Don't miss out! Could you get a significant refund on medical expenses through the High-Cost Medical Expense Benefit system?

The High-Cost Medical Expense Benefit system is
a core component of Japan's public health insurance system,
a mechanism designed to limit the burden of medical expenses on household budgets
.

Even if medical costs become high,
the portion exceeding a certain maximum out-of-pocket limit is
later refunded, making it, so to speak,
a safety net for medical expenses.

Purpose and significance of the system

The final line of defense against household financial collapse
This is established to prevent people from falling into financial hardship due to excessive out-of-pocket costs when
medical expenses become high due to hospitalization, surgery, or long-term treatment.

Fair burden based on income
The maximum out-of-pocket limit is set in detail according to age and income,

with lower-income individuals receiving consideration to ensure their burden is lighter.

System structure and basic rules

1. Eligibility conditions

All individuals enrolled in public health insurance
(such as Health Insurance, National Health Insurance) are eligible.

It applies when the
out-of-pocket payment at the counter for each medical institution or department
for one month (from the 1st to the end of the same month)
exceeds the
maximum out-of-pocket limit.

2. How the maximum out-of-pocket limit is determined

The

maximum out-of-pocket limit
per month varies depending on age (69 or younger, 70 or older) and income bracket.

For example, for those 69 or younger with an annual income between 3.7 million and 7.7 million yen,
the cap is
approximately 90,000 yen per month until July 2025.

(If you pay more than that, it will be refunded later)

3. Refund mechanism

You pay the full amount at the counter, and the portion exceeding the limit is later refunded as

"High-Cost Medical Expense Benefit".

For hospitalizations and similar cases, if you present a "Certificate of Maximum Amount Application" to the medical institution, your payment at the counter will be limited to the maximum amount.

(By using your My Number Card as a health insurance card, you are exempt from paying amounts exceeding the limit even without a "Certificate of Maximum Amount Application".)

Specific examples of maximum out-of-pocket limits

Example until August 2025 (before revision)

Key changes from August 2025 onwards

Increase in the maximum limit

The
out-of-pocket maximum limit
for the High-Cost Medical Expense Benefit system will be increased in stages.

The higher the income bracket, the greater the increase, and even for the
middle-income group, an increase of about 10% is expected in costs.

Revisions will be made in
three stages in August 2025, August 2026, and August 2027,
and the income categories are scheduled to be subdivided from 5 categories to
13 categories.

Examples of specific increases

• Annual income over approx. 11.6 million yen: + approx. 40,000 yen

• Annual income approx. 7.7 to 11.6 million yen: + approx. 20,000 yen

• Annual income approx. 3.7 to 7.7 million yen: + approx. 8,000 yen

• Annual income under approx. 3.7 million yen: + 3,000 yen

• Resident tax-exempt households: + 900 yen

How to use the system

1. Post-payment application (refund)

Pay the full amount at the medical institution first,
and apply to the insurer (health insurance association or municipality)
at a later date to receive a refund for the excess amount.

2. Certificate of Maximum Amount Application

If you know in advance that you will be hospitalized or require expensive treatment,
apply for a
"Certificate of Maximum Amount Application" from your insurer,
and present it to the medical institution
to limit your out-of-pocket payment at the counter to the maximum amount.

(By using your My Number Card as a health insurance card, you are exempt from paying over the limit even without a "Certificate of Maximum Amount Application")

Special provisions and additional support for the system

Frequent use

If you have reached the out-of-pocket maximum limit 3 or more times within the past 12 months,
the maximum limit will be further reduced from the 4th time onwards.

Outpatient Special Provision (Aged 70 and Over)

For those aged 70 and over,
there is a
set limit on out-of-pocket expenses for outpatient care.

Points to Note and Limitations of the System

Not all medical expenses are covered
Costs such as hospital meal charges, private room surcharges,
advanced medical treatment fees, and non-insurance
treatment costs are excluded.

Expenses from multiple medical institutions and departments can be combined
Within the same month,
you can combine out-of-pocket expenses from
multiple medical institutions and departments, but
pharmacies and dental clinics may
be calculated separately.

Combining with private medical insurance
To prepare for costs that cannot be
fully covered by the High-Cost Medical Expense Benefit System alone,
or for expenses that are not covered,
combining it with private medical insurance is also considered.

Background and Future of System Revisions

Addressing an aging society and rising medical costs
Due to Japan's aging population and the
advancement of medical technology, overall medical costs are increasing,
making the deterioration of insurance finances a challenge.

Revisions aimed at fair burden sharing
Focusing on increasing the burden on high-income earners,
such as setting more detailed brackets based on income,
revisions are being implemented to improve the
sustainability of the system.

Summary

The High-Cost Medical Expense Benefit System is
the foundation of a society where everyone can
receive medical care with peace of mind.

By having public insurance cover medical expenses
that exceed the out-of-pocket limit,
it plays a role in preventing a sudden collapse of household finances.

Since future system revisions may change
the burden amounts and brackets,
be sure to check the latest information,
and consider utilizing
private insurance as needed.

*This article is based on information as of June 2025. Please be aware of future legal revisions and system changes.