If the total medical expenses paid in a single month become high, the amount exceeding a certain limit (self-pay limit) is refunded or exempted. (The self-pay limit is determined by age and income status)
This system is called the "High-Cost Medical Care System".
If it is known in advance that medical expenses will be high, by obtaining the certification of the "Limit Amount Application Certificate" in advance, you can limit the medical expenses you pay at the counter to the self-pay limit.
The Limit Amount Application Certificate is issued by submitting a limit amount application form to the public health insurance and receiving certification, then receiving the "Limit Amount Application Certificate".
In infertility treatment, even the 30% self-pay amount can become high, so it is convenient to use the High-Cost Medical Care System.
| Application Category | Self-payment limit | |
|---|---|---|
| ① | Annual income about ¥11,600,000- Health insurance: Standard insurance premium ¥830,000 or more National insurance: Old footnote income over ¥9,010,000 |
¥252,600 + (medical expenses - 842,000) × 1% |
| ② | Annual income about ¥7,700,000 to about ¥11,600,000 Health insurance: Standard insurance premium ¥530,000 to ¥790,000 National insurance: Old footnote income 6 million to 9.01 million ¥ |
¥167,400 + (medical expenses - 558,000) × 1% |
| ③ | Annual income about ¥3,700,000 to about ¥7,700,000 Health insurance: Standard insurance premium ¥280,000 to ¥500,000 National insurance: Old footnote income ¥2,010,000 to ¥6,000,000 |
¥80,100 + (medical expenses - 267,000) × 1% |
| ④ | Up to annual income about ¥3,7000,000 Health insurance: Standard insurance premium ¥260,000 or more National insurance: Old footnote income ¥2,1000,000 or less |
¥57,600 |
| ⑤ | Exempt from municipal tax | ¥35,400 |
*The application for high-cost medical care is obliged to be made within two years, starting from the first day of the month following the month when you received medical treatment at the medical institution.
Please note that if you exceed the application period, you will not be able to apply for a refund of high-cost medical care.
When paying medical expenses at the medical institution's counter, by presenting the "Limit Amount Application Certificate", you do not need to pay medical expenses beyond your own burden at the medical institution's counter.
In this case, medical expenses exceeding your own contribution will be paid directly to the medical institution from the insurance union you are enrolled in.
Ms. A: Monthly infertility treatment cost: ¥700,000
80,100 + (medical expenses - ¥267,000) × 1% = self-payment limit
■ In the above example, the self-payment limit when using the High-Cost Medical Care System
80,100 + (700,000 - 267,000) × 1% = ¥84,430
Of the self-payment amount of ¥210,000 (30% of ¥700,000) that was once paid at the counter, you can receive a refund of the amount of ¥125,570 (¥210,000 - ¥84,430) that exceeded the self-payment limit (¥84,430).
By presenting the Limit Amount Application Certificate when paying medical expenses at the counter, your monthly medical expenses will be limited to the self-payment limit of ¥84,430.
If you visit multiple medical institutions in a month, you will incur payments at each counter up to the self-payment limit.
However, since the monthly medical expense self-payment upper limit is the amount certified by the limit amount application, if the total amount of medical expenses at multiple medical institutions exceeds the self-payment limit, you can refund the medical expenses paid above the self-payment amount by applying for high-cost medical care.
(However, for those under 69, it is necessary to incur payments of ¥21,000 or more at each medical institution's counter.)
Also, even at the same medical institution, if there are hospitalization, outpatient (medical), and outpatient (dental), payments will be incurred at each counter.
If the total amount of medical expenses in a month also exceeds the self-payment limit, you can refund the medical expenses paid above the self-payment limit by applying for high-cost medical care.
Ms. B: Visits multiple medical institutions in one month
If the family members living in the same household and enrolled in the same health insurance have combined medical expenses in one month that exceed the self-payment amount, they may qualify for high-cost medical care benefits.
*For those aged 70 and over, the calculation method is different. Please check with the counter of your health insurance for details.
If family members living in the same household and enrolled in the same health insurance have received a high-cost medical fee refund three times or more within the past 12 months, the self-payment upper limit will be reduced from the fourth time.