If you have severe eczema, or psoriasis and are considering the treatment with biological drugs (injection therapy), the cost of the medical expense may be an obstacle. These treatment may exceed the ‘pre-fixed ceiling amount.’ If you have Japanese insurance coverage, you can avoid unnecessary medical expenses by correctly understanding the refund system.
High-cost Medical Expense Benefit (KOGAKU-IRYO-HI-SEIDO)
If your are charged a high medical expense at a hospital’s reception or a pharmacy’s cashier, you can apply for a ‘High-cost Medical Expense Benefit (KOGAKU-IRYO-HI-SEIDO)’ to lessen the burden. By doing so, you can later receive a refund of the total amount paid that is beyond the pre-fixed ceiling amount (each month). This pre-fixed ceiling amount varies in accordance with your age and annual income (Table 1). You may have to wait for at least three months from the month of your hospital visit (Figure 1).
You are eligible to apply for this ‘High-cost Medical Expense Benefit’ if you have public health insurance coverage in Japan. Public health insurance includes ‘National Health Insurance’, ‘employees’ insurance’, and ‘Medical Care System for Older Senior Citizens’. Application methods for ‘High-cost Medical Expense Benefit’ depend on the insurance coverage that you have. Please check with your medical insurance office.
Eligibility Certificate for Ceiling-Amount Application (GENDOGAKU TEKIYO NINTEISHO)
Although you can receive the refund by applying for the ‘High-cost Medical Expense Benefit’ it may take a couple of months for you to get the refund, and this initial cost may cost a lot. If you know beforehand that you will be charged a high medical expense above the pre-fixed ceiling amount, there is an option to avoid paying the excessive medical expense and waiting for the refund. This can be accomplished by applying for ‘Eligibility Certificate for Ceiling-Amount Application (GENDOGAKU TEKIYO NINTEISHO).’ Having this will only require you to pay the pre-fixed ceiling amount (Table 1) at the cashiers desk (Figure 2). As for the issuance of ‘Eligibility Certificate for Ceiling-Amount Application, please inquire at your medical insurance office.
High-cost Medical Expense Benefit (KOGAKU-IRYO-HI-SEIDO)
If your are charged a high medical expense at a hospital’s reception or a pharmacy’s cashier, you can apply for a ‘High-cost Medical Expense Benefit (KOGAKU-IRYO-HI-SEIDO)’ to lessen the burden. By doing so, you can later receive a refund of the total amount paid that is beyond the pre-fixed ceiling amount (each month). This pre-fixed ceiling amount varies in accordance with your age and annual income (Table 1). You may have to wait for at least three months from the month of your hospital visit (Figure 1).
You are eligible to apply for this ‘High-cost Medical Expense Benefit’ if you have public health insurance coverage in Japan. Public health insurance includes ‘National Health Insurance’, ‘employees’ insurance’, and ‘Medical Care System for Older Senior Citizens’. Application methods for ‘High-cost Medical Expense Benefit’ depend on the insurance coverage that you have. Please check with your medical insurance office.
Eligibility Certificate for Ceiling-Amount Application (GENDOGAKU TEKIYO NINTEISHO)
Although you can receive the refund by applying for the ‘High-cost Medical Expense Benefit’ it may take a couple of months for you to get the refund, and this initial cost may cost a lot. If you know beforehand that you will be charged a high medical expense above the pre-fixed ceiling amount, there is an option to avoid paying the excessive medical expense and waiting for the refund. This can be accomplished by applying for ‘Eligibility Certificate for Ceiling-Amount Application (GENDOGAKU TEKIYO NINTEISHO).’ Having this will only require you to pay the pre-fixed ceiling amount (Table 1) at the cashiers desk (Figure 2). As for the issuance of ‘Eligibility Certificate for Ceiling-Amount Application, please inquire at your medical insurance office.
Figure 1. If your medical expense (usually 30% of the total medical expense) within a month exceeds the pre-fixed ceiling amount, you will be charged the excess amount beyond the ceiling amount temporarily when you only have a health insurance card. You can apply for the High-Cost Medical Expense Benefit afterwards, and you will be able to receive the refund of the excess amount paid that is beyond the ceiling amount later.
Figure 2. If you show the ‘Eligibility Certificate for Ceiling Amount Application’ in addition to your ‘health insurance card’ at the reception, you will not be asked to pay any excess fees beyond pre-fixed ceiling amount. The amount you will be charged is exactly the same as your pre-fixed ceiling amount if your medical expense exceeds the ceiling amount.
A sample of Eligibility Certificate for Ceiling-Amount Application
(GENDOGAKU TEKIYO NINTEISHO)
(GENDOGAKU TEKIYO NINTEISHO)
Multiple time High-Cost Medical Expense payers
If you are charged a high medical expense above the pre-fixed ceiling amount more than three times within 12 months, you will be recognized as ‘multiple-time high-cost medical expense payer’ and will be required to pay a reduced amount of your ceiling amount from the fourth and each subsequent time. Please refer to the ‘table 1 and 2’ for the reduced ceiling amount.
Table 1. Ceiling amount for those below 70 years of age
|
Classification (approximate annual income)
|
Ceiling amount per month
|
Multiple time High-Cost Medical Expense payers**
|
|
|
A (ア)
|
11,600,000 JPY ~
|
252,600 JPY + (Medical expense* of the month – 842,000 JPY) x 1%
|
140,100 JPY
|
|
B (イ)
|
7,700,000 ~ 11,600,000 JPY
|
167,400 JPY + (Medical expense of the month – 558,000 JPY) x 1%
|
93,000 JPY
|
|
C (ウ)
|
3700000 ~ 7700000 JPY
|
80,100 JPY + (Medical expense of the month – 267,000 JPY) x 1%
|
44,400 JPY
|
|
D (エ)
|
~ 3,700,000 JPY
|
57,600 JPY
|
44,400 JPY
|
|
E (オ)
|
Low-income household
|
35,400 JPY
|
24,600 JPY
|
*Please be aware that the term ‘medical expense’ refers to the entire medical cost(s), NOT the amount the patients pay at the cashier.
**Multiple time High-Cost Medical Expense payer refers to patients who pay more than the pre-fixed ceiling amount for at least three times within 12 months
**Multiple time High-Cost Medical Expense payer refers to patients who pay more than the pre-fixed ceiling amount for at least three times within 12 months
Table 2. Ceiling amount for those who are 70 years of age and older
|
Classification (approximate annual income)
|
Ceiling amount per month (per household)
|
Multiple time High-Cost Medical Expense payers**
|
|
|
High-income household
III |
11,600,000 JPY ~
|
252,600 JPY + (Monthly medical expense* – 842,000 JPY) x 1%
|
140,100 JPY
|
|
High-income household
II |
7,700,000 ~ 11,600,000 JPY ~
|
167,400 JPY + (Monthly medical expense of – 558,000 JPY) x 1%
|
93,000 JPY
|
|
High-income household
I |
3,700,000 ~ 7,700,000 JPY
|
80,100 JPY + (Monthly medical expense – 267,000 JPY) x 1%
|
44,400 JPY
|
|
Average income household
|
1,560,000 ~ 3,700,000 JPY
|
57,600 JPY (however, in cases with only individual outpatient clinic trips; 18,000 JPY)
|
44,400 JPY
|
|
Low-income household
|
24,600 JPY or 15,000 JPY depending on individual’s taxation situation
(however, in cases with only individual outpatient clinic trips; 8,000 JPY) |
Not applicable
|
|
*Please be aware that the term ‘medical expense’ refers to the entire medical cost(s), NOT the amount the patients pay at the cashier.
**Multiple time High-Cost Medical Expense payer refers to patients who pay more than the pre-fixed ceiling amount for at least three times within 12 months
**Multiple time High-Cost Medical Expense payer refers to patients who pay more than the pre-fixed ceiling amount for at least three times within 12 months
About 'Additional Benefit System' (FUKA-KYUFU SEIDO)
Additional Benefit System (FUKA-KYOFU SEIDO) refers to a system where the medical insurance that one belongs to may have its own original ceiling amount, and if your medical expense exceeds that amount, you can receive a refund. The original ceiling amount of the medical insurance may be set lower than the ‘pre-fixed ceiling amount (table 1 and 2), and you may benefit from it. Please be informed that this Additional Benefit is NOT necessarily available for all medical insurance. Please check with your medical insurance authority for further information.
Other medical expense subsidy systems
Each local government has its own medical expense subsidy system for preschool, elementary school, junior high school, and high school patients. Please check the details with the city hall office of your residence.
If you are a university student, you may benefit from your university’s original medical expense subsidy system. Please check with your university’s student’s affairs office for your eligibility to the subsidy.
If you are a university student, you may benefit from your university’s original medical expense subsidy system. Please check with your university’s student’s affairs office for your eligibility to the subsidy.