It all started with what was supposed to be a nice family day out at the park, ending up with a fall on concrete while rollerblading. My husband landed on his wrist when he fell. We applied the proper first aid, and there were no symptoms of a fracture – or so we thought. Little did we know that falling on one’s wrists, more often than not, leads to a permanent fracture that can only be fixed with surgery due to the lack of blood and oxygen flowing through that area.

He woke up one day with sudden pain, and we went for a checkup. The orthopedic surgeon said he had a scaphoid fracture non-union, requiring hospital admission for a minimum of 2 days and surgery. What surprised us was how the hospital staff readily informed us to apply for a “high-cost medical expense benefit” called Kogaku Ryoyohi Seido (高額療養費制度).

They said that this will help reduce the total hospital bill. And it did! I was initially skeptical, but the ordeal would have cost us around ¥1,000,000. We only paid ¥58,000 at the end.

What’s a ninteisho?

Under the High-Cost Medical Care Benefit System, patients under 70 can reduce their monthly medical care costs according to their income bracket. There is a maximum copayment amount per income category, and regardless of the total medical costs, you will only pay that amount.

Income classification Maximum copayment medical care amount until the 3rd time 4th time onwards (in a year)
9.01 million and above ¥252,600 + (Total medical expenses – ¥842,000) x 1% ¥140,100
6 to 9.01 million ¥167,400 + (Total medical expenses – ¥558,000) x 1% ¥93,000
2.1 to 6 million ¥80,100 + (Total medical expenses – ¥267,000) x 1% ¥44,000
2.1 million and below ¥57,600 ¥44,000
Tax exempt household ¥35,400 ¥24,600

Sample computation for someone in the 2.1 to 6 million household income category with medical expenses amounting to ¥1,000,000.

Calculation: ¥80,100+¥1,000,000-¥267,000)×0.01

Total copayment: ¥87,430

Without ninteisho, the copayment rate is 30% or ¥300,00.

Coverage of the benefit

Aside from subsidizing expenses for medical procedures, the benefit has some limitations, such as items not covered by the insurance. This includes private room charges, pajama rental fees, hospital food service fees, and extra bed charges for inpatient or hospital admissions. There are some medical expenses, like advanced medical treatments, that might not be covered by the insurance.

On a positive note, multiple payments exceeding ¥21,000 at a single medical institution within the same month can be added up, and the amount exceeding the copayment limit can be considered high-cost medical expenses.

How to get the certificate. 

The Eligibility Certificate for Ceiling-Amount Application or Gendogaku Tekiyo Ninteisho (限度額適用認定) or Ninteisho for short, might look different per city. Still, it should contain more or less the same details, such as the validity period (one year), the insured’s identification number, address, name, birthday, and income category. The card will also have the city name and seal. It is also easy to get by showing your insurance card and an ID.

I was also able to get the certificate on the same day while my husband was in the hospital. I recommend going to your main city hall rather than an extension office because they take longer to process applications (1 week for this certificate compared to same-day release at the main city hall).

Take note that the process might be different if you have private insurance, so it’s best to inquire with the company directly.

Redeeming the benefit 

It was easy claiming the benefit once we got the certificate. I showed it to the cashier while paying for the hospital admission fee and surgery, and the staff deducted everything on the spot. We had an idea how much it would cost with or without the benefit, and it was a mini thrill waiting for the final amount to appear on the register screen.

If you already paid the bill before applying for a certificate, you can still get a refund! It will take more steps, but after applying at your local city hall, you will receive a postcard in the mail confirming reimbursement. Use that postcard to claim the money at the municipal office. Take note that each city has its own process, so it’s recommended to do prior research to avoid delays.

If you ever find yourself in the same situation with high medical expenses, it’s worth a shot to apply for ninteisho to help ease the load off your wallet.