined total exceeds the ceiling amount, the excess amount is paid as “household combined high-cost medical expenses.”

Persons Who Are Receiving Benefits from a Medical Care Costs Subsidy System for Infants and Children

If subsidies are available from public institutions such as the national government or local governments (prefectures and municipalities), subsidies will be given priority. In order to prevent double benefits for local government subsidies and health insurance benefits, we do not, in principle, provide automatic family medical care cost supplement benefits to dependents who are covered by the "infant," "child," or "high school student" medical expense subsidy system in area of residence. If you are unable to receive medical expense subsidies from the local government due to income restrictions or other reasons, please contact the Health Insurance Association.

Eligibility Certificate for Ceiling-Amount Application

Insured persons and dependents can apply to have a certificate issued by the EY Japan Health Insurance Society in advance for any out-of-pocket payments exceeding the ceiling amount to present at the billing counter of the healthcare provider in order to limit payment to only the medical costs up to the maximum amount. After you complete the procedure below, an Eligibility Certificate Card will be sent to your specified address.
If you use your Individual Number Card (My Number Card) as your health insurance card, you will be exempt from paying any out-of-pocket expenses that exceed the maximum amount under the High-Cost Medical Expenses System without undertaking any prior procedures.
There is no need to apply for an Eligibility Certificate for Ceiling-Amount Application in advance.

Calculation Method for High-Cost Medical Care Expenses

Regardless of whether or not you submit the Eligibility Certificate for Ceiling-Amount Application, the amount calculated by deducting 20,000 yen from the medical care costs paid at the hospital billing counter will be paid approximately 3 months after the month in which medical treatment was received (If the calculation result is less than 500 yen, no payment will be made).

*High-cost medical care expense benefits are calculated automatically and do not require an application.

In either case, the amount of final co-payment is the same.

Aggregated High-cost Medical Care Expenses for a Household

*If there are two or more cases of out-of-pocket payments of 21,000 yen or more in the same household for the same month, and if the combined total exceeds the ceiling amount, the excess amount is paid as “household combined high-cost medical expenses.”

Four Months or More of High-cost Medical Care Expenses (Multiple Occurrences)

The co-payments from the fourth month in which high-cost medical care expenses exceed the ceiling amount vary as follows when insured persons and dependent have paid high-cost medical care expenses three or more times in one year (last 12 months) in the same household.

Regarding "the Annual Maximum"

Special Exception for Specified Diseases

Patients with hemophilia, acquired immune deficiency syndrome (AIDS) administered antiviral agents, and chronic renal failure requiring dialysis for an extended period only need to pay 10,000 yen per month to a healthcare provider once certified as a person with a specified disease. However, patients who require dialysis have a co-payment of 20,000 yen if their standard monthly remuneration is 530,000 yen or more. (This applies to both insured persons and dependents.)