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Reduction of medical expenses

When a member or dependent has paid more than a certain amount for insurance covered treatment, they are entitled to receive Benefit for High-cost Medical Care, Copayment refund, Copayment refund for dependent or other benefits. These benefits are automatically paid three to four months after visiting the doctor. You do not need to submit a form or receipt to PMAC.

Benefit for High-cost Medical Care(Monthly)

When a member or dependent has paid medical expenses exceeding the ceiling amount within the same month as set forth in the table below per medical institution or facility, per medical or dental, and per as an inpatient or outpatient, the exceeded amount shall be reimbursed as the Benefit for High-cost Medical Care.

Calculation standards for Benefit for High-cost Medical Care (ceiling amount of copayment per month)

Age 70 and over (Elderly Recipient)

High income earner

Income level Ceiling amount of copayment per month [A]
Type 3
Monthly standard salary equal to or over 830,000 yen
252,600 yen + (medical expenses(*1) − 842,000 yen) × 1% [140,100 yen](*2)
Type 2
Monthly standard salary equal to or over 530,000 yen and under 830,000 yen
167,400 yen + (medical expenses(*1) − 558,000 yen) × 1% [93,000 yen](*2)
Type 1
Monthly standard salary equal to or over 280,000 yen and under 530,000 yen
80,100 yen + (medical expenses(*1) − 267,000 yen) × 1% [44,400 yen](*2)

Regular income earner

Income level Ceiling amount of copayment per month
per outpatient 【A】 per inpatient 【B】
Monthly standard salary under 280,000 yen 18,000 yen
Annual ceiling amount is 144,000 yen
57,600 yen
[44,400 yen] (*2)

Low income earner(exempt from residence tax)

Income level Ceiling amount of copayment per month
per outpatient 【A】 per inpatient 【B】
Type 2
Other than Type 1 below
8,000 yen 24,600 yen
Type 1
Total taxable(net)income is 0 yen(A person with a pension income less than 800,000 yen,when pension is the only source of income)
8,000 yen 15,000 yen

Under 70 years

Income level based on the Monthly Standard Salary Ceiling amount of copayment per month 【C】
830,000 yen or more 252,600 yen+(medical expenses (*1) −842,000 yen) × 1%
[140,100 yen](*2)
530,000 yen or more and less than 83,000 yen 167,400 yen+(medical expenses (*1) −558,000 yen) × 1%
[93,000 yen](*2)
280,000 yen or more and less than 530,000 yen 80,100 yen+(medical expenses (*1) −267,000 yen) × 1%
[44,400 yen](*2)
Less than 280,000 yen 57,600 yen
[44,400 yen](*2)
Low income earner (exempt from residence tax) 35,400 yen
[24,600 yen](*2)

Note:

  • (*1) The “medical expenses” here means a full amount (100%) of medical expenses without any deduction or discount (not 30% of the medical expenses).
  • (*2) When a member or dependent is provided the Benefit for High-cost Medical Care three times or more a year per household, the Benefit for the fourth time and onward shall be the fixed amount in parenthesis marked with an asterisk.

    Reimbursement is payable in principle to:

    1. The outpatient aged 70 or more (the elderly recipient) whose copayment exceeds the amount A.
    2. The inpatient aged 70 or more (the elderly recipient) whose copayment exceeds the amount B.
      • Monthly Standard Salary above or equal to 280,000 yen ... When copayment exceeds “A”
      • Monthly Standard Salary below 280,000 yen ... When copayment exceeds “B”
    3. The patient aged less than 70 whose copayment exceeds the amount C.

    Household medical expenses added up

    1. The family are all 70 years old or older (elderly recipients only):
      Sum up the total copayment amount of the individuals age 70 or above within the household and if;
      • The monthly standard salary is 280,000 yen or above ... Deduct “A” from the summed up total when the amount exceeds “A.”
      • The monthly standard salary is below 280,000 yen ... Deduct “B” from the summed up total when the amount exceeds “B.”
    2. The family includes a member(s) aged less than 70 years:
      When the total amount of copayments by the whole family exceeds the amount C, the total amount deducted by the amount A shall be reimbursed as the Benefit for High-cost Medical Care.
      * As for copayments by a family member(s) aged less 70 years, only those of 21,000 yen or more shall be included in the total amount.

    Maximum Amount Application

    By presenting the “Maximum Amount Application Certificate” at the medical institution, those under age 70 or those age 70 and above who are categorized as Type II or Type I, will be exempted from the portion of high-cost medical care expenses in your health insurance copayment, which we will pay to the medical institution for you.

    Benefit for High-cost Medical Care (Annual total outpatient visit amount)

    Members and their dependents age 70 or above and under age 75 who are categorized as “Regular income earner” or “Low income earner” in the income category, whose copayment for outpatient visits totalled more than the specified amount (144,400 yen) a year (between August 1st of the previous year and July 31st of that year) can receive a Benefit for High-cost Medical Care.
    If the individual had been a PMAC member or a dependent for the full length of the period between August of the previous year and July of that year, the benefit will be automatically paid without the need to make any claim.
    Note that in case a PMAC member or a dependent started to participate somewhere during that period or became no longer a member of PMAC during that period, there will be no automatic payment of the benefit and a claim is necessary.

Specified disease

The maximum copayment for a patient under treatment of dialysis or other specified disease is 10,000 yen per month in principle; however, a dialysis patient whose Monthly Standard Salary is 530,000 yen or more shall pay 20,000 yen per month. PMAC will cover the amount exceeding the said 10,000 yen or 20,000 yen. The “Certificate for Specified Disease Treatment” must be presented at the hospital.

Copayment refund and Copayment refund for dependent

When a member or dependent has paid copayments exceeding 25,000 yen per medical institution or facility, per medical or dental, and per as an inpatient or outpatient within the same month, the amount exceeding 25,000 (excluding the Benefit for High-cost Medical Care) yen will be paid to the member as Copayment refund or to the dependent as benefit for dependent’s medical care expense.

Note:

  1. Refund less than 100 yen shall be rounded off.
  2. When the total copayment is less than 26,000 yen, which means that the refund is less than 1,000 yen, there is no refund.
  3. The expenses not to be covered by health insurance such as the use of an amenity bed are not within the scope of our refund policy.

Image of Copayment refund and Copayment refund for dependent

Municipal subsidies for medical expenses

When the copayment amount has already been reduced by municipal subsidies, the above mentioned refund of copayment or benefit for dependent’s medical care expenses may not be payable to avoid double subsidies. If you are found to have benefited from such double subsidies, you may be requested to return our refund.
Also when Benefit for High-cost Medical Care are reimbursed by PMAC while the copayment amount has already been reduced by municipal subsidies, you may be requested by the municipal to return their subsidies for the High-cost medical care expenses.

Benefit for Combined High-cost Medical Care and Nursing Care

Reimbursement is made when the total copayment amount paid by the whole family (a member and his/her dependents certified by us) for medical services covered by the medical treatment insurance and the nursing-care insurance exceeds the ceiling amount by the standard calculation.
The reimburse procedures are enacted upon your claim.

  • The copayment amount for the standard calculation of the Benefit for Combined High-cost Medical Care and Nursing Care is the amount of copayments deducted by Benefit for High-cost Medical Care and Copayment refund or Copayment refund for dependent.
  • The calculation is based on the period of twelve months from August of the previous year to July of the current year.
Standard calculation of the ceiling amount (based on the period from August of the previous year to July of the current year)
Income level based on the Monthly Standard Salary Short-term benefits & nursing-care insurance
Family with an elderly family member(s) aged 70 to 74 Family with an elderly family member(s) aged under 70
830,000 yen and more 2,120,000 yen 2,120,000 yen
530,000 yen and more and less than 830,000 yen 1,410,000 yen 1,410,000 yen
280,000 yen and more and less than 530,000 yen 670,000 yen 670,000 yen
Less than 280,000 560,000 yen 600,000 yen
Low income earner[Type2] 310,000 yen 340,000 yen
Low income earner[Type1] 190,000 yen 340,000 yen

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