Japan’s High-Cost Medical Expense Benefit: Explained

When you’re a JET, you may not think about healthcare expenses. If you’re coming from America, you may think highly of Japan’s healthcare system. Let’s face it, America has its issues with healthcare access, which makes Japan’s system quite good in comparison. However, you are subject to paying 30% of the total cost in Japan, which could bankrupt those with chronic health conditions. There’s good news, and it comes in the form of the High-Cost Medical Expense Benefit. I’m going to explain in story form how this works, using “JETonio,” a fictional JET participant dealing with an autoimmune disease.

JETonio regularly receives immunosuppressant injections to treat their autoimmune disease. These medications, even in Japan, cost around $10,000 per dose (total cost, or cost without insurance) and are administered every 6-8 weeks. As you can see, JETonio’s costs quickly add up. When JETonio received their first injection in Japan, they were shocked to receive a bill for ¥234,410, or about $2,000 USD (30% co-pay). Luckily, JETonio had their credit card with them and was able to pay the bill after receiving treatment. Note that in Japan, you pay immediately after visiting the doctor or hospital.

Luckily, an administrator at JETonio’s hospital informed them of the Gendogaku Tekiyo Ninteisho, or High-Cost Medical Expense Benefit. This certificate limits JETonio’s co-pay to ¥80,100 + (total treatment cost – ¥267,000) * 1%. Upon receiving this certificate, JETonio returned to the hospital to get a refund, reducing their co-pay to ¥85,244, or roughly $800 USD.

How To Get A High-Cost Medical Expense Benefit Certificate

First, you can only get this special certificate if you have a chronic medical condition that requires special treatment. Autoimmune diseases, such as Inflammatory Bowel Disease and Rheumatoid Arthritis, fall under this category due to the advanced medications required to treat them. In addition, they are considered disabilities in Japan, thus allowing sufferers to receive a copay maximum.

It’s also worth noting that this benefit only applies to those with public health insurance. If you have private health insurance, it is not available to you. Since most JETs receive teacher’s health insurance through their schools, they qualify for this benefit.

In JETonio’s case, the hospital administrator applied for the benefit on their behalf. Normally, JET program participants with chronic medical conditions should discuss with their supervisor and apply through their school’s administrator. One applies for the benefit through their insurance provider, so JETs should apply through their school. Since JETs with chronic conditions normally disclose these things on their applications, the contracting organization is ready to assist.

After a few weeks, the JET will receive their certificate from their school office. In JETonio’s case, they received their certificate upon returning to the hospital to request a refund.

What If I Already Paid?

Good news! It’s still possible to get a refund. JETonio received theirs after receiving their certificate. They presented their certificate to the hospital accounting office, along with their health insurance card, receipt, and hospital card, and received a refund.

The Pros of the High-Cost Medical Expense Benefit

You don’t have to wait to get a refund when you have the High-Cost Medical Expense Benefit. Considering how JETonio’s original expense was equivalent to a month’s salary, the certificate prevented them from needing to break contract.

Another major benefit is further cost reduction. Based on JET salaries, the certificate reduces your maximum co-pay to ¥80,100 + (total treatment cost – ¥267,000) * 1%. If you hit this maximum more than three times per year, your co-pay maximum decreases to just ¥44,400. While still expensive, this results in JETonio never having to pay more than $3,600 USD per year for their lifesaving medications.

Explaining The Math

The formula for calculating the limited copay is as follows. Your Maximum Copay with the Benefit = ¥80,100 + (total cost – ¥267,000) * 0.01.

Note: 0.01 = 1%.

Remember, JETonio’s out of pocket (30% co-pay) cost was ¥234,410. First, take your copay total (¥234,410) and divide by 0.3, or 30%. This will give you the total treatment cost (¥781,367).

Next, plug your total treatment cost into the formula. Now you have ¥80,100 + (¥781,367 – ¥267,000) * 1%.

Subtract the numbers in parenthesis and you get ¥80,100 + (¥514,367) * 0.01.

Now, multiply, and you get ¥80,100 + ¥5,144.

Simply add and you end up with ¥85,244, the new grand total for JETonio’s treatment.

If JETonio hits maximum four or more times per year, they will only have to pay ¥44,400 out of pocket per visit. No fancy math required.

Conclusion

You never have to worry about going bankrupt over medical costs in Japan. However, you may need to be proactive as you need to obtain the High-Cost Medical Expense Benefit first. For those of you without chronic health conditions, no need to worry. Most of you will never see a medical bill for more than about ¥10,000, or $100 USD. For those of you dealing with chronic issues, this piece of paper will make your life in Japan easier.

Learn More Here

Because this is such an important benefit for people, I linked the following resources below.

Nagoya University Hospital’s page explaining how the benefit works: https://www.med.nagoya-u.ac.jp/hospital_en/guide/payment/high-cost/

The Ministry of Health, Labour, and Welfare’s description of the benefit: https://www.mhlw.go.jp/seisakunitsuite/bunya/kenkou_iryou/iryou/kokusai/setsumeisiryo/dl/en09.pdf