Japan's Combined Medical-and-Care Refund (Gassan): The Once-a-Year Cap Families Forget to Claim

The Refund Nobody Applies For Automatically

The combined high-cost medical-and-care system (kogaku iryo-kogaku kaigo gassan seido) refunds a household's medical-plus-care co-payments once they cross an income-tied ceiling over a fixed one-year period, but in most municipalities nobody calculates it until a family files.

This is a separate layer from the two refunds most families already know. The monthly high-cost medical benefit caps a single month's hospital and clinic co-payments; the monthly high-cost care refund caps a single month's care-service co-payments. The combined system sits above both, on an annual clock, and only pays out after those two monthly caps have already done their work. It exists because a household can pay two capped-but-still-large monthly bills, medical and care, in parallel for a full year and still end up carrying a heavy total burden that neither monthly cap alone was designed to catch.

The households this actually helps are narrower than the name suggests. A parent using only care services, with no significant medical spending, will rarely clear the combined ceiling; the same is true of a parent hospitalized once with no ongoing care plan. It is the household running both systems hard at the same time, a parent on dialysis with a certified care level, a spouse managing a chronic condition alongside a partner's home-care plan, where the combined totals start to matter. Our medical insurance versus care insurance explainer covers how the two systems divide responsibility in the first place; this article is about the one place their costs are added back together.

The core mechanic to hold onto: the ceiling is not a household's total spending on medical plus care for the year. It is what remains after each system's own monthly ceiling has already reduced the bill, added up across twelve months, and compared against a single annual figure. Cross that figure, and the excess comes back, split between the two insurers.

The Fiscal Year That Does Not Match The Calendar

The combined system runs on its own year, August 1 through the following July 31, not the calendar year or the tax year, and every deadline in this article is measured from that date.

Per the Foundation for Longevity Science (Chouju Net) and municipal guidance, the calculation period is fixed nationwide: costs incurred from August 1 of one year through July 31 of the next are totaled together, and the reference date for the ceiling and the filing clock is that July 31. A family tracking receipts by calendar year or by Japanese fiscal year (April to March) will be off by several months if they try to apply the combined system's rules to the wrong window. Set a recurring check for late July or early August each year if a parent is using both systems heavily; that is when the prior period closes and the two-year filing clock on it begins.

The Income-Tied Annual Limits

The annual ceiling is set by income band and by whether the household member is 70 or older or under 70, and the two age groups use different tables.

For households where the person is 70 or over, the combined annual ceiling by income band runs roughly as follows: a household with income of about ¥11.6 million or more faces a ¥2.12 million annual ceiling; ¥7.7 million to ¥11.6 million faces roughly ¥1.41 million; ¥3.7 million to ¥7.7 million faces roughly ¥670,000; the general-income band (roughly ¥1.56 million to ¥3.7 million) faces roughly ¥560,000; a municipal-tax-exempt household faces roughly ¥310,000; and a municipal-tax-exempt household at the lowest income tier faces roughly ¥190,000. These figures reflect the standard ceiling structure in place since August 2018 as summarized by Chouju Net; a household's own municipality confirms the exact figure that applies to it.

For households under 70, the top three income bands use the same figures as the 70-and-over table, but the general-income band sits at roughly ¥600,000 rather than ¥560,000, and both municipal-tax-exempt bands sit at roughly ¥340,000 rather than ¥310,000 or ¥190,000. This is one of the more common mixups families make: checking the 70-and-over row for a 62-year-old spouse using care insurance under the under-65 route produces the wrong ceiling.

The Japanese government's December 2025 cabinet-approved budget confirmed a phased increase to the separate monthly high-cost medical benefit, raising self-payment ceilings by roughly 4 to 38 percent depending on income band across two stages, the first from August 2026 and the second from August 2027, after an earlier August 2025 start date was frozen in spring 2025 following patient-group opposition. Because the combined system's annual ceiling is calculated on top of that monthly benefit, the combined-ceiling figures for the August 2026 to July 2027 period and beyond will shift from the pre-2026 table above once each stage takes effect. Families whose qualifying year starts in August 2026 should confirm the current-year figure with their medical insurer rather than relying on the pre-2026 table above.

Reading The Ceiling Against A Real Household

The ceiling only bites once both systems' own monthly caps have already reduced the bill, so the combined benefit is smaller than it looks on paper.

Because the combined refund only reaches costs left over after the monthly caps, a family that has already been diligent about claiming the monthly high-cost care refund and the monthly medical benefit each month will see a smaller combined refund than a family that let bills run uncapped all year, simply because less remains once the monthly ceilings have already done their job. The combined system is not a bonus on top of good bookkeeping; it is a backstop for what the monthly systems structurally cannot reach when both are heavy at once. Our cost-of-elderly-care overview walks through where the monthly ceilings themselves land for different care levels and income bands.

The Two-Step Filing Sequence

The claim is not filed in one place; it runs through the municipality first for a certificate, then through the medical insurer for the actual payment.

Per the Japan Health Insurance Association (Kyokai Kenpo) and multiple municipal guides including Kyoto City's, the sequence is fixed: first, the household files an application with the municipality (the care insurer) to receive a self-payment certificate covering the care-insurance side of the year's costs; second, that certificate is attached to a separate application filed with the medical insurer, whichever health insurance society, National Health Insurance office, or Late-Stage Elderly Medical Care office covered the household member as of the July 31 reference date; third, the medical insurer calculates the combined refund and coordinates the payout with the municipality, and the refund is then paid out from both insurers according to each system's share of the excess.

The reference date matters because insurers can change mid-year. If a parent switched from a company health insurance society to National Health Insurance, or turned 75 and moved into the Late-Stage Elderly system partway through the August-to-July period, the insurer that was active on July 31 is the one that receives the combined application, even though other insurers covered part of the same period's costs. A family unsure which insurer applies should start at the municipal care insurance desk, which can direct the filing regardless of which medical insurer turns out to be correct.

Two years is the filing deadline, running from the day after the reference date. Because the statute of limitations under the National Health Insurance Act runs two years from the day after the July 31 reference date of the period being claimed, a family that misses the deadline loses the refund permanently; there is no late-filing exception for forgetting or for being overseas when the postcard arrived.

When The Family Filing Is Overseas

The paperwork for this system is mailed to the parent's registered address in Japan, which creates a specific failure mode for families abroad: the certificate request or the refund notice sits unopened.

Municipalities generally do not proactively calculate the combined refund; several send an informational notice or a paper application to households whose combined costs look likely to cross the ceiling, based on records already on file, but this is discretionary practice that varies by municipality rather than a guaranteed service, and it is generally addressed to the household member in Japan, not to a family contact overseas. If that mail sits at an empty apartment, in a care facility's administrative pile, or with a parent who cannot process a Japanese-language government form, the two-year window can close with no one aware a refund existed.

The practical fix is procedural, not legal: whoever holds power of attorney or another form of legal authority for the parent's affairs in Japan, whether a family member with mail access, a care manager willing to flag municipal correspondence, or a professional agent, should build a July or August check into the yearly routine specifically for this filing, separate from routine care-plan reviews. A single annual reminder, timed to the reference date, is the whole fix for a deadline this specific.

Where the refund actually lands is worth confirming before the certificate stage, not after. The combined benefit is paid into the bank account registered with the medical insurer for benefit payments, which for many households is the same account already used for pension deposits or medical refunds; our banking guide for foreign retirees in Japan covers how that account access typically works when the account holder is aging or when a family member overseas needs visibility into it. Confirming the registered payout account matters most when a parent has changed banks, closed an account, or moved into a facility that manages finances differently from an independent household.

None of this requires a lawyer or a translator to execute correctly; it requires someone checking, once a year, whether the household crossed the line, and filing before the two-year window on that specific year closes. Families managing a parent's care from a distance often build this into the same annual review where they check the parent's care level and the monthly care refund status, rather than treating it as a separate task that is easy to forget.