General medical benefits

When the insured person uses a medical facility that accepts NHI, they will only need to pay part of the cost. As of 2011 this copayment will be either 10% or 30% depending on the income of the insured person, and in April 2011 the lowest rate will rise to 20%.^[14]

Those aged between 70 and 74 are entitled to a NHI Elderly Recipient Certificate. Those with this certificate have to make a copayment of either 10% or 30% depending on their income.^[14]

Exceptions

NHI cannot be used in the following cases:

• Failure to follow doctor's instructions regarding treatment.
• Intentionally inflicted injury or illness resulting from a crime or suicide attempt.
• Injury or illness resulting from a fight or drunkenness.
• Treatment unrelated to illness (health examinations, preventative injections, cosmetic surgery, orthodontic work, normal child delivery/abortion for economic reasons, etc.).
• Private or semi-private room charges during your hospitalization.
• Injury during work (either covered by worker's compensation or the employer).
• When a patient themselves desired to receive treatment without using the insurance.
• Combination of insured and uninsured treatment or totally uninsured treatment in dental treatment using special materials.

Members can apply for benefits within two years of becoming entitled.^[15]

Hospitalization expenses

For those under 70 years of age: If NHI members show their NHI card and a Maximum Ceiling Amount Applicable Certificate together the member will only have to pay the amount specified as their personally borne expense ceiling. For members who are exempt from residents tax, a Ceiling Applied/Standard Personally Borne Amount Reduction Certificate is required. These certificates must be applied for at the city office.^[16]

For those over 70 years of age: If NHI members over 70 years old who pay Resident's tax show their NHI card and an Old Age Medical Insurance card they only have to pay the amount specified as their personally borne expense ceiling.

Maximum Ceiling Amount Applicable Certificate together the member will only have to pay the amount specified as their personally born expense ceiling. For members who are exempt from residents tax, their NHI card, Old-Age Medical Insurance Card and a Ceiling Applied/Standard Personally Borne Amount Reduction Certificate is required. This certificate must be applied for at the city office.^[16]

Cash reimbursements

NHI members can go to their city office to apply for cash reimbursements for when they pay the full amount for medical services. It takes about three months. Situations covered are:

• If a member was treated for a sudden illness without showing their NHI card and had to pay the entire cost.
• When the NHI member unavoidably received treatment at a facility that does not accept NHI. If using this facility was voluntary no reimbursement can be received.
• For the costs of medical corsets, casts, or other therapeutic devices recommended by a doctor.
• When acupuncture, moxibustion, or massage is received upon a doctors consent. Reimbursement does not always happen in this case.
• Transportation costs during emergencies or if the member has trouble walking when hospitalized and leaving the hospital.
• If a member receives medical treatment overseas after falling suddenly ill. This does not apply if the member travels overseas for the purpose of recuperating.^[17]

Subsidies for high medical expenses

If the personally borne medical expenses exceed a certain amount NHI members can apply to have a certain amount reimbursed. Reimbursements are paid about four months after the medical service is provided.

NHI members under 70 years of age must show their NHI card and either their Maximum Ceiling Amount Applicable Certificate or Ceiling Applied/Standard Personally-Borne Amount Reduction Certificate to pay only their personally borne expense ceiling. Members under 70 years old are not eligible for the high-cost medical benefit.

NHI members over 70 and under 75 years of age are responsible for paying up to their expense ceiling as usual. But members from households who are exempt from resident's tax will be categorized as Low Income Earner 1 or 2.

Ceiling Applied/Standard Personally-Borne Amount Reduction Certificate is required for these members to have the amount they must pay decreased from their normal personally borne expense ceiling.^[18]

Designated ceilings for personally-borne medical expenses

High medical expense subsidy application procedures

An application kit should be sent three or four months after the month of the examination/treatment. The form should be completed and returned to the city office.

If the expenses were from hospitalization, members should apply for a Maximum Ceiling Amount Applicable Certificate or a Ceiling Applied/Standard Personally Borne Amount Reduction Certificate, whichever is appropriate. Members who have one of these certificates will only need to pay the maximum ceiling amount for the examination/treatment, and therefore have no need to apply for a High Medical Expense Subsidy.^[21]

Loans for high medical expenses

As it takes a long time for reimbursements for high medical expenses to be made, loans are available for those who have trouble paying their medical bills in the meantime.

Requirements: Those who are prospective candidates for a High Medical Expense Subsidy.

Loan amount: Within 90% of the estimated High Medical Expense Subsidy.

• There is also another method by which the NHI member pays the personally-borne expense ceiling amount to the medical institution, and the city pays the high medical expense subsidy directly to the medical institution, pending approval of the medical institution.
• For hospitalization expenses, members who apply for a Maximum Ceiling Amount Applicable Certificate or a Ceiling Applied/Standard Personally Borne Amount Reduction Certificate, whichever is appropriate and show it to the medical institution counter, members will only need to pay the maximum ceiling amount for the examination/treatment, and therefore have no need to apply for a loan.^[21]

Meal expenses during hospitalization

During hospitalization, members must bear a portion of the meal expense.

(i) Hospitalized up to 90 days in the last 12 months

(ii) Hospitalized over 90 days in the last 12 months

(iii) Recipient of the Elderly Recipient Certificate whose household is exempt from resident's ta and the total income of the household is ¥0 (Pension income is calculated with deduction amount as ¥800,000.

Childbirth allowance

When a NHI member gives birth, ¥420,000 will be provided for each child. This allowance is also paid in cases of miscarriage or stillbirth if this occurs after 85 days (4 months) of pregnancy. However, this will not be provided to those who receive a childbirth allowance from other health insurance programs. The mother presents her NHI card at the hospital, and NHI will pay the hospital directly. If the cost of childbirth is more than ¥420,000 the member must pay the remainder. If the cost is less than ¥420,000, the member will receive the balance. A form will be sent approximately 2 months after delivery, which must be returned to claim the balance.^[23]

It is also possible to apply for this childbirth allowance if the NHI member has their baby outside Japan, the member should speak to the local city office about the procedures for doing this.^[24]

Funeral allowances

When a NHI member dies, ¥70,000 is paid for funeral services. However, if a person who was covered under Employees' Health Insurance died within 3 months of resignation, Employees' Health Insurance will pay for the funeral allowance, not NHI. Also, if the death was due to the act of a third party (such as a traffic accident) and their compensation is available, NHI will not provide the funeral allowance.^[24]

Individual medical expense reductions or exemptions

A portion of the cost of medical treatment must be paid by the NHI member. However, if their livelihood has been effected by a natural disaster, unemployment, or other difficulties, then reductions of or exemptions from paying their copayment are possible for a period of up to three months.^[24]

Injuries from traffic accidents or attacks

Reports are required before receiving treatment with an NHI certificate. For injuries caused by a third party (for example a traffic accident or assault) the person who caused the injury is liable. However, it may be possible to use NHI if the person responsible does not pay and if the proper notifications are filed. The NHI will charge the responsible person afterwards. If you receive treatment using NHI, you must contact the NHI and Pension section of the city office before and submit "report of accident and sickness by the third party" later.^[24]

Exceptions

NHI cannot be used in the following cases:

• The treatment fee was already paid by the person who caused the accident
• Work-related injuries
• Injuries due to driving while intoxicated or without a license^[24]