If copayments for medical care and long-term care are high

If total annual copayments for both medical care and long-term care (after deducting amounts refunded from health insurance and long-term care insurance) exceed a certain amount, the excess amount is paid by health insurance and by long-term care insurance as “high aggregate cost for long-term care services”.
However, note that you may apply for this benefit only if you made a copayment for both long-term care insurance and medical care during the period subject to calculations. You cannot apply if, for example, you made a copayment for medical care but not for long-term care insurance.

Copayments and maximum copayment amounts eligible for payment of this benefit (basic amounts)

In principle, calculation is conducted on an annual basis for the period August 1 – July 31. Copayments eligible for calculation are the total copayments for medical care and long-term care insurance paid by the insured person and his or her dependents. However, for medical care costs of a person under 70 years of age, only amounts in excess of the monthly maximum copayment amount*1 of 21,000 yen are eligible.

• *1  Rezept units: by month (first through last day of calendar month), by patient, by inpatient/outpatient care category, and by medical/dental/pharmaceutical category (at a former general hospital, by department)

• * If the same household received payment of high-cost medical care benefits in three or more of the most recent 12 months, the copayment will be reduced in the fourth month and beyond.
• * Refunds from health insurance and long-term care insurance (e.g., high-cost medical care benefits, additional benefits, or high long-term care service costs) and amounts of public assistance received are not included.
• * Costs of inpatient meals and living expenses and costs not eligible for insurance benefits (such as premium bed costs) are not included in the calculations.
• * Cases in which the copayment for either medical care costs or long-term care costs was 0 yen are not included in the calculations. The amount paid will be the amount by which the household’s cost exceeds the base high aggregate cost for long-term care services amount (maximum copayment amount) in the table below.
  

Base high aggregate cost for long-term care services amount (maximum copayment amount)

Contact the Sony Health Insurance Society benefits staff to apply. The Society will send an application form after first confirming membership status and other details.

1. STEP1 The applicant applies for a copayment certificate from long-term care insurance through the insured person.
2. STEP2Receive the copayment certificate from the long-term care insurance insurer.
   • * A member of the Sony Health Insurance Society covered by another health insurance plan during the subject period may need to apply for a copayment certificate from the other insurance plan.
3. STEP3Attach the copayment certificate to the application form and submit to the Society.
4. STEP4After calculating the amounts to be paid, the Sony Health Insurance Society will notify each insurer of the amount to be paid.
   • * High aggregate cost for long-term care services is paid by long-term care insurance and health insurance in proportion based on each insurer’s copayment amount.
5. STEP5High aggregate cost for long-term care services is paid by each insurer to the insured person (the head of household in the case of National Health Insurance).
   • * Each insurer will send a notice of the amount paid when it makes the payment.
   • * Since medical care costs incurred in July are confirmed in October or later, payment will occur in November or later.