Japan's Late-Stage Elderly Medical System at 75

Automatic enrollment

On the day a person turns 75, Japan's public health insurance changes. The old National Health Insurance card or company health insurance card stops being the working document, and the person joins the Late-Stage Elderly Medical Care System (kouki koureisha iryou seido, 後期高齢者医療制度).

The system covers people aged 75 and over who live in Japan, plus people aged 65 to 74 with a qualifying disability who apply and are certified. The insurer is not a city or a company. It is a prefectural "wide-area union" (kouiki rengou, 広域連合), one per prefecture, which sets premium rates by ordinance. The city or ward office collects premiums and handles counter procedures. Eligibility comes from Article 50 of the Act on Assurance of Medical Care for Elderly People.

Enrollment is automatic from the birthday, with no application (Meguro Ward guidance). There are no dependents in this system. Each person has a separate membership and premium, so a couple who are both over 75 are two members. Because each prefecture runs its own union, rates and many procedures are local.

Excluded groups

Being 75 is not enough. A person must have an address in Japan, and a foreign national must be a registered resident with a qualifying status.

The last row of the table below comes from the Tokyo union's page for foreign residents, which also excludes diplomatic status and Designated Activities granted for medical treatment or sightseeing. Other prefectures may differ, so ask the union where your parent lives. For the years before 75, see national health insurance for foreign residents over 40.

Incoming documents

In Nerima Ward's example, a certificate of eligibility (shikaku kakunin-sho, 資格確認書) or a notice of qualification information (shikaku jouhou no oshirase, 資格情報のお知らせ) is mailed in the month before the birthday. Which one arrives depends on age and on whether the person uses the My Number insurance card. Our guide to the My Number health insurance card for foreign seniors explains how to check what your parent holds.

The premium notice comes later. Nerima sends it in mid-month after the birthday month for people born July to March, and in mid-July for April to June births.

Two-part premium

The premium is a flat per-person amount (kintou-wari, 均等割) plus an amount based on income (shotoku-wari, 所得割). The Ministry of Health, Labour and Welfare (MHLW) states that the totals of the two parts are in a ratio of 48 to 52. Each union sets the rates, revised every two years.

The Tokyo union calculates income as total income minus a basic deduction of ¥430,000 (when total income is ¥24 million or less), and rounds the premium down to ¥100. A person who joins mid-year pays from the month of joining.

From fiscal 2026, a child and child-rearing support contribution is added to the medical premium. The national average is expected to be ¥194 per member per month.

Regional gaps

MHLW compiled the fiscal 2026-27 rates on April 10, 2026. The national average is expected to be ¥7,989 per person per month, up ¥578 (7.8 percent) from ¥7,411.

In the table below, the last column is for a person living on a basic pension alone, with the largest reduction on the flat part. If your parent moves to another prefecture, the rates change with the address.

Income reductions

If household income is at or below set levels, the flat part is cut by 70, 50 or 20 percent. The test uses your parent's income and that of the other members and the household head. The fiscal 2026 formula is from Sakai City and Ota Ward, which give the same additions. All three tests add ¥100,000 for each wage or pension earner after the first.

The fiscal 2024 additions were ¥295,000 and ¥545,000 (MHLW), so households once outside may now qualify. The test uses income on record, so confirm your parent's income declaration has been filed. People who were dependents under an employee scheme the day before turning 75 get a separate cut: for two years the flat part is reduced by 50 percent, and no income part is charged for the time being, whatever their income. The larger reduction applies if both fit.

Payment and the cap

If annual public pension income is ¥180,000 or more, the premium is normally deducted from the pension every two months (Tokyo union). Others pay by slip or bank debit, due at month end.

Deduction starts later. In Nerima's example, January births start in August, February to June births in October, July to September births the next April, October and November births the next June, and December births the next August. A direct debit used for National Health Insurance is not carried over, so apply again.

When paying by slip or debit, the household head and spouse share liability (Article 108). Check who is head on the resident record.

Annual premiums have a cap: for fiscal 2026, ¥850,000 for the medical portion and ¥21,000 for the child-support portion, ¥871,000 in total (Ota Ward, Sakai City). Unions can reduce or defer premiums for special reasons such as disaster damage (Article 111). Pension deductions are not treated as paid by you. How premiums you pay from your own account are deducted is covered in our tax deduction guide for care costs.

Three copayment rates

At the counter, a member pays 10, 20 or 30 percent. The 20 percent rate began in October 2022. The category is judged each year with August 1 as the reference date, using the previous year's income. For August 2026 to July 2027, it follows the fiscal 2026 resident tax taxable income (Tokyo union).

Long-term care insurance has its own test, with a 20 percent threshold around ¥2.8 million for one person and ¥3.46 million for a couple. Your parent can be at 20 percent for medical care and 10 percent for care services. See medical versus care insurance in Japan.

Exceptions to 30 percent

Taxable income of ¥1.45 million or more does not always mean 30 percent. The Tokyo union lists two rules that matter when the only income is a pension.

If a 30 percent notice arrives and income is likely below the limits listed here, ask the city office whether to apply. A late filing means paying more in the meantime.

• A member born on or after January 2, 1945 whose income total for premium calculation is ¥2.1 million or less is not treated as current-income level. No application is needed.
• With annual income under ¥3.83 million (one member) or ¥5.2 million (two or more), an application for the standard income amount (kijun shuunyuugaku tekiyou shinsei, 基準収入額適用申請) can return the person to 10 or 20 percent. It takes effect from the first of the month after applying.

Monthly outpatient cap

The high-cost medical expense benefit (kogaku ryoyohi, 高額療養費) caps a member's monthly payment, and the excess is paid back. For care received from August 2026, the general 10 and 20 percent groups have a higher cap.

When the 20 percent rate started, a transitional measure limited the added outpatient burden to ¥3,000 a month for three years. It ended on September 30, 2025 (Kashiwa City) and never covered inpatient stays. From August 2026 care, low-income categories have outpatient caps of ¥8,000 and ¥11,000. MHLW plans a further revision from August 2027 that splits the general group by income. See also the combined medical and care cost refund and the high-cost care refund.

Investment income

A law promulgated on June 5, 2026 will bring financial income into premium and copayment tests. Dividends on listed shares that were not reported in a tax return are invisible to cities now. The start date is set by cabinet order within five years.

At the Social Security Council on October 16, 2026, MHLW proposed reflecting about 80 percent of reports (by number) from August 2029 and all from August 2030. This is a proposal until the order is issued. It affects a parent with dividends through a Japanese brokerage. Declared dividends already count. Long-term care insurance is not part of this reform and is still under study, and a review of the copayment rates themselves had no decision as of October 2026.

Premium review

At the Social Security Council's medical insurance committee on November 5, 2026 (219th meeting), MHLW put a review of premiums for people 75 and over on the agenda. Its paper says average income in this group is rising as more older people work, while some households have no savings and prices are going up. As of November 6, 2026, nothing has been decided.

The paper gives two examples: raising the annual cap by a set rule as incomes grow, and making the low-income reductions finer-grained. The cap has risen from ¥500,000 in fiscal 2008 to ¥850,000 for the medical part in fiscal 2026. In fiscal 2025, 1.30 percent of members paid the cap.

The second issue is the special reduction for former dependents, described under Income reductions above. In fiscal 2025, about 1.35 million of roughly 20.54 million members (about 7 percent) were former dependents. About 120,000 of them have income but pay no income part because of the rule, and about 49.1 percent of the 167,000 in their first two years get the 50 percent cut on the flat part. MHLW asked the committee to consider the rule's role, citing fairness to members who were never dependents and the 18 years since the system began.

If your parent is still a dependent on your or a spouse's employer plan when they turn 75, the outcome affects their premium. Rates are reset every two years, and the next reset is fiscal 2028. Until a decision is made, budget with the amount on the current notice.

Dependent family

A family member under 75 who depended on the person turning 75 loses coverage the same day. The system has no dependents, so that person cannot join it.

In January 2020, a regional office of the Ministry of Internal Affairs and Communications mediated after a citizen complained of poor notice. The husband's card arrived, but nothing came for the wife, who did not know a procedure was needed. A delay can mean paying the full cost of care until a new card is issued.

National Health Insurance brings a new premium that varies by city and household income, so ask the counter for an estimate.

Moving and facilities

Moving within a prefecture keeps the union. Moving to another prefecture makes the person a member of the new union from the move date (Article 53), reported at the city office.

People who move because of hospital admission or entry to a facility stay with their previous union. This is the residence-based special rule (jusho-chi tokurei, 住所地特例) in Article 55. It covers hospitals, clinics, facilities for people with disabilities, publicly placed care homes, and specified facilities and long-term care insurance facilities.

Under the Long-Term Care Insurance Act, Article 8, paragraph 11, a specified facility means fee-based nursing homes plus yogo and keihi rojin homes (Enforcement Regulations, Article 15), excluding the community-based type with 29 or fewer residents, whether or not the home provides in-house care. Ask the city office before moving. Our guide to nursing homes in Japan for foreigners compares the types.

Leaving and returning

If a parent leaves Japan and cancels the resident record, membership ends the next day. On return at 75 or over, it resumes from the day an address is set (Articles 52, 53).

Before departure, ask about premium settlement, the eligibility certificate and My Number card, and a domestic contact for notices. If the resident record stays while abroad, whether overseas treatment costs are repaid depends on the union. Article 77 lets a union pay when it considers the case unavoidable, so no amount can be stated. See re-enrolling in health insurance and long-term care insurance. A returnee aged 75 or over joins this system, not National Health Insurance.

Paperwork from afar

Premium decisions, slips and eligibility documents are mailed to your parent's address. Decide who opens them and reports to you.

If dementia or hospital admission means your parent cannot manage paperwork, the household head can file for the member (Article 54, paragraph 2). That depends on who is head on the resident record. If a relative or friend can attend the counter, ask the city office in advance what a representative may do. MHLW publishes union contact details. Our guide to healthcare for foreign retirees shows where this fits. Long-term care procedures use a separate counter, and the care plan sits with a care manager.

• Your parent's birthday, and that the eligibility document arrives the month before.
• The copayment rate, reset each August 1.
• How premiums are paid, and whether a debit application is done.
• Whether the household qualifies for a 70, 50 or 20 percent reduction.
• Any family member who was your parent's dependent.
• Whether Japanese dividends are declared (this matters from 2029).
• For a planned facility move, whether the residence-based special rule applies.