If you paid the entire medical care cost up front
In certain cases, if you were required to pay the full medical care cost at a medical care institution or other facility for unavoidable reasons, you may later be reimbursed by the Health Insurance Society for the portion covered by health insurance as a benefit.
Medical Care Expenses (for medical care costs paid up front)
In certain cases, if you paid the full medical care cost at a medical care institution or other facility, you may later be reimbursed by the Health Insurance Society for the portion covered by health insurance as a benefit. Such benefits are referred to as Medical Care Expenses.
You will receive the amount calculated by applying the Health Insurance Society’s cost-sharing ratio to the actual cost incurred. (Amounts less than one yen are rounded down.)
| Younger than ages of compulsory education | Ages of compulsory education to age 69 | Ages 70-74 | |
|---|---|---|---|
| Cost-sharing ratio (Paid by health insurance) |
80% | 70% | Persons with income comparable to active workers: 70% General (other than above): 80% |
- * Please note that not all the costs you paid up front are eligible for benefit calculations. The amount reimbursed as a benefit is calculated based on the treatment methods and fees/charges authorized under the Health Insurance Act.
- Reference link
Medical Care Expenses will be paid in the following cases
| Reason for payment of Medical Care Expenses | Payment conditions, etc. |
|---|---|
| If you paid the full medical care cost at a medical care institution because you could not present your My Number Card as your Health Insurance Certificate or similar document If you accidentally used your previous health insurance |
Unable to verify health insurance eligibility |
| If you purchased and used prosthetic or other equipment (e.g., corset, artificial arm or leg, artificial eye) as instructed by an insurance doctor | Prosthetic or other equipment |
| If you purchased eyeglasses or contact lenses or had them prepared to treat juvenile amblyopia, etc. of a child less than nine years of age | Eyeglasses to treat juvenile amblyopia, etc. |
If you purchased a compression garment, etc. to treat the following conditions:
|
Compression garment, etc. |
| If you underwent acupuncture, moxibustion, massage, or shiatsu with an insurance doctor’s approval | Acupuncture, moxibustion, massage |
If you purchased limbal-supported rigid contact lenses for disfigured corneas caused by ocular sequelae of Stevens-Johnson syndrome or toxic epidermal necrolysis |
Contact the Health Insurance Society for more information. |
| If you received a live blood transfusion | Contact the Health Insurance Society for more information. |
If your health insurance enrollment is still being processed
If you visited a medical care institution shortly after enrollment and paid the full medical care cost because your eligibility could not be verified
If you could not present your My Number Card as your Health Insurance Certificate due to sudden illness
If you could not present your My Number Card as your Health Insurance Certificate or similar document and paid the full medical care cost at a medical care institution due to sudden illness while traveling
If you accidentally used your previous health insurance
If you mistakenly used your previous health insurance at a medical care institution and subsequently received a request from your former health insurer to repay the health insurance portion of the cost, and you paid it
If you purchased prosthetic or other equipment (prosthetic equipment / eyeglasses to treat juvenile amblyopia, etc. / compression garment such as compression stockings)
Prosthetic or other equipment eligible for reimbursement includes prosthetic equipment, eyeglasses to treat juvenile amblyopia, etc., and compression garments (e.g., compression stockings) deemed necessary by a doctor and prepared based on a doctor’s instructions.
Prosthetic or other equipment intended for convenience in everyday living, that intended for cosmetic purposes, and that prepared after the patient’s condition has stabilized are not eligible for reimbursement.
Additionally, health insurance will not cover prosthetic or other equipment prepared again before the end of the designated useful life of the same type of equipment prepared previously.
| Eligible eyeglasses | Those prepared as instructed by a doctor to treat amblyopia or strabismus or for refractive correction following surgery for congenital cataracts in a child less than nine years of age |
|---|---|
| Maximum reimbursable amount | The maximum reimbursable amount is 106% of the price specified pursuant to the provisions of the Act on Providing Comprehensive Support for the Daily Life and Life in Society of Persons with Disabilities. October 1, 2019 – March 31, 2024: 38,902 yen |
| Replacement of therapeutic eyeglasses | For children under five years of age: Therapeutic eyeglasses can be replaced with new ones no earlier than one year after the child began wearing them. For children five years and older: Therapeutic eyeglasses can be replaced with new ones no earlier than two years after the child began wearing them. * The starting date for this period is the date on which the therapeutic eyeglasses were purchased (date shown on the receipt). |
| Eligible conditions | Postoperative lymphedema of the arms or legs following surgery for malignant tumor involving a lymphadenectomy (extensive resection) in the groin, pelvic, or axillary region; or primary lymphedema of the arms or legs | Intractable ulcer caused by chronic venous insufficiency |
|---|---|---|
| Maximum reimbursable amounts | Compression stockings: 28,000 yen (25,000 yen for one leg)
|
Compression stockings: 28,000 yen (25,000 yen for one leg)
|
| Maximum quantity purchased | Given laundering needs, two (and no more) compression garments can be purchased at one time for each body part. | Given laundering needs, two (and no more) compression garments can be purchased at one time for each body part. |
| Repurchase of compression garments | Compression garments cannot be repurchased earlier than six months after the previous purchase. | The repurchase is not eligible for reimbursement; the benefit is paid only once. (If the condition recurs after recovery, the purchase is eligible for reimbursement again.) |
| Notes | Compression garments with a pressure level of 30 mmHg or higher are eligible for reimbursement. However, if a doctor provides special instructions, compression garments with a pressure level of 20 mmHg or higher may also be eligible for reimbursement. |
Compression garments with a pressure level of 30 mmHg or higher are eligible for reimbursement. However, if a doctor provides special instructions, compression garments with a pressure level of 15 mmHg or higher may also be eligible for reimbursement. |
Acupuncture, moxibustion, massage
Judo Therapy Treatment Expenses (when visiting a bonesetter’s clinic or other such facility)
- Reference link
Overseas Medical Care Expenses (if you become sick or are injured overseas)
You can also be reimbursed for medical care costs paid at medical care institutions overseas as Medical Care Expenses. Note the following:
- (1) Medical procedures not covered by insurance in Japan are not eligible for reimbursement.
- (2) If you travel abroad for the purpose of receiving medical treatment, such treatment is not eligible for reimbursement.
- (3) Not all of the costs you paid are eligible for reimbursement.
The amount to be reimbursed is calculated by subtracting the patient’s copayment amount from the medical care cost that would be incurred for treating the same injury or illness at a medical care institution in Japan (or the actual amount paid overseas, if lower).- * Even if insurance coverage is approved, the amount reimbursed may be as little as one-tenth of the actual cost incurred, because medical systems and treatment procedures differ between Japan and other countries, and overseas medical care costs must be converted in accordance with Japanese rules.
- * Be sure to contact the Sony Health Insurance Society before applying for Overseas Medical Care Expenses.
Transportation Expenses
In certain cases, Transportation Expenses may be paid if a doctor recognizes that temporary or urgent transportation is necessary because the patient has difficulty moving due to illness or injury and the current facilities at the medical care institution are not sufficient for adequate treatment.
(Examples)
- Emergency transportation of a patient injured at a disaster site
- Transportation of a patient who are seriously ill or injured on a remote island or in a similar location, when nearby hospitals cannot provide adequate medical care
Caution
- Transportation Expenses will be paid only if a doctor recognizes the need for temporary or urgent transportation.
- Prior approval from the Health Insurance Society is required (post-approval is accepted only in unavoidable situations).
- Non-urgent transportation costs, such as those for ordinary outpatient visits, are not eligible for this benefit.
Payment standards for Transportation Expenses
Transportation Expenses will be paid only if a doctor recognizes the need for temporary or urgent transportation and the Health Insurance Society recognizes that all of the following conditions apply:
- The treatment for which the transportation is required is appropriate and covered by health insurance.
- The patient has difficulty moving due to the illness or injury requiring treatment.
- The situation is urgent or otherwise unavoidable.
Benefit amount
The amount paid as Transportation Expenses is calculated based on the cost of transportation using the most economical and standard route and method (or the actual cost incurred, if this calculated amount exceeds the actual cost).
Statute of limitations for health insurance benefits
The right to receive health insurance benefits expires after two years.
The statute of limitations period for claiming Medical Care Expenses begins on the day following the date the cost of treatment was paid. (Article 193 of the Health Insurance Act)