High-Cost Medical Expense Benefit After 70 in Japan

The monthly ceiling

The high-cost medical expense benefit (kogaku ryoyohi, 高額療養費) refunds the part of your insured medical co-payments in one calendar month that goes above a ceiling set by income tier. The month that counts is the month of treatment, not the month you paid.

The calculation has two steps for people aged 70 and over. Outpatient co-payments are first totalled for each person and checked against an individual outpatient ceiling. That result is then added to inpatient costs, combined with the rest of the household, and checked against a household ceiling. The Kanagawa Prefecture association for the late-stage elderly medical system describes the same order: individual first, household second.

Younger adults can only combine bills of ¥21,000 or more. From age 70 every insured co-payment in the month counts, from a hospital, clinic or dentist.

Household here means family members in the same medical insurer, according to the Ministry of Health, Labour and Welfare (MHLW) Q&A, not everyone at one address.

Finding the income tier

There are six tiers for people aged 70 and over. Three are active-income tiers (gen'eki-nami shotoku), III, II and I, for people whose resident-tax taxable income is ¥6.9 million or more, ¥3.8 million or more, and ¥1.45 million or more. Below those, anyone paying resident tax is General. A household where everyone is exempt from resident tax is Category II, and Category I covers the lowest incomes within that group.

An active-income tier can drop to General. The Kanagawa association gives the test: income under ¥3.83 million for a single insured person, or under ¥5.2 million in total for two or more. The high-cost tier follows that decision. How that co-payment test works from 75 is set out in Japan's late-stage elderly medical system.

Old leaflets describe Category I as pension income of ¥800,000 or less. The August 2026 guidance from the Kanagawa association and Chigasaki City uses a ¥826,500 pension deduction, so an old pamphlet should not rule a parent out.

For National Health Insurance members aged 70 to 74, Chigasaki City explains that the tier uses income from two calendar years earlier for January to July, and from the previous year for August to December. A co-payment rate alone cannot tell you the tier, so ask the insurer or the hospital billing desk (iji-ka, 医事課).

Ceilings from August 2026

The table shows the ceilings that apply to treatment from August 2026 through July 2027. They come from the MHLW revision notice for treatment from August 2026 and from the Kanagawa association's guidance.

Total medical cost means the full insured cost before any co-payment. For Active-income I, ¥1,000,000 in total costs gives ¥85,800 + (¥1,000,000 − ¥286,000) × 1% = ¥92,940 for treatment from August 2026. The formula for treatment up to July 2026 gave ¥87,430.

The ¥410,000 annual figure for General applies to people confirmed under roughly ¥2 million in annual income, and from August 2027 it is paid back afterwards as a refund.

Before and after

The revision comes in two stages. The first applies to treatment from August 2026: monthly ceilings rose and annual caps were added. The MHLW says it asks more mainly of people with short treatment periods, while long treatment is supported by the unchanged fourth-month figure and the annual caps.

The second stage, from August 2027, is still a plan, and amounts can change.

The outpatient annual cap

People in General and the two low-income categories have an extra layer, the outpatient special rule (gairai tokurei, 外来特例), which applies to outpatient bills alone. The three active-income tiers have no individual outpatient cap, so they have no outpatient annual cap either.

For treatment from August 2026 the outpatient annual cap is ¥216,000 for General and ¥96,000 for Category II. The year runs from August to the following July.

A Category II patient at ¥11,000 every month would pay ¥132,000 in twelve months, but the cap stops it at ¥96,000, an average of ¥8,000. A General patient at ¥22,000 a month would pay ¥264,000, but the cap stops it at ¥216,000, an average of ¥18,000. The old annual cap was ¥144,000, so someone using the full ceiling every month pays up to ¥72,000 more a year than before.

Chigasaki City pays the household head when the outpatient total for months in General or a low-income category passes those amounts, with 31 July as the reference date. As of its 30 July 2026 update, the Kanagawa association said claim details would be announced later.

A proposal to abolish the outpatient special rule is also on the table. In material for the Fiscal System Council on November 4, 2026, the Ministry of Finance argued that the rule should be abolished, noting that it applies only to people aged 70 and over and was introduced in 2002 to soften a sudden rise in costs. This is the Finance Ministry's position, not a decision. If a parent sees a doctor as an outpatient every month, check the government's conclusion toward the end of the year.

Fourth month onward

If a household reaches the monthly ceiling three times within twelve months, the ceiling falls from the fourth month. This is the multiple-occurrence rule (tasukai, 多数回). The reduced figures were left unchanged in the August 2026 revision.

Under the Kanagawa association's guidance, a month in which only the individual outpatient ceiling was exceeded does not count toward the three. For active-income members, a month in which their own outpatient bills alone reached the household ceiling does count.

The annual cap added in August 2026 covers medical costs alone. It differs from the combined medical and care limit explained in combined medical and care cost refund. For General, the medical-only annual cap is ¥530,000 and the combined limit is ¥560,000.

A worked example

Chigasaki City's National Health Insurance guidance gives a General-tier example at the 20 percent window rate. A husband has two outpatient bills of ¥15,000, and his wife an inpatient bill of ¥80,000. The ceilings are those for August 2026 to July 2027.

When several hospitals are involved, each stops the bill only at its own ceiling, so the combined refund arrives later. An admission that crosses a month boundary is judged month by month and may face two sets of ceilings.

• Husband, outpatient: ¥15,000 at clinic A plus ¥15,000 at clinic B is ¥30,000. The individual outpatient ceiling is ¥22,000, so ¥8,000 comes back.
• Wife, inpatient: ¥80,000 against a ceiling of ¥61,500. If the window payment is already capped, she pays ¥61,500 and the insurer covers ¥18,500.
• Household: ¥22,000 plus ¥61,500 is ¥83,500, against a household ceiling of ¥61,500. A further ¥22,000 is refunded.
• Total refunded afterwards: ¥8,000 plus ¥22,000, which is ¥30,000.

Meals and room charges

The benefit covers only the co-payment for insured treatment. Hospital meals, the daily living and housing charge, a room charge for a private room chosen by the patient (sagaku bed) and advanced medical treatment are all outside it.

A 30-day stay at three meals a day is 90 meals. At ¥550 each, a General patient is billed ¥49,500 for meals, on top of the medical ceiling. Category I and II patients who paid the general rate can apply later at the municipal counter for the difference.

A private-room fee may not apply if the hospital places a patient there for its own reasons. Ask for a written estimate of all uninsured charges before admission.

Extra layers

The ceilings are the same across insurers, but some company health associations add a supplementary benefit (fuka kyufu, 付加給付) that lowers the effective ceiling further. A person aged 70 to 74 who is still on a company plan should read the association's rules. Some local governments also pay their own medical subsidies, so the window payment can fall below the national ceiling.

Large medical or care bills may also qualify for a tax deduction, covered in the medical expense deduction for care costs. The care-insurance side has its own ceiling: see the high-cost care refund.

Long, very expensive treatment has a special rule. It covers chronic kidney failure that needs dialysis, hemophilia and HIV infection caused by blood products. The MHLW leaflet says the ceiling under this rule is, in principle, ¥10,000 a month.

To use it, apply to the parent's insurer for a specified disease certificate (tokutei shippei ryoyo juryo-sho, 特定疾病療養受療証). Setagaya City's pages say that from age 70, on both National Health Insurance and the late-stage elderly system, the cap is ¥10,000 a month per medical institution whatever the income. As a rule the certificate takes effect from the first day of the month of application. Setagaya City adds that a person who joins National Health Insurance partway through a month is covered from the date insurance eligibility begins instead. A family member can apply with a letter of authorization. Bunkyo City says a patient who already has the certificate and uses the My Number card can agree at reception to share it instead of showing the paper. If dialysis starts, ask family in Japan to apply within that month.

Avoiding the front payment

You can avoid paying more than the ceiling at the window. With the health insurance function of the My Number card, a patient who agrees at reception to share their insurance information pays no more than the ceiling. This applies to outpatient visits at the same institution as well as to admissions.

Category I and II and Active-income I and II members used to need a limit application certificate (gendo gaku tekiyo nintei-sho, 限度額適用認定証), or its version that also lowers the meal charge, to get this at the window. The Kanagawa association says that, with the end of the old health insurance card, no new certificates have been issued since 2 December 2024. A certificate already held stays valid until it expires if the address and tier do not change.

Without a My Number card, the same notice says a patient who agrees at the window can still have the payment limited through the online eligibility check. Some hospitals ask to see the income tier, and the member then applies to the municipality for an eligibility certificate (shikaku kakunin-sho, 資格確認書) that states it. Other insurers publish their own procedure.

You can still claim afterwards, but a long admission can mean a large advance payment, and a family abroad may be asked to send money. When admission is decided, ask a relative in Japan to confirm that the My Number card works at that hospital or that an eligibility certificate showing the tier is in hand.

Refund notices and timing

Under the late-stage elderly system, the Kanagawa association says a notice and form arrive three to five months after treatment, and payment follows two to four months after applying. Later refunds then go to the same account automatically.

For National Health Insurance members aged 70 to 74, Chigasaki City sends the form to the household head about two months after treatment. Online, counter or postal applications are accepted, and payment comes in the middle of the following month. After the first claim the form is skipped, until three years pass since the last transfer or the household head changes.

The right to claim runs for two years from the first day of the month after the treatment month, and the MHLW says earlier months can still be claimed within it. The Kanagawa association tells members the right generally lapses two years after the notice arrives. Because wording differs by association and city, act soon after a notice comes. Expect to wait at least about three months from treatment, since the hospital's claim must be reviewed first.

Notices go by post to the insured person or household head, so a son or daughter abroad will not see them. Arrange for a relative in Japan to photograph each letter and send it on.

Where the money goes

In the Kanagawa association's example, an account other than the insured person's can be named with the insured person's seal. The public benefit account registered on the My Number portal must be the insured person's own, not an agent's, heir's or household member's.

If a guardian has been appointed, a registry certificate copy may be requested. Chigasaki City advises a passbook in the household head's name. Whether an overseas bank account works differs by insurer. For the budget picture see the cost of elderly care for families abroad, and for enrolment see healthcare for foreign retirees.

After a death

If medical bills in the last months of life went over the ceiling, the refund for those months is still payable after the death. Heirs can claim it, and the two-year period runs from the first day of the month after each treatment month.

Our page on what to do when a parent dies in Japan covers the other steps. Under the late-stage elderly system, the Kanagawa association's example asks an heir for identity documents, proof of heirship such as a family register copy or a notarial deed, bank details and the applicant's seal. Documents can sometimes be omitted if the heir was on the same resident register as the deceased.

If the parent was under 75 and in National Health Insurance or another scheme, ask that insurer, since forms differ by city. A city letter arriving for a deceased parent can be this refund notice.

Questions for the hospital

Before an admission, ask the billing desk or the medical social worker for a cost outlook.

Care-insurance bills arrive separately; see the long-term care insurance guide.

• Which income tier applies, and what ceiling the window will use
• Whether the My Number card is enough or an eligibility certificate showing the tier is needed
• Whether the stay crosses a month boundary
• The per-meal charge and a written estimate of uninsured charges
• Where the refund notice and payment will go