When a member or dependent has paid more than a certain amount for insurance covered treatment, they are entitled to receive Benefit for High-cost Medical Care, Copayment refund, Copayment refund for dependent or other benefits. These benefits are automatically paid three to four months after visiting the doctor. You do not need to submit a form or receipt to PMAC.
When a member or dependent has paid medical expenses exceeding the ceiling amount within the same month as set forth in the table below per medical institution or facility, per medical or dental, and per as an inpatient or outpatient, the exceeded amount shall be reimbursed as the Benefit for High-cost Medical Care.
Calculation standards for Benefit for High-cost Medical Care (ceiling amount of copayment per month)
Income level |
Ceiling amount of copayment per month [A] |
---|---|
Type 3 |
252,600 yen + (medical expenses(Note1) − 842,000 yen) × 1% [140,100 yen](Note2) |
Type 2 |
167,400 yen + (medical expenses(Note1) − 558,000 yen) × 1% [93,000 yen](Note2) |
Type 1 |
80,100 yen + (medical expenses(Note1) − 267,000 yen) × 1% [44,400 yen](Note2) |
Income level |
Ceiling amount of copayment per month |
Ceiling amount of copayment per month |
---|---|---|
Monthly standard salary under 280,000 yen |
18,000 yen |
57,600 yen |
Income level |
Ceiling amount of copayment per month |
Ceiling amount of copayment per month |
---|---|---|
Type 2 |
8,000 yen |
24,600 yen |
Type 1 |
8,000 yen |
15,000 yen |
Income level based on the Monthly Standard Salary |
Ceiling amount of copayment per month 【C】 |
---|---|
830,000 yen or more |
252,600 yen+(medical expenses (Note1) −842,000 yen) × 1% |
530,000 yen or more and less than 830,000 yen |
167,400 yen+(medical expenses (Note1) −558,000 yen) × 1% |
280,000 yen or more and less than 530,000 yen |
80,100 yen+(medical expenses (Note1) −267,000 yen) × 1% |
Less than 280,000 yen |
57,600 yen |
Low income earner (exempt from residence tax) |
35,400 yen |
Note:
By presenting the “Maximum Amount Application Certificate” at the medical institution, those under age 70 or those age 70 and above who are categorized as Type II or Type I, will be exempted from the portion of high-cost medical care expenses in your health insurance copayment, which we will pay to the medical institution for you.
Members and their dependents age 70 or above and under age 75 who are categorized as “Regular income earner” or “Low income earner” in the income category, whose copayment for outpatient visits totalled more than the specified amount (144,000 yen) a year (between August 1st of the previous year and July 31st of that year) can receive a Benefit for High-cost Medical Care.
If the individual had been a PMAC member or a dependent for the full length of the period between August of the previous year and July of that year, the benefit will be automatically paid without the need to make any claim.
Note that in case a PMAC member or a dependent started to participate somewhere during that period or became no longer a member of PMAC during that period, there will be no automatic payment of the benefit and a claim is necessary.
The maximum copayment for a patient under treatment of dialysis or other specified disease is 10,000 yen per month in principle; however, a dialysis patient whose Monthly Standard Salary is 530,000 yen or more shall pay 20,000 yen per month. PMAC will cover the amount exceeding the said 10,000 yen or 20,000 yen. The “Certificate for Specified Disease Treatment” must be presented at the hospital.
When a member or dependent has paid copayments exceeding 25,000 yen per medical institution or facility, per medical or dental, and per as an inpatient or outpatient within the same month, the amount exceeding 25,000 (excluding the Benefit for High-cost Medical Care) yen will be paid to the member as Copayment refund or to the dependent as benefit for dependent’s medical care expense.
Note:
1. Refund less than 100 yen shall be rounded off.
2. When the total copayment is less than 26,000 yen, which means that the refund is less than 1,000 yen, there is no refund.
3. The expenses not to be covered by health insurance such as the use of an amenity bed are not within the scope of our refund policy.
When the copayment amount has already been reduced by municipal subsidies, the above mentioned refund of copayment or benefit for dependent’s medical care expenses may not be payable to avoid double subsidies. If you are found to have benefited from such double subsidies, you may be requested to return our refund.
Also when Benefit for High-cost Medical Care are reimbursed by PMAC while the copayment amount has already been reduced by municipal subsidies, you may be requested by the municipal to return their subsidies for the High-cost medical care expenses.
Reimbursement is made when the total copayment amount paid by the whole family (a member and his/her dependents certified by us) for medical services covered by the medical treatment insurance and the nursing-care insurance exceeds the ceiling amount by the standard calculation.
The reimburse procedures are enacted upon your claim.
Income level based on the Monthly Standard Salary |
Short-term benefits & nursing-care insurance |
Short-term benefits & nursing-care insurance |
---|---|---|
830,000 yen and more |
2,120,000 yen |
2,120,000 yen |
530,000 yen and more and less than 830,000 yen |
1,410,000 yen |
1,410,000 yen |
280,000 yen and more and less than 530,000 yen |
670,000 yen |
670,000 yen |
Less than 280,000 |
560,000 yen |
600,000 yen |
Low income earner[Type2] |
310,000 yen |
340,000 yen |
Low income earner[Type1] |
190,000 yen |
340,000 yen |