When you incur high medical care costs

Procedures

When the self-pay amount of medical expenses exceeds a certain amount, the health insurance association automatically calculates it based on the medical treatment statement (receipt) sent from the medical institution, and at a later date, "high medical expenses" and the total amount of "additional benefit expenses" will be paid.
(Expenses not covered by insurance, such as bed charges, and meals when hospitalized are not covered)

High medical expenses

If you are hospitalized due to illness or injury, a large amount of medical expenses may be incurred. If the self-pay amount exceeds a certain amount, the excess amount will be provided by the health insurance association as "high medical expenses".
High medical expenses are usually paid once at a medical institution, etc., and then refunded at a later date. It is not necessary for insured persons and dependents to submit applications.
In addition, the Health Insurance Society will pay the amount after deducting ¥20,000 from the self-pay limit at a later date (less than ¥1,000 will not be paid, rounded down to the nearest ¥100). This is called "Partial contribution reduction (family medical treatment surcharge)." Payment will be calculated automatically based on the "medical treatment statement" sent from the medical institution to the health insurance association, but the payment will be made approximately 3 to 4 months after the medical treatment month.

* There is also a high-priced medical treatment / high-value nursing care complex system that refunds the total amount of self-paid medical insurance and long-term care insurance if the total amount exceeds a certain amount.

Payment and additional benefits

Payment	The excess amount when the out-of-pocket amount for medical care costs incurred for one procedure in one month exceeds the ceiling amount *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.” The excess amount when the total out-of-pocket expenses during the calculation period (from August 1 of the previous year to July 31) exceed the annual limit for the income category as of the reference date (July 31)
Health insurance association additional benefits	Partial refund, family medical treatment surcharge ：Pay the amount of ¥20,000 deducted from the self-pay amount (less than ¥1,000 will not be paid, rounded down to the nearest ¥100) * Excludes high-cost medical treatment, standard medical expenses for hospital meals, and standard medical expenses for daily living at hospitals.

Payment

The excess amount when the out-of-pocket amount for medical care costs incurred for one procedure in one month exceeds the ceiling amount
*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.”
The excess amount when the total out-of-pocket expenses during the calculation period (from August 1 of the previous year to July 31) exceed the annual limit for the income category as of the reference date (July 31)

Health insurance association additional benefits

Partial refund, family medical treatment surcharge
：Pay the amount of ¥20,000 deducted from the self-pay amount (less than ¥1,000 will not be paid, rounded down to the nearest ¥100)

* Excludes high-cost medical treatment, standard medical expenses for hospital meals, and standard medical expenses for daily living at hospitals.

Cost-Sharing maximum amount of medical expenses

＜For those under age 70＞

Income classification	Up to 3rd time*1	From 4th time*1	Annual maximum*2
Standard monthly remuneration of 830,000 yen or more	270,300 yen ＋（total medical care costs － 901,000 yen）× 1％	140,100 yen	1,680,000 yen
Standard monthly remuneration of 530,000 yen to 790,000 yen	179,100 yen ＋（total medical care costs － 597,000 yen）× 1％	93,000 yen	1,110,000 yen
Standard monthly remuneration of 280,000 yen to 500,000 yen	85,800 yen ＋（total medical care costs － 286,000 yen）× 1％	44,400 yen	530,000 yen
Standard monthly remuneration of 260,000 yen or less	61,500 yen	44,400 yen	530,000 yen*3
Low-income earner*4	36,900 yen	24,600 yen	290,000 yen

*1 If a household has qualified for High-Cost Medical Expense benefits three or more times within the past 12 months, the maximum out-of-pocket limit will be reduced from the fourth time onward.

*2 If the total out-of-pocket expenses during the calculation period (from August 1 of the previous year to July 31) exceed the annual limit for the income category as of the reference date (July 31), the excess amount will be paid as a benefit.

*3 For those who are confirmed to have a standard monthly remuneration of 150,000 yen or less as of July 31, 2027, an annual maximum of 410,000 yen will be applied, and any amount exceeding the annual maximum incurred from August 2027 onward will be reimbursed on a retrospective payment basis.

*4 Insured persons and their dependents who are exempt from municipal inhabitant tax, or insured persons and their dependents who do not require public assistance (welfare) by being classified under the "low-income earner" category. Please note that individuals with a monthly standard remuneration of 530,000 yen or more do not qualify as "low-income earners" even if they are exempt from municipal inhabitant tax, and the standard classification based on monthly standard remuneration will apply.

Effective August 1, 2026

＜For those between the ages of 70 and 75＞

Income classification		Outpatient (per Individual)	Outpatient + Inpatient (per household)	Annual maximum*3
Persons earning the same level as those of working age*2	Persons earning the same level as those of working age - III Standard monthly remuneration of 830,000 yen or more	Persons earning the same level as those of working age*2 Persons earning the same level as those of working age - III Standard monthly remuneration of 830,000 yen or more	－	270,300 yen ＋（total medical care costs － 901,000 yen）× 1％ [140,100 yen]*1	1,680,000 yen
	Persons earning the same level as those of working age - II Standard monthly remuneration of 530,000 yen to 790,000 yen	Persons earning the same level as those of working age Persons earning the same level as those of working age - II Standard monthly remuneration of 530,000 yen to 790,000 yen	－	179,100 yen ＋（total medical care costs － 597,000 yen）× 1％ [93,000 yen]	1,110,000 yen
	Persons earning the same level as those of working age - I Standard monthly remuneration of 280,000 yen to 500,000 yen	Persons earning the same level as those of working age Persons earning the same level as those of working age - I Standard monthly remuneration of 280,000 yen to 500,000 yen	－	85,800 yen ＋（total medical care costs － 286,000 yen）× 1％ [44,400 yen]	530,000 yen
General	Standard monthly remuneration of 260,000 yen or less	General Standard monthly remuneration of 260,000 yen or less	22,000 yen （Annual maximum　216,000 yen*4）	61,500 yen [44,400 yen]	530,000 yen*5
Low-income earners (resident tax exemption)*6	Ⅱ	Low-income earners (resident tax exemption)*6 Ⅱ	11,000 yen （Annual maximum　96,000 yen*4）	25,700 yen [24,600 yen]	290,000 yen
Low-income earners (resident tax exemption)*6	Ⅰ (Annual income of 806,700 yen or less, etc.)	Low-income earners (resident tax exemption)*6 Ⅱ (Annual income of 806,700 yen or less, etc.)	8,000 yen	15,700 yen	180,000 yen

*1 Figures in square brackets represent the ceiling amount from the fourth month. The maximum amount decreases from the fourth month of high-cost medical expenses if medical care costs for the same household in the last 12 months satisfies the payment requirements for high-cost medical care expenses for three or more months.

*2 Income earners at the same level as active employees are insured persons or dependents who have a standard monthly remuneration of 280,000 yen or more.
However, these insured persons and dependents may pay the standard 20% out-of-pocket costs by filing an application with the Demo Health Insurance Society if:

The individual is age 70 or older and earns less than 3.83 million yen annually without any dependents
The individual has a dependent or former dependent age 70 or older and has a total combined annual income of less than 5.20 million yen

*3 When the total out-of-pocket expenses incurred over one fiscal year (August 1 of the previous year through July 31) exceed the "Annual Maximum" for the income bracket as of the standard date (July 31), in principle, the amount exceeding the ceiling will be paid as "High-Cost Medical Care Expenses."

*4 If, as of the reference date (July 31), you are classified as having a standard income level, and the total amount of your out-of-pocket expenses for outpatient medical care during the months in the calculation period (August 1 of the previous year through July 31) in which you were classified as having a standard income level exceeds JPY 216,000, the amount exceeding JPY 216,000 will be reimbursed. Similarly, if, as of the standard date (July 31), you are classified as a low-income individual, and the total amount of your out-of-pocket expenses for outpatient medical care during the months in the calculation period (August 1 of the previous year through July 31) in which you were classified as low-income exceeds JPY 96,000, the amount exceeding JPY 96,000 will be reimbursed. If you have been a member of our Health Insurance Society throughout the calculation period, the payment will be made automatically and no application is required. If you changed insurers during the calculation period, you will need to apply for the payment, so please contact the Health Insurance Society.

*5 For those who are confirmed to have a standard monthly remuneration of 150,000 yen or less as of July 31, 2027, an annual maximum of 410,000 yen will be applied, and any amount exceeding the annual maximum incurred from August 2027 onward will be reimbursed on a retrospective payment basis.

*6 Those who qualify as “persons earning the same level as those of working age” are not considered “low-income earners,” even if they are exempt from municipal tax. Therefore, the classification of “persons earning the same level as those of working age” applies.

Effective August 1, 2026

Those who receive infants and children medical expenses subsidy system, etc.

Regarding medical expenses (high-cost medical treatment expenses and family medical treatment surcharges) during compulsory education, local governments (prefectures and municipalities) have also implemented a "medical expense subsidy system" to subsidize medical expenses.
In order to prevent double payment of benefits with the subsidy of the local government, the Health Insurance Society does not automatically provide high-cost medical treatment expenses and family medical treatment surcharges for persons during the compulsory education period.
If the medical expenses become high and four months after the medical treatment month and there is no benefit from the local government or the health insurance association, please contact the health insurance association.

Limit application certificate.

If the self-pay amount exceeds the limit, if you apply to the health insurance association in advance and receive a certificate, you can show it to a medical institution and pay at the counter up to the self-pay limit.
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.

* To use your Individual Number Card as a health insurance card, you must register on the "Myna Portal site", etc.
For more information, please see here.

* Medical institutions that do not support the use of the Individual Number Card as your health insurance card are not exempt.
In addition, if the medical institution cannot confirm your eligibility using your Individual Number Card, you may not be able to receive an exemption.

(Note) If you are classified as a "low-income earner", you must apply for "Eligibility Certificate for Ceiling-Amount Application and Reduction of the Standard Amount of Patient Liability（限度額適用・標準負担額減額認定証）".

Procedure

Required documents

Health insurance limit application certificate application form
EXCEL

*If you present your Myna Health Insurance Card at the time of treatment, you do not need to apply for an Eligibility Certificate for Ceiling-Amount Application.
However, if you fall into the low-income earner category, you are required to apply in advance for the Eligibility Certificate for Ceiling-Amount Application and Reduction of the Standard Amount of Patient Liability, even when using your Myna Health Insurance Card.
If you fall into this category, please contact your health insurance society.

How to calculate high medical expenses.

Calculation for each consultation month (1st to last day of the month)
Calculated for each examinee
Calculation for each medical institution (Inpatient / outpatient / dentistry is calculated separately. For old general hospital, each department is calculated)

How to pay at the hospital window when a large amount of medical expenses are required for hospitalization

(Ex) If the standard remuneration monthly fee is ¥280,000 to ¥500,000 and the total medical expenses are ¥1,000,000

Regardless of whether or not a limit application certificate is used, the amount of medical expenses paid at the hospital window minus ¥20,000 will be paid approximately 3 months after the medical treatment month (less than ¥1,000 is not paid. Less than ¥100 Rounded down).

* Application is not required as it will be calculated automatically.

In either case, the final copayment remains the same.

In case of household total

If there are two or more self-payments of ¥21,000 or more per month in the same household, if the sum of those amounts exceeds the self-pay limit, the amount exceeding that amount will be paid as "total high medical treatment expenses".

When high-cost medical expenses apply for the fourth time or more (many apply)

If the same household receives high-cost medical treatment three or more times in the last 12 months, the self-pay limit will be as follows after the fourth time.

In case of many cases

Standard monthly fee	Self-pay ceiling
¥830,000 or more	¥140,100
More than ¥530,000 and less than ¥790,000	¥93,000
More than ¥280,000 and less than ¥500,000	¥44,400
¥260,000 or less	¥44,400
Low income (Exemption from residence tax)	¥24,600

Regarding "the Annual Maximum"

Effective August 2026, an "Annual Maximum" has been established to help those requiring long-term medical treatment better plan for their "future medical expenses," which have been a source of anxiety.

When the total out-of-pocket expenses incurred over one fiscal year (August 1 of the previous year through July 31) exceed the "Annual Maximum" for the income bracket as of the standard date (July 31), in principle, the amount exceeding the ceiling will be paid as "High-Cost Medical Care Expenses."

* The "Annual Maximum" is calculated on a household basis, and the ceiling amount varies depending on the age and income of the insured person.

* If additional benefits are received, the additional benefit amount is deducted from out-of-pocket expenses, and the remaining amounts are totaled.

* If the insurer changes during the calculation period, the "Annual Maximum" applies separately to the medical care received during the period of enrollment with each insurer.

Special cases of specific diseases.

Long-term patients with "hemophilia", "acquired immunodeficiency syndrome with antiviral agents", and "chronic renal failure requiring artificial dialysis" will be admitted to a medical institution when certified for a specific disease. The payment is ¥10,000 per month. However, if a patient who needs artificial dialysis has a standard monthly salary of ¥530,000 or more, the self-pay will be ¥20,000 per month. (Same for dependents)

Procedure

Those who receive treatment for a specific illness will receive the "Specific illness medical treatment medical treatment certificate" after submitting it to the Health Insurance Society with the proof of the doctor in the "Specific medical treatment medical treatment certificate application".
The "specific medical treatment medical treatment certificate" issued by the Health Insurance Society will be submitted together with the Myna Health Insurance Card or Health Insurance Eligibility Certificate to the medical institution counter.

* Since the amount received by the Health Insurance Society until the end of the month will be applied this month, if you are to be treated for a specific disease, please submit the application form immediately.

Required documents

Application form for specific medical treatment certificate　
EXCEL

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