Procedures

High-cost Medical Care Expenses

The HGST Health Insurance Association automatically calculates and pays the total amount of high-cost medical expenses and additional benefits for any out-of-pocket medical care costs exceeding the ceiling amount at a later date based on the medical cost statement (insurance claim) sent from the healthcare provider.
(This excludes amenity bed costs and other expenses not covered by insurance and the cost of inpatient meals.)

High-cost Medical Care Expenses

High-cost Medical Care Expenses and Co-payment Reductions (Additional Family Medical Expense Benefit)

The HGST Health Insurance Association reimburses insured persons and dependents for high-cost medical care expenses paid at the billing counter for inpatient or other medical care at a later date. A co-payment reduction (additional family medical expense benefit) is also offered as a unique benefit from the HGST Health Insurance Association.

Insured persons and dependents can limit payments at the billing counter of healthcare providers to the ceiling amount of out-of-pocket costs by applying for and presenting an Eligibility Certificate for Ceiling-Amount Application. See more details about the Eligibility Certificate for Ceiling-Amount Application here.

These benefits are calculated and automatically paid based on the certificate of medical remuneration sent by the healthcare provider to the HGST Health Insurance Association (insured persons and dependents do not need to submit an application), but the payment period is roughly three to four months after the month in which the insured person or dependent received medical care.

*Insured persons and dependents can reduce the burden of co-payments when the total amount of out-of-pocket payments for medical insurance or long-term care exceeds a certain amount through programs such as the high-cost medical care expense and high-cost long-term care cooperation system for reimbursements of excess medical care costs or certificates issued for specific disease treatments to reduce the ceiling amount for specific diseases incurring high-cost medical care expenses.

High-cost Medical Care Expense Payments and Additional Benefits

Amount of payment
Amount exceeding out-of-pocket medical costs for one treatment per month when above the maximum amount
(the maximum amount differs for low-income earners and individuals age 70 to 74)
Additional Benefits from the HGST Health Insurance Association Co-payment Reductions and Additional Family Medical Expense Benefit:
Payment of an amount calculated by deducting 25,000 yen from the out-of-pocket amount (rounded down to the nearest 1,000 yen)

*This excludes standard out-of-pocket payments related to high-cost medical care expenses, in-patient dietary treatments, and in-patient daily living treatments.

Maximum Out-of-pocket Payments for High-cost Medical Care Expenses (Upper Monthly Limit)
<Individuals Under age 70>
Classification 3 Months or less*1 4 Months or more*1
Standard monthly remuneration of 830,000 yen or more 252,600 yen +
(total medical care costs - 842,000 yen) x 1%
140,100 yen
Standard monthly remuneration of 530,000 yen to 790,000 yen 167,400 yen +
(total medical care costs - 558,000 yen) x 1%
93,000 yen
Standard monthly remuneration of 280,000 yen to 500,000 yen 80,100 yen +
(total medical care costs - 267,000 yen) x 1%
44,400 yen
Standard monthly remuneration of 260,000 yen or less 57,600 yen 44,400 yen
Low-income earner*2 35,400 yen 24,600 yen
*1 The maximum amount decreases from the fourth month in which high-cost medical expenses were incurred if the medical care costs for the same household in the last 12 months satisfies the payment requirements for high-cost medical care costs for three or more months.
*2 Insured persons or dependents who are exempt from local residence taxes or insured persons or dependents who do not require public assistance because they receive coverage as low-income earners
<Individuals Age 70 to 74>
Applicable Classification Outpatient
(per Individual)
Outpatient + Inpatient
(per household)
Persons earning the same level as those of working age Persons earning the same level as those of working age - III
Standard monthly remuneration of 830,000 yen or more
Income earners at the same level as active employees

Persons earning the same level as those of working age - III (standard monthly remuneration of 830,000 yen or more)
252,600 yen + (medical care costs - 842,000 yen) x 1%
[140,100 yen]
Persons earning the same level as those of working age - II
Standard monthly remuneration of 530,000 yen to 790,000 yen
Income earners at the same level as active employees

Persons earning the same level as those of working age - II (standard monthly remuneration of 530,000 yen to 790,000 yen)
167,400 yen + (medical care costs - 558,000 yen) x 1%
[93,000 yen]
Persons earning the same level as those of working age - I
Standard monthly remuneration of 280,000 yen to 500,000 yen
Income earners at the same level as active employees

Persons earning the same level as those of working age - I (standard monthly remuneration of 280,000 yen to 500,000 yen)
80,100 yen + (medical care costs - 267,000 yen) x 1%
[44,400 yen]
General Standard monthly remuneration of 260,000 yen or less General
(Standard monthly remuneration of 260,000 yen or less)
18,000 yen
(Annual maximum:
144,000 yen)
57,600 yen [44,400 yen]
Low-income earners
(resident tax exemption)
II Low-income earners
(resident tax exemption) II
8,000 yen 8,000 yen 24,600 yen
I (Annual income of 800,000 yen or less, etc.) Low-income earner
(resident tax exemption) I
(annual income of 800,000 yen or less, etc.)
8,000 yen 15,000 yen
*Figures in square brackets represent the ceiling amount from the fourth month. The maximum amount decreases from the fourth month of high-cost medical expenses if medical care costs for the same household in the last 12 months satisfies the payment requirements for high-cost medical care expenses for three or more months.
*Income earners at the same level as active employees are insured persons or dependents who have a standard monthly remuneration of 280,000 yen or more.
However, these insured persons and dependents may pay the standard 20% out-of-pocket costs by filing an application with the HGST Health Insurance Association if:
  • The individual is age 70 or older and earns less than 3.83 million yen annually without any dependents
  • The individual has a dependent or former dependent age 70 or older and has a total combined annual income of less than 5.20 million yen
Aggregated High-cost Medical Care Expenses

The HGST Health Insurance Association pays the amount exceeding the combined maximum total of 21,000 yen in out-of-pocket costs for two or more cases in the same household as aggregated high-cost medical care expenses.

Eligibility Certificate for Ceiling-Amount Application

Insured persons and dependents can apply to have a certificate issued by the HGST Health Insurance Association in advance for any out-of-pocket payments exceeding the ceiling amount to present at the billing counter of the healthcare provider in order to limit payment to only the medical costs up to the maximum amount.
Please file an application online or by postal mail if you would like to limit out-of-pocket payments to the ceiling amount at the billing counter of each healthcare provider.

Procedures
Please file an application using one of the procedures below if you would like to limit out-of-pocket payments to the ceiling amount at the billing counter of each healthcare provider.
Digital Applications Digital application
Applications by postal mail Request for Issue of Health Insurance Eligibility Certificate for Ceiling-Amount Application Form
PDFEntry Sample

Calculation Method for High-Cost Medical Care Expenses

Calculation Method for High-Cost Medical Care Expenses

  • Monthly calculation of medical care(first to last day of the month)
  • Calculation by patient
  • Calculation by healthcare provider (calculated separately for inpatient, outpatient, and dental care and by each medical department at medical institutions formerly certified as general hospitals)
e.g. Payment methods at hospital billing counters for inpatient care or other high-cost medical care expenses
(1,000,000 yen in medical expenses for individuals with a standard monthly remuneration of 280,000 yen to 500,000 yen)
Example Image of High-cost Medical Care Expenses
The HGST Health Insurance Association reimburses the amount of medical care expenses paid at the hospital billing counter less 25,000 yen (rounded down to the nearest 1,000 yen) about three months after the insured person or dependent receives medical care regardless of whether a Certificate for Ceiling-Amount Application is presented.
*High-cost medical care expense benefits are calculated automatically and do not require an application.
In either case, the amount of final co-payment is the same.

Aggregated High-cost Medical Care Expenses for a Household

The HGST Health Insurance Association pays the amount exceeding the combined maximum total of 21,000 yen in out-of-pocket costs for two or more cases in the same month for the same household.

Four Months or More of High-cost Medical Care Expenses (Multiple Occurrences)

The co-payments from the fourth month in which high-cost medical care expenses exceed the ceiling amount vary as follows when insured persons and dependent have paid high-cost medical care expenses three or more times in one year (last 12 months) in the same household.

[Multiple Occurrences]
Standard Monthly Remuneration Limit for out-of-pocket payments
830,000 yen or more 140,100 yen
530,000 yen to
less than 790,000 yen
93,000 yen
280,000 to less than
500,000 yen
44,400 yen
260,000 yen or less 44,400 yen
Low-income earners
(resident tax exemption)
24,600 yen

Special Exception for Specific Diseases

Patients with hemophilia, acquired immune deficiency syndrome (AIDS) administered antiviral agents, and chronic renal failure requiring dialysis for an extended period only need to pay 10,000 yen per month to a healthcare provider once certified as a person with a specific disease. However, patients who require dialysis have a co-payment of 20,000 yen if their standard monthly remuneration is 530,000 yen or more. (This applies to both insured persons and dependents.)

Procedures
Individuals undergoing treatment for specific diseases attach a physician’s certificate to the Application for Issuance of Certificate Issued for Specific Disease Treatment to the HGST Health Insurance Association to receive a Certificate of Care for Specified Diseases. The insured person or dependent presents the Certificate of Care of Specified Diseases issued by the HGST Health Insurance Association with their health insurance card to the billing counter of the healthcare provider.
*Please submit the application promptly when undergoing treatment for a specified disease because only applications received by the HGST Health Insurance Association by the end of the month are applied to the current month.
Required
documents
  • Health Insurance Application for Issuance of Certificate Issued for Specific Disease Treatment
    PDF Entry Sample
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