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Health insurance benefits
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When you incur high medical care costs

Your copayment for medical care costs is capped by the insured person’s income category. If your copayment (30% of medical care costs) exceeds the maximum, the excess amount will be calculated by the Society and paid as “High-Cost Medical Care Benefits.” However, some procedures are required to ensure that the amount you pay at the reception desk of the hospital does not exceed the Cost-Sharing Maximum Amounts.

High-Cost Medical Care Benefits

If the copayment amount for medical care costs paid at the reception desk of the hospital becomes high, the Health Insurance Association will automatically pay the amount beyond a certain amount later (the Cost-Sharing Maximum Amount) to help ease the burden of medical care costs. This is referred to as “High-Cost Medical Care Benefits.”

High-Cost Medical Care Benefits are calculated for medical care costs incurred over a one-month period, from the first through the last day of the month. High-Cost Medical Care Benefits are also calculated on a per-person, per-hospital (outpatient/inpatient, medical/dental, etc.) basis.

If you want to make sure that the amount you pay at the reception desk of the hospital will not exceed the Cost-Sharing Maximum Amounts

If a person less than 70 years of age expects to incur high medical care costs, it can be more convenient to obtain “a Certificate of Application of Maximum Copayment Amount” in advance. By showing this “Certificate of Application of Maximum Copayment Amount” to the medical care institution together with your health insurance card, you can ensure that the amount of medical care costs for which the hospital bills you (per month) will not exceed the Cost-Sharing Maximum Amount and reduce the amount of medical care costs you must pay at the hospital on any single visit (You can use this certificate for both inpatient and outpatient care).

Prior application required

“The Certificate of Application of Maximum Copayment Amount” is used to confirm your income category. You must apply to the Health Insurance Association in advance for this Certificate.

How High-Cost Medical Care Benefits are calculated

If your copayment is reduced still further

You can combine copayments for an entire household (Total High-cost Medical Care Benefits)

Even when the copayment for one case for one month is less than the maximum, if members of the same household have made copayments of 21,000 yen and its payments are more multiple times in the same month, they can combine those amounts for the purposes of the Cost-Sharing Maximum Amount.
If the total amount exceeds the Cost-Sharing Maximum Amount, then the excess amount is paid by the Health Insurance Association as “Total High-cost Medical Care Benefits”.

The SUNTORY HEALTH INSURANCE ASSOCIATION also pays as additional benefits the Cost-Sharing Maximum Amounts minus 25,000 yen per person.

The Cost-Sharing Maximum Amount will be reduced for frequent qualification of expenditures.

If a single household qualifies for High-Cost Medical Care Benefits three or more months in a single year (the most recent 12 months), the Cost-Sharing Maximum Amount will be reduced to the amount of the table below starting with the fourth month.

Standard monthly remuneration Cost-sharing maximum amounts
830,000 yen or more 140,100 yen
530,000 yen - 790,000 yen 93,000 yen
280,000 yen - 500,000 yen 44,400 yen
260,000 yen or less 44,400 yen

If you receive medical care for specified diseases and disorders

Patients suffering from haemophilia, AIDS for which they are administered antiviral drugs, or chronic nephritics requiring artificial dialysis for an extended period may be eligible to pay only 10,000 yen/month to the medical care institution if they obtain certification for specified diseases and disorders.
However, if a patient requiring artificial dialysis qualifies as a person with 530,000 yen or more of standard monthly remuneration, his or her copayment will be 20,000 yen/month.
If you are eligible, apply for issue of Certificates Issued for Specific Disease Treatment.

Caution

The right to claim health insurance benefits expires in two years.

There is no frequently asked questions and answers that have been registered.

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