People covered by health insurance can receive medical services, such as consultation, treatment or medication, by paying only a part of the expense by showing a health insurance certificate at hospitals or pharmacies. In the case the expense is highly expensive, they can also use the high-cost medical care benefit system, which is aimed to limit the amount borne by patients. Since there were revisions in this system in August, this article reviews changes affecting people covered by the Japan Health Insurance Association (Association Kenpo).
[1] The high-cost medical care benefit system
When insured people are hospitalized for a long period of time due to a severe illness or prolonged treatment, a portion of medical expense exceeding a limit amount will be paid back. Under the normal procedure, patients pay full amounts first and claim reimbursement later, but by showing the “My Number” individual number card associated with their health insurance record or the “Certificate of Approval of Limit Amount,” they will be exempted from the payment beyond the limit.
The limit amount is determined based on patients’ ages and insured workers’ income (standardized remuneration) groups. The limit amount becomes higher in proportion of income.
Additionally, if a person used the high-cost medical care benefit system for three months or more over the past twelve months, the limit amount will be lowered from the fourth month (multiple occurrence system).
[2] Raising of the limit amount
The revision in August 2026 included raising of the limit amounts. Shown below is an example of a person under age 70 whose standard remuneration is between 280,000 yen and 500,000 yen.
Before the change (until July 2026)
80,100 yen + (total medical expense – 267,000 yen) x 1%
After the change (from August 2026)
85,800 yen + (total medical expense – 286,000 yen) x 1%
Limit amounts in the case of multiple occurrence have been left unchanged.
[3] Establishment of an annual cap
While the limit amount has been raised, the government has introduced an annual cap to support people receiving long-term care. Under the high-cost medical care benefit system, a portion of medical expense is refunded on a monthly basis. Even if the expense does not reach the monthly limit, when the total amount for a year from August to July exceeds the annual limit, the portion beyond the limit will be reimbursed. This system is aimed to support people who were not applicable to multiple occurrence or need to receive extremely high-cost treatment.
The government plans further changes in the high-cost medical care benefit system for August 2027, including more detailed income segments. If companies have employees receiving long-term treatment or due to receive a major surgery, etc., please inform them of the latest changes in the system.
■Reference
Japan Health Insurance Association (Association Kenpo), “Revision in the high-cost medical care benefit system in August 2026”
https://www.kyoukaikenpo.or.jp/about/business/public_relations/009/002/index.html
*This information is based on laws and regulations as of the date of the original article.
