Calculation of High-Cost Medical Expenses (Frequent Claims, Annual Cap, Outpatient Exception)

*Due to the annual cap, subtotals will be calculated as of the end of July.

High-Cost Medical Expense Reimbursement

High-Cost Medical Expense Reimbursement is a system whereby, if your out-of-pocket medical expenses for a single month (from the 1st to the last day of the month) reach a high amount, the portion exceeding a certain threshold is reimbursed later. *Expenses such as meal costs during hospitalization, charges for private rooms, and costs for advanced medical treatments are not eligible.

Household Aggregation

If multiple members of a household become ill or injured in the same month and receive treatment at medical institutions, or if one person receives treatment at multiple medical institutions, or if a person receives both inpatient and outpatient care at a single medical institution, the out-of-pocket expenses can be combined for the entire household. If the combined total exceeds the out-of-pocket limit, the amount exceeding that limit will be reimbursed.
However, for individuals under 70 years of age, only out-of-pocket expenses totaling 21,000 yen or more are eligible for aggregation. Individuals 70 years of age or older may aggregate all their out-of-pocket expenses.
*The same applies when applying for high-cost medical care benefits under the annual cap.

Multiple Instances

If you received high-cost medical care benefits for three or more months during the one-year period preceding the month in which you received treatment (including cases where you used a Certificate of Eligibility for the Out-of-Pocket Maximum and paid the out-of-pocket maximum), you will be classified as a “Frequent Recipient” starting from the fourth month, and your out-of-pocket maximum will be further reduced.

Annual Cap

The annual cap is calculated based on the total out-of-pocket expenses incurred over the 12-month period from August of one year to July of the following year.
Even if your monthly out-of-pocket expenses accumulate, once you reach the annual cap, you will not be required to pay any additional medical expenses. (*This applies only to the portion of medical expenses covered by the High-Cost Medical Care Support System. Non-covered expenses, such as meal costs during hospitalization and charges for private rooms, will be billed separately.)

Outpatient Special Provision

This is a cost-relief measure under the High-Cost Medical Care Support System whereby seniors aged 70 or older are reimbursed for the amount exceeding the monthly (or annual) out-of-pocket limit when their out-of-pocket medical expenses for outpatient care at medical institutions exceed that limit.

Calculation of Out-of-Pocket Expenses

Calculations are made separately for each medical institution. Even within the same medical institution, calculations are broken down by medical inpatient care, medical outpatient care, dental inpatient care, and dental outpatient care.
If you receive medication at a pharmacy based on a prescription issued by a medical institution,
the out-of-pocket amount paid at the pharmacy is included in the calculation for the medical institution that issued the prescription.

*This calculation provides an estimate of out-of-pocket expenses under the High-Cost Medical Care Expense System based on the starting month and year.
*This has been updated to reflect the revision of the High-Cost Medical Care Expense System in August Reiwa 8.
*In response to the August Reiwa 9 revision of the High-Cost Medical Care Expense System, income categories have been subdivided (please select the subdivided income categories even for periods prior to July Reiwa 9). The amounts following this revision are subject to change in the future.
*This calculator does not support the automatic application of the limit when using the My Number health insurance card.
*This calculator does not account for the special provision regarding the out-of-pocket maximum in the month a person turns 75.
*This website assumes no responsibility whatsoever for calculation results or other information provided. Furthermore, we do not provide individual consultations.