High-cost Medical Care Expenses
The Western Digital Technologies Health Insurance Association automatically calculates and pays the total amount of high-cost medical expenses and additional benefits for any out-of-pocket medical care costs exceeding the ceiling amount at a later date based on the medical cost statement (insurance claim) sent from the healthcare provider.
(This excludes amenity bed costs and other expenses not covered by insurance and the cost of inpatient meals.)
High-cost Medical Care Expenses
High-cost Medical Care Expenses and Co-payment Reductions (Additional Family Medical Expense Benefit)
The Western Digital Technologies Health Insurance Association reimburses insured persons and dependents for high-cost medical care expenses paid at the billing counter for inpatient or other medical care at a later date. A co-payment reduction (additional family medical expense benefit) is also offered as a unique benefit from the Western Digital Technologies Health Insurance Association.
Insured persons and dependents can limit payments at the billing counter of healthcare providers to the ceiling amount of out-of-pocket costs by applying for and presenting an Eligibility Certificate for Ceiling-Amount Application. See more details about the Eligibility Certificate for Ceiling-Amount Application here.
These benefits are calculated and automatically paid based on the certificate of medical remuneration sent by the healthcare provider to the Western Digital Technologies Health Insurance Association (insured persons and dependents do not need to submit an application), but the payment period is roughly three to four months after the month in which the insured person or dependent received medical care.
*Insured persons and dependents can reduce the burden of co-payments when the total amount of out-of-pocket payments for medical insurance or long-term care exceeds a certain amount through programs such as the high-cost medical care expense and high-cost long-term care cooperation system for reimbursements of excess medical care costs or certificates issued for specific disease treatments to reduce the ceiling amount for specific diseases incurring high-cost medical care expenses.
High-cost Medical Care Expense Payments and Additional Benefits
Amount of payment |
Amount exceeding out-of-pocket medical costs for one treatment per month when above the maximum amount
(the maximum amount differs for low-income earners and individuals age 70 to 74) |
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Additional Benefits from the Western Digital Technologies Health Insurance Association |
Co-payment Reductions and Additional Family Medical Expense Benefit: Payment of an amount calculated by deducting 25,000 yen from the out-of-pocket amount (rounded down to the nearest 1,000 yen) *This excludes standard out-of-pocket payments related to high-cost medical care expenses, in-patient dietary treatments, and in-patient daily living treatments. |
Classification | 3 Months or less*1 | 4 Months or more*1 |
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Standard monthly remuneration of 830,000 yen or more | 252,600 yen + (total medical care costs - 842,000 yen) x 1% |
140,100 yen |
Standard monthly remuneration of 530,000 yen to 790,000 yen | 167,400 yen + (total medical care costs - 558,000 yen) x 1% |
93,000 yen |
Standard monthly remuneration of 280,000 yen to 500,000 yen | 80,100 yen + (total medical care costs - 267,000 yen) x 1% |
44,400 yen |
Standard monthly remuneration of 260,000 yen or less | 57,600 yen | 44,400 yen |
Low-income earner*2 | 35,400 yen | 24,600 yen |
Applicable Classification | Outpatient (per Individual) |
Outpatient + Inpatient (per household) |
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Persons earning the same level as those of working age | Persons earning the same level as those of working age - III Standard monthly remuneration of 830,000 yen or more |
Income earners at the same level as active employees Persons earning the same level as those of working age - III (standard monthly remuneration of 830,000 yen or more) |
252,600 yen + (medical care costs - 842,000 yen) x 1% [140,100 yen] |
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Persons earning the same level as those of working age - II Standard monthly remuneration of 530,000 yen to 790,000 yen |
Income earners at the same level as active employees Persons earning the same level as those of working age - II (standard monthly remuneration of 530,000 yen to 790,000 yen) |
167,400 yen + (medical care costs - 558,000 yen) x 1% [93,000 yen] |
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Persons earning the same level as those of working age - I Standard monthly remuneration of 280,000 yen to 500,000 yen |
Income earners at the same level as active employees Persons earning the same level as those of working age - I (standard monthly remuneration of 280,000 yen to 500,000 yen) |
80,100 yen + (medical care costs - 267,000 yen) x 1% [44,400 yen] |
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General | Standard monthly remuneration of 260,000 yen or less | General (Standard monthly remuneration of 260,000 yen or less) |
18,000 yen (Annual maximum: 144,000 yen) |
57,600 yen [44,400 yen] | |
Low-income earners (resident tax exemption) |
II | Low-income earners (resident tax exemption) II |
8,000 yen | 8,000 yen | 24,600 yen |
I (Annual income of 800,000 yen or less, etc.) | Low-income earner (resident tax exemption) I (annual income of 800,000 yen or less, etc.) |
8,000 yen | 15,000 yen |
However, these insured persons and dependents may pay the standard 20% out-of-pocket costs by filing an application with the Western Digital Technologies Health Insurance Association if:
- The individual is age 70 or older and earns less than 3.83 million yen annually without any dependents
- The individual has a dependent or former dependent age 70 or older and has a total combined annual income of less than 5.20 million yen
The Western Digital Technologies Health Insurance Association pays the amount exceeding the combined maximum total of 21,000 yen in out-of-pocket costs for two or more cases in the same household as aggregated high-cost medical care expenses.
Eligibility Certificate for Ceiling-Amount Application
Insured persons and dependents can apply to have a certificate issued by the Western Digital Technologies Health Insurance Association in advance for any out-of-pocket payments exceeding the ceiling amount to present at the billing counter of the healthcare provider in order to limit payment to only the medical costs up to the maximum amount.
If you use your Individual Number Card (My Number Card) as your health insurance card, you will be exempt from paying any out-of-pocket expenses that exceed the maximum amount under the High-Cost Medical Expenses System without undertaking any prior procedures.
There is no need to apply for a Eligibility Certificate for Ceiling-Amount Application in advance.
For more information, please see here.
In addition, if the medical institution cannot confirm your eligibility using your Individual Number Card, you may not be able to receive an exemption.
Please check with the medical institution you will be visiting in advance regarding the status of Individual Number Card compatibility.
Digital Applications | Digital application |
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Applications by postal mail | Request for Issue of Health Insurance Eligibility Certificate for Ceiling-Amount Application Form PDFEntry Sample |
Calculation Method for High-Cost Medical Care Expenses
Calculation Method for High-Cost Medical Care Expenses
- Monthly calculation of medical care(first to last day of the month)
- Calculation by patient
- Calculation by healthcare provider (calculated separately for inpatient, outpatient, and dental care and by each medical department at medical institutions formerly certified as general hospitals)
Aggregated High-cost Medical Care Expenses for a Household
The Western Digital Technologies Health Insurance Association pays the amount exceeding the combined maximum total of 21,000 yen in out-of-pocket costs for two or more cases in the same month for the same household.
Four Months or More of High-cost Medical Care Expenses (Multiple Occurrences)
The co-payments from the fourth month in which high-cost medical care expenses exceed the ceiling amount vary as follows when insured persons and dependent have paid high-cost medical care expenses three or more times in one year (last 12 months) in the same household.
Standard Monthly Remuneration | Limit for out-of-pocket payments |
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830,000 yen or more | 140,100 yen |
530,000 yen to less than 790,000 yen |
93,000 yen |
280,000 to less than 500,000 yen |
44,400 yen |
260,000 yen or less | 44,400 yen |
Low-income earners (resident tax exemption) |
24,600 yen |
Special Exception for Specific Diseases
Patients with hemophilia, acquired immune deficiency syndrome (AIDS) administered antiviral agents, and chronic renal failure requiring dialysis for an extended period only need to pay 10,000 yen per month to a healthcare provider once certified as a person with a specific disease. However, patients who require dialysis have a co-payment of 20,000 yen if their standard monthly remuneration is 530,000 yen or more. (This applies to both insured persons and dependents.)
documents
- Health Insurance Application for Issuance of Certificate Issued for Specific Disease Treatment
PDF Entry Sample