Treatment Costs and the High-Cost Medical Expense Benefit
The High-Cost Medical Expense Benefit — a Monthly Cap
Public insurance sets an upper limit on what you pay at the counter in one calendar month. Anything above the limit is refunded when you apply. The limit depends on your age and income.
Caps from August 2026 (through July 2027)
The scheme was revised from August 2026 (stage 1). In August 2027 the income categories will be subdivided further (stage 2, below).
Under 70 (monthly)
| Income category (approx. annual income) | Monthly cap | Frequent-user cap (4th month on) | Annual cap |
|---|---|---|---|
| ¥11.6M and above | ¥270,300 + (bill − ¥901,000) × 1% | ¥140,100 | ¥1,680,000 |
| ¥7.7–11.6M | ¥179,100 + (bill − ¥597,000) × 1% | ¥93,000 | ¥1,110,000 |
| ¥3.7–7.7M | ¥85,800 + (bill − ¥286,000) × 1% | ¥44,400 | ¥530,000 |
| Up to ¥3.7M | ¥61,500 | ¥44,400 | ¥530,000 |
| Exempt from resident tax | ¥36,900 | ¥24,600 | ¥290,000 |
Aged 70 and over (monthly)
| Income category | Outpatient (per person) | Outpatient + inpatient (household) | Frequent-user cap | Annual cap |
|---|---|---|---|---|
| Working-age-equivalent III (¥11.6M and above) | ¥270,300 + (bill − ¥901,000) × 1% | same | ¥140,100 | ¥1,680,000 |
| Working-age-equivalent II (¥7.7–11.6M) | ¥179,100 + (bill − ¥597,000) × 1% | same | ¥93,000 | ¥1,110,000 |
| Working-age-equivalent I (¥3.7–7.7M) | ¥85,800 + (bill − ¥286,000) × 1% | same | ¥44,400 | ¥530,000 |
| General (up to ¥3.7M) | ¥22,000 (outpatient annual cap ¥216,000) | ¥61,500 | ¥44,400 | ¥530,000 |
| Exempt from resident tax | ¥11,000 (outpatient annual cap ¥96,000) | ¥25,700 | ¥24,600 | ¥290,000 |
| Exempt, income below a set level | ¥8,000 | ¥15,700 | — | ¥180,000 |
Worked example: someone under 70 earning ¥3.7–7.7M who has a ¥3,000,000 operation in one month pays ¥85,800 + (3,000,000 − 286,000) × 1% = about ¥113,000 for that month. Even for a very large bill, only 1% is added on top of the base cap.
If your annual income is under about ¥2M, the annual cap is ¥410,000 (refunded from August 2027). The "frequent-user cap" applies from the fourth month in any twelve in which you reach the cap.
Stage 2 from August 2027
- The five income categories become thirteen, with higher caps for middle and upper incomes (for example ¥98,100 + 1% for ¥5.1–6.5M, ¥110,400 + 1% for ¥6.5–7.7M). The ¥3.7–5.1M band stays at ¥85,800 + 1%.
- For people 70 and over in the general category, the outpatient cap stays at ¥22,000 up to about ¥2M of income and becomes ¥28,000 for ¥2–3.7M. The household cap becomes three steps: ¥61,500, ¥65,400, ¥69,600.
- The frequent-user cap for incomes under about ¥2M falls from ¥44,400 to ¥34,500.
- The way you use the scheme (certificate, My Number card) does not change.