◆ What is a certificate of maximum amount application?
Under the High -Cost Medical Care Benefits System , if you apply after paying the full amount of the medical expenses billed by the medical institution, you will be reimbursed the amount that exceeds the maximum copayment amount. However, it will be a big financial burden because you will have to pay a large amount of money, even temporarily.
By receiving a “Ceiling Amount Application Certificate” in advance and presenting it at the counter of the medical institution, the monthly payment amount for each medical institution will be up to the copayment ceiling.
*Meals and expenses not covered by insurance (such as extra bed charges) must be paid separately.
*For outpatient treatment, it will be applied from April 1, 2012.
About the limit application certificate for those aged 70 or over and under 75
| From August 2018, if you are 70 years old or older and your income category is the same level as active workers I or active workers II, please bring your health insurance card, elderly beneficiary certificate, and ceiling application certificate to the medical institution window. By presenting it to , you will be able to pay up to the self-pay limit. If you are in the general income category or level III, you will be able to pay up to the copayment limit by presenting your health insurance card and elderly recipient certificate at the medical institution window. (A Certificate of Eligibility for Ceiling Amount Application will not be issued to those whose income category is General or equivalent to that of active workers III.) |
◆ Self-pay limit
It is classified as follows according to the age of the examinee and the income category of the insured person.
Category for those under the age of 70
[ From medical treatment in January 2015 ]
| income category | Out-of-pocket limit | Many applicable *2 |
| ① Category A (those with a standard monthly remuneration of 830,000 yen or more) | 252,600 yen + (total medical expenses*1 – 842,000 yen) x 1% | 140,100 yen |
| ( 2) Category A (those with a standard monthly remuneration of 530,000 to 790,000 yen) | 167,400 yen + (total medical expenses*1 – 558,000 yen) x 1% | 93,000 yen |
| ③ Category C (Those with a standard monthly remuneration of 280,000 to 500,000 yen) | 80,100 yen + (total medical expenses*1 – 267,000 yen) x 1% | 44,400 yen |
| ④ Category D (those with a standard monthly remuneration of 260,000 yen or less) | 57,600 yen | 44,400 yen |
| ⑤ Category E (low-income earners ) | 35,400 yen | 24,600 yen |
*1 Total medical expenses are the total medical expenses covered by insurance (100%).
*2 If you received high-cost medical care benefits for 3 months or more during the year prior to the month you received medical treatment (including cases where you used a ceiling amount application certificate and paid the maximum copayment amount), From the 4th month onwards, it will become “multiple applicable” and the co-payment limit will be further reduced.
Note) If you fall under “Category A” or “Category B”, even if you are exempt from municipal tax, you will fall under “Category A” or “Category B” based on your standard monthly remuneration.
Over 70 and under 75
[ Up to July 2017 medical treatment ]
| Insured person’s income category | Out-of-pocket limit | ||
| Outpatient (per individual) | Outpatient/hospitalization (household) | ||
| ( 1) People with an income equivalent to that of active workers (Those who have a standard monthly remuneration of 280,000 yen or more and who bear 30% of the elderly recipient certificate) | 44,400 yen | 80,100 yen + (Medical expenses – 267,000 yen) x 1% [Multiple cases: 44,400 yen] | |
| ( 2) General income earners (those other than (1) and (3)) | 12,000 yen | 44,400 yen | |
| (3) Low-income earners | II (*3) | 8,000 yen | 24,600 yen |
| I (*4) | 15,000 yen |
[ from August 2017 medical treatment]
| Insured person’s income category | Out-of-pocket limit | ||
| Outpatient (per individual) | Outpatient/hospitalization (household) | ||
| ( 1) People with an income equivalent to that of active workers (Those who have a standard monthly remuneration of 280,000 yen or more and who bear 30% of the elderly recipient certificate) | 57,600 yen | 80,100 yen + (total medical expenses – 267,000 yen) x 1% [multiple cases: 44,400 yen] | |
| ( 2) General income earners (those other than (1) and (3)) | 14,000 yen (up to 144,000 yen per year) | 57,600 yen [Multiple entries: 44,400 yen] | |
| (3) Low-income earners | II (*3) | 8,000 yen | 24,600 yen |
| I (*4) | 15,000 yen |
[ from medical treatment in August 2018 ]
| Insured person’s income category | Out-of-pocket limit | ||
| Outpatient | Outpatient/hospitalization | ||
| (per individual) | (household) | ||
| (1) Income earners at the same level as active workers | Equivalent to active workers III (Those who have a standard monthly remuneration of 830,000 yen or more and who bear 30% of the elderly recipient certificate) | 252,600 yen + (total medical expenses – 842,000 yen) x 1% [multiple cases: 140,100 yen] | |
| Equivalent to active workers II (those who have a standard monthly remuneration of 530,000 to 790,000 yen and bear a burden ratio of 30% for the elderly recipient certificate) | 167,400 yen + (total medical expenses – 558,000 yen) x 1% [multiple cases: 93,000 yen] | ||
| Same level as active workers I (Those who have a standard monthly remuneration of 280,000 to 500,000 yen and who bear 30% of the elderly recipient certificate) | 80,100 yen + (total medical expenses – 267,000 yen) x 1% [multiple cases: 44,400 yen] | ||
| ( 2) General income earners (those other than (1) and (3)) | 18,000 yen (up to 144,000 yen per year) | 57,600 yen | |
| [Multiple applicable: 44,400 yen] | |||
| (3) Low-income earners | II (*3) | 8,000 yen | 24,600 yen |
| I (*4) | 15,000 yen |
*3 When the insured person is exempt from municipal tax.
*4 When there is no income after deducting necessary expenses and deductions from the income of the insured person and all of his/her dependents.
Note) If you qualify as an income earner at the same level as a working person, you will be considered an income earner at the same level as a working person even if you are exempt from municipal tax.
◆ Flow when using a ceiling application certificate
(1) Submit the Application for Approval of Maximum Amount Applicability to each prefectural branch of the Japan Health Insurance Association.
(2) A ceiling application certificate will be issued. (Estimated time until issuance: about 1 week)
(3) Present your ceiling application certificate at the counter of the medical institution.
④ The monthly payment amount for the same medical institution will be up to the self-pay limit.
