Salesforce
Health Association

High-cost Medical Care Expenses

High-cost Medical Care Expenses and Co-payment Reductions (Additional Family Medical Expense Benefit)

The Salesforce Health 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 Salesforce Health 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 through the Salesforce business operator based on the statement of medical expenses sent by the healthcare provider to the health 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 specified disease treatments to reduce the ceiling amount for specified diseases incurring high-cost medical care expenses.

*If there are two or more cases of out-of-pocket payments of 21,000 yen or more in the same household, and if the combined total exceeds the ceiling amount, the excess amount is paid as “household combined high-cost medical expenses.”

Persons Who Are Receiving Benefits from a Medical Care Costs Subsidy System for Infants and Children

Local governments (prefectural, city, ward, town and village) may implement a medical care costs subsidy system that provides subsidies toward medical care costs (high-cost medical care and additional benefits for family medical care) paid out-of-pocket for persons under 18 years of age.
To prevent duplicate subsidies from the health association and the local governments, in principle, health insurance societies do not implement the automatic payment of high-cost medical care benefits and additional benefits for family medical care for persons under 18 years of age.
If you do not receive any benefits from the local government or health association even after 4 months have passed since the month in which high-cost medical care was incurred, please contact the health association.

Eligibility Certificate for Ceiling-Amount Application

Insured persons and dependents can apply to have a certificate issued by the Salesforce Health 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 an Eligibility Certificate for Ceiling-Amount Application in advance.

Calculation Method for High-Cost Medical Care Expenses

Regardless of whether or not you submit the Eligibility Certificate for Ceiling-Amount Application, the amount calculated by deducting 20,000 yen from the medical care costs paid at the hospital billing counter will be paid approximately 3 months after the month in which medical treatment was received (amounts less than 1,000 yen will not be paid; amounts less than 100 yen are rounded down).

*High-cost medical care expense benefits are calculated automatically and do not require an application.

In either case, the amount of final co-payment is the same.

Aggregated High-cost Medical Care Expenses for a Household

*If there are two or more cases of out-of-pocket payments of 21,000 yen or more in the same household for the same month, and if the combined total exceeds the ceiling amount, the excess amount is paid as “household combined high-cost medical expenses.”

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.

Regarding "the Annual Maximum"

Special Exception for Specified 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 specified 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.)