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- High medical expenses payment system
- High medical expenses payment system
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High medical expenses payment system
[If you are under 74 years old and have taken out Yokohama City National Health Insurance]
Last Updated December 27, 2024
Contents
If medical expenses's partial co-payment is high, if the application is accepted, the amount exceeding the co-payment limit will be paid later by high medical costs.
In addition, in the following cases, the amount paid at the time of consultation will be up to the copayment limit per month.
・If you agree to the use of information such as limit application certificates at the window of a medical institution that has an online qualification confirmation system.
・When the ward office receives a “National Health Insurance Limit Application Certificate” in advance and presents the certificate to a medical institution.
(Please check here for the application for the limit application certificate.)
In addition, the co-payment limit and calculation method are different for those aged 70 and over and those under 70.
・・・ For those aged 75 and over, go to the medical system for elder senior citizens.
For those under the age of 70, high medical costs's calculation is based on a calendar month, medical institution, hospitalization and outpatient, medical and Dentistry contributions exceeding ¥21,000.
However, if a prescription is issued by a medical institution and a medicine is prescribed at a dispensing pharmacy, the partial contribution will be added to the partial contribution paid by the medical institution.
Category | Income requirements | Monthly |
---|---|---|
A | Amount of income Over 9.01 million yen | 252,600 yen + (medical expenses -842,000 yen) x 1% |
I | Amount of income More than 6 million yen 9.01 million yen or less | 167,400 yen + (medical expenses -558,000 yen) x 1% (From the 4th time limit: 93,000 yen) |
C | Amount of income More than 2.1 million yen and less than 6 million yen | 80,100 yen + (medical expenses -267,000 yen) x 1% (From the 4th time limit: 44,400 yen) |
D | Amount of income 2.1 million yen or less | 57,600 yen (From the 4th time limit: 44,400 yen) |
O | Head of household and National Health Insurance members All employees are exempt from residence tax | 35,400 yen (From the 4th time limit: 24,600 yen) |
・The medical treatment from January to July is determined by the previous year, and the medical treatment from August to December is determined by the income amount of the previous year.
※The income amount is the total income amount minus the basic deduction and the net loss carryforward.
In addition, the amount used for classification judgment is the total amount of income of all National Health Insurance members in the household.
For more information about basic deductions, please refer to the terms related to insurance premiums.
※Households with those who cannot confirm their income are classified as Category A.
If you are unemployed due to bankruptcy or dismissal of a company and have taken out National Health Insurance and are a “qualified recipient” or “dismissed employee for a specific reason” in employment insurance, your income classification may be reduced. For more information, please consult with your ward office Insurance and Pension Division National Health Insurance Section.
Category | Income requirements | Outpatient (Individual) | Outpatient + inpatient (Household Unit) |
---|---|---|---|
Active-income earner III | Those who belong to a household with at least one National Health Insurance insured person 70 years or older (hereinafter referred to as "elderly person") who has the same level of income as active duty (the standard amount of residence tax is 6.9 million yen or more). | 252,600 yen + (medical expenses -842,000 yen) x 1% (From the 4th time limit: 140,100 yen) | |
Active-income earner II | Those who belong to a household with at least one National Health Insurance insured person 70 years or older (hereinafter referred to as "elderly person") who has the same level of income as active duty (the standard amount of residence tax is 3.8 million yen or more). | 167,400 yen + (medical expenses -558,000 yen) x 1% (From the 4th time limit: 93,000 yen) | |
Active-income earner I | Those who belong to a household with at least one National Health Insurance insured person 70 years or older (hereinafter referred to as "elderly people") who has the same level of income as active duty (the standard amount of residence tax is 1.45 million yen or more). | 80,100 yen + (medical expenses -267,000 yen) x 1% (From the 4th time limit: 44,400 yen) | |
General | Those who do not fall under any of "low income 1", "low income 2", or "income equal to active duty" | 18,000 yen | 57,600 yen (From the 4th time limit: 44,400 yen) |
Low income 2 | Households exempt from residence tax | 8,000 yen | 24,600 yen |
Low income 1 | Household tax-exempt households with no income for all household members (Public pension deduction is calculated as 800,000 yen). If employment income is included after the medical treatment in August 2021, 100,000 yen will be deducted from the amount of employment income. ) | 8,000 yen | 15,000 yen |
・The medical treatment from January to July is determined by the previous year, and the medical treatment from August to December is determined by the income amount of the previous year.
※For outpatients aged 70 or older (general and low-income individuals), if the total amount of outpatient co-payment for one year (from August to July of the following year) exceeds the annual limit (144,000 yen), the excess amount will be paid by employee health insurance as "high medical costs." The application method, etc. will be notified separately to those who apply.
※If any of the following conditions 1. to 3. are met among the active earners, the category will be "general" and the out-of-pocket ratio will be "20%".
In addition, in the following cases 1. and 2., this system is originally changed by the application of the insured person, but in Yokohama City, if the applicable conditions of those who are considered eligible can be confirmed, in principle, the application We change to 20% burden without.
1.When the amount of income of those 70 years or older who have taken out National Health Insurance falls under the following.
- A single household…Less than 3.83 million yen
- Households of 2 or more…Less than 5.2 million yen
2.When all of the following conditions (1) to (3) are met.
(1)One household is 70 years or older who has taken out National Health Insurance, and that person is an active earner.
(2)In same household, there are those who have transitioned from the National Health Insurance to the Medical System for the Elderly (limited to those who continue to belong to the same household from the date of transition to the Medical System for the Elderly).
(3)(1)The total income of all persons and those who are eligible for (2) is less than 5.2 million yen.
3.Income amount of those 70 years or older who are enrolled in National Health Insurance who have reached their 70th birthday after January 2, 2015, and who are enrolled in National Health Insurance (Total Income Amount-Deduction for Net Loss Carryover-Basic Deduction) is 2.1 million yen or less.
※Households with those who cannot confirm their income do not have low income.
※For details on basic deductions, please refer to the terms related to insurance premiums.
In the case of hemophilia or chronic renal failure who is undergoing dialysis, if you present a “special illness medical treatment receipt certificate”, the monthly co-payment at one hospital will be 10,000 yen Up to.
However, among insured persons under the age of 70 who are undergoing dialysis, those who belong to Category A and Category A, the monthly co-payment limit for dialysis is up to 20,000 yen .
Issuance of a certificate of medical treatment for specific illness
If applicable, please bring documents proving the fact (doctor's opinion, etc.) and identification documents, and notify the ward office National Health Insurance Section of your ward.
From the month of application, the co-payment limit will be 10,000 yen (or 20,000 yen).
For those who meet the following conditions, a special case in which the copayment limit is half price will be applied only in the applicable month.
Those who are subject to the special limit | Month to which the special limit is applied |
---|---|
Those who have been transferred from the National Health Insurance to the medical system for the elderly on their 75th birthday (except when the 75th birthday is one day) | 75th birthday month |
Dependents of social insurance who have taken out National Health Insurance due to the transition of the social insurance person to the medical system for the elderly on their 75th birthday (the date of joining the National Health Insurance is one day) Except for those who are). | Month of joining the National Health Insurance |
Family members of the National Health Insurance Association who joined the National Health Insurance Association due to the transition of the National Health Insurance Association to the medical system for the elderly on their 75th birthday (National Health Insurance) Excludes those who have a one-day subscription date.) | Month of joining the National Health Insurance |
- high medical costs calculation example for households under the age of 70
1.When the amount of the monthly co-payment exceeds the co-payment limit
2. When the total exceeds the co-payment limit by the same household
3. If you receive high medical costs at least four times a year
- high medical costs calculation example for households with National Health Insurance members aged 70 and over and under 70
- For subscribers aged 70 and over…To the page of subscribers over 70 years old
- high medical costs calculation example for households with National Health Insurance members aged 70 and over and under 70
- Calculated by calendar month: Consultations from the first day of the month to the end of the month are calculated as one month.
- Hospital clinics: Calculated for each hospital and clinics.
- Hospitalization and outpatients: Even in one hospital, clinics, hospitalization and outpatient care are calculated separately.
- Dentistry is calculated separately: If one hospital clinics has a department such as Internal medicine and a Dentistry, Dentistry treats it as another hospital or clinics.
- Standard burden related to food and living expenses at the time of hospitalization: It is not included in the co-payment for calculating high medical costs.
- Differential beds, etc.: Excludes items that are not covered by insurance medical treatment, such as the difference in bed charges when hospitalized.
- Out-of-pocket expenses for medical expenses: You may be eligible for high medical costs. ・・ ・ To the payment of medical expenses (partial contribution)
- When you pay for the drug by out-of-hospital prescription: You may be eligible for high medical costs.
Normally, we will send you an application form and application form at the end of the month following the month in which high medical costs was paid (for example, June if the target month is April). Please fill in required items and mail it in the enclosed reply envelope.
※If you do not receive the payment application and petition within three months or more from the target month, please contact the ward office National Health Insurance Section. high medical costs will provide payment based on the “description” submitted by medical institutions, so if the submission of the “description” is delayed, the application form and petition will be delayed.
※Please note that the statute of limitations will expire two years from the first day of the month following the medical treatment month, and you will not be able to apply.
※When you receive the payment application and petition, make sure that the receipt of the person who received the medical treatment matches the contents.
If the contents of the receipt and the payment application form and petition do not match or do not understand, please bring the receipt to the counter.
※Partial contributions actually paid at medical institutions are rounded off to the nearest 10 yen, so the amount stated on your receipt and payment application and petition may differ.
※If you file a tax return (medical expenses deduction), you must first apply for a high medical costs payment.
For more information, please contact the relevant tax office (outside site).
※You can also apply at the ward office window. For details, please refer to the notice enclosed in the payment application and petition.
About automatic transfer in the case of the second and subsequent times
Once you apply for high medical costs to Insurance and Pension Division National Health Insurance Section in your ward, high medical costs will be automatically transferred in principle.
[Households subject to automatic transfer]
Households that meet all of the following requirements are eligible for automatic transfer. (From October 2021, the scope has been expanded to households including those under the age of 70.)
・Receipts relating to third-party acts are not included in high medical costs's calculations
・The head of the household has not died at the time of calculation in high medical costs
※ If there is a delinquency of insurance premiums or a partial payment has not been paid, it may not be eligible for automatic transfer and you may need to submit an application every time.
[Flows up to payment]
If you fall under high medical costs after your first application, you will be automatically transferred to your designated account. (Normally, the transfer will be made at the end of the month three months after the medical treatment month.)
We will send you a notice of payment decision (postcard) at the time of transfer.
※ If you wish to change your account or do not wish to make an automatic transfer, please contact your local ward office Insurance and Pension Division National Health Insurance Section.
※ Depending on the date of receipt of the application form, mail arrival status, etc., the next time high medical costs applies, it may be necessary to submit the application form without automatic transfer.
Inquiries regarding procedures
Please contact Insurance and Pension Division National Health Insurance Section in your ward office.
Inquiries to this page
Insurance and Pension Division, Health and Social Welfare Bureau Life and Welfare Department
Telephone: 045-671-2424
Telephone: 045-671-2424
Fax: 045-664-0403 (For inquiries regarding procedures, please contact the ward office above)
Email address: kf-hokennenkin@city.yokohama.jp
Page ID: 140-781-987