Japan's high-cost medical expense benefit (kōgaku ryōyōhi) refunds what you pay at the counter above a monthly cap set by income bracket. An increase to that cap was planned for 2025, and then shelved. For most people the news stopped there. It did not end there.
The short answer first.
- The increase planned for August 2025 was in fact shelved. But the scheme was redrawn, and the new version took effect on 1 August 2026
- In terms of treatment dates, the new figures apply from August 2026 treatment onwards
- For the under-70 bracket that covers the most people (standard monthly remuneration ¥280,000–500,000), the cap moved from ¥80,100 + (total cost − ¥267,000) × 1% to ¥85,800 + (total cost − ¥286,000) × 1%
- The next bracket down went from ¥57,600 to ¥61,500, and the residence-tax-exempt bracket from ¥35,400 to ¥36,900
- The multiple-occurrence figures were held. From the fourth month they remain ¥44,400 and so on
- An annual ceiling was created. It runs 1 August to 31 July, and is ¥530,000 for the two middle brackets
- From August 2027 the brackets are subdivided further and the multiple-occurrence figure for those under ¥2 million a year drops from ¥44,400 to ¥34,500. That Cabinet Order is already promulgated
- Private room charges, meals and advanced medical treatment are outside the benefit
- With a My Number card used as a health insurance card, no eligibility certificate is needed
- Claims can be made for two years from the first day of the month after treatment
The rest of this article traces each point back to ministry material and to the statutory text.
This article organises what the law and public documents say. Decisions on individual benefit amounts rest with the insurer. Figures are from the provisions and Ministry of Health, Labour and Welfare material as I checked them on 14 August 2026. Procedures differ between insurers, so confirm an actual claim with your own. Translations of Japanese legal text are my own and are given for orientation, not as official renderings.
1. What happened after it was shelved
On 7 March 2025 the then Prime Minister announced that implementation would be suspended. The remark is recorded in the ministry's expert committee material.
I have decided to suspend implementation of the review as a whole, including the proportional revision scheduled for this August.
1st Expert Committee on the High-Cost Medical Expense Benefit, document 2 (26 May 2025, my translation)The same document gives the reasons: patient groups had warned it "would still risk suppressing access to care", and the process had been criticised as "lacking in care". It adds that a policy would be "reconsidered and decided by the autumn of this year".
From there, the Expert Committee on the High-Cost Medical Expense Benefit met nine times, from 26 May to 25 December 2025. The outcome became a statute and two Cabinet Orders.
Three instruments carry it.
- Act Partially Amending the Health Insurance Act and Others (Act No. 31 of 2026), passed 29 May and promulgated 5 June 2026
- Cabinet Order Partially Amending the Health Insurance Act Enforcement Order and Others (Cabinet Order No. 219 of 2026), promulgated 25 June, in force 1 August 2026
- The same, Cabinet Order No. 240 of 2026, promulgated 29 July, in force 1 August 2027 (not yet in force)
If your memory stops at "it was shelved", you will have the wrong figure. What was shelved was the increase planned for August 2025. What applies from August 2026 was drawn up separately and is already in force.
2. The caps now in force (under 70)
These apply from August 2026 treatment. The middle column is the new figure; the right-hand column is what applied through July 2026.
| Bracket (standard monthly remuneration) | From Aug 2026 | Through Jul 2026 | Multiple occurrence |
|---|---|---|---|
| A ¥830,000 and above | ¥270,300 + (total − ¥901,000) × 1% | ¥252,600 + (total − ¥842,000) × 1% | ¥140,100 |
| B ¥530,000–790,000 | ¥179,100 + (total − ¥597,000) × 1% | ¥167,400 + (total − ¥558,000) × 1% | ¥93,000 |
| C ¥280,000–500,000 | ¥85,800 + (total − ¥286,000) × 1% | ¥80,100 + (total − ¥267,000) × 1% | ¥44,400 |
| D ¥260,000 and below | ¥61,500 | ¥57,600 | ¥44,400 |
| E residence-tax exempt | ¥36,900 | ¥35,400 | ¥24,600 |
These figures are not only in ministry leaflets. They appear in Article 42 of the Health Insurance Act Enforcement Order itself, written out in Japanese numerals — 85,800, 286,000, 270,300, 61,500, 36,900 and the rest.
The size of the increase differs by bracket: ¥5,700 for bracket C, ¥1,500 for bracket E. The lower the income bracket, the smaller the rise.
3. The caps for those aged 70 and over
Here outpatient care (per person) and outpatient plus inpatient care (per household) are separated. These apply from August 2026 to July 2027.
| Bracket | Outpatient (per person) | Outpatient + inpatient (household) | Multiple occurrence |
|---|---|---|---|
| Working-income III (¥830,000+) | — | ¥270,300 + (total − ¥901,000) × 1% | ¥140,100 |
| Working-income II (¥530,000–790,000) | — | ¥179,100 + (total − ¥597,000) × 1% | ¥93,000 |
| Working-income I (¥280,000–500,000) | — | ¥85,800 + (total − ¥286,000) × 1% | ¥44,400 |
| General (¥260,000 and below) | ¥22,000 | ¥61,500 | ¥44,400 |
| Low income II | ¥11,000 | ¥25,700 | ¥24,600 |
| Low income I | ¥8,000 | ¥15,700 | — |
4. A new annual ceiling
This is probably the largest change. A new provision, Article 41-2 of the Enforcement Order, "requirements for and amount of the annual high-cost medical expense benefit", was inserted. The calculation period runs from 1 August each year to 31 July the following year.
Even where the monthly out-of-pocket amounts accumulate, once the annual ceiling is reached, medical costs beyond it can be refunded by the insurer.
MHLW, "On the revision of the high-cost medical expense benefit (from August 2026 treatment)" (my translation)| Bracket | Annual ceiling (Aug–Jul) |
|---|---|
| A (¥830,000+) | ¥1,680,000 |
| B (¥530,000–790,000) | ¥1,110,000 |
| C (¥280,000–500,000) | ¥530,000 |
| D (¥260,000 and below) | ¥530,000 (¥410,000 where standard remuneration is ¥150,000 or less) |
| E (residence-tax exempt) | ¥290,000 |
For those aged 70 and over there is also an annual ceiling for outpatient care alone: ¥216,000 for the general bracket and ¥96,000 for the residence-tax exempt. Both appear in Article 42, paragraph 10 of the Order.
The first period runs 1 August 2026 to 31 July 2027. The Japan Health Insurance Association explains the design as raising the monthly burden while holding the multiple-occurrence figures and adding an annual ceiling, so as to strengthen "the safety-net function for those needing long-term treatment".
How and when to claim the refund once the annual ceiling is reached is not described in the material I was able to open. That will presumably come from each insurer.
5. The multiple-occurrence figures were held
Multiple occurrence lowers the cap from the fourth month, where the cap has been reached three or more times in the preceding twelve months.
Where the cap has been reached three or more times within the past twelve months, from the fourth time it becomes a "multiple occurrence" and the cap is lowered.
MHLW, "For those using the high-cost medical expense benefit" (my translation)These figures did not rise in this revision. The expert committee's statement of basic thinking says the multiple-occurrence caps "should be maintained at their current level". The monthly cap went up; the cap for people who hit it repeatedly did not.
It applies within the same insurer. Counts do not carry across a change of insurer — changing jobs or leaving employment resets the tally.
6. A line was added to the statute
The revision also touched the Health Insurance Act itself, at Article 115, paragraph 2.
The requirements for payment of the high-cost medical expense benefit, the amount payable and other necessary matters shall be prescribed by Cabinet Order, taking into account the household burden of the costs necessary for medical treatment, and in particular the effect on the household of a person receiving continuous treatment over a long period, and the amount of the costs incurred.
Health Insurance Act, Article 115(2); the bold text is what was added (my translation)The same wording went into Article 57-2, paragraph 2 of the National Health Insurance Act. The new annual ceiling and the held multiple-occurrence figures line up with that sentence.
7. It changes again in August 2027
The next revision is already promulgated as Cabinet Order No. 240 of 2026, dated 29 July 2026, entering into force on 1 August 2027. The ministry page puts it as:
From August 2027: subdivide the income brackets, and reduce the multiple-occurrence figure for those under ¥2 million a year by 25%
MHLW, "On the revision of the high-cost medical expense benefit" (my translation)Committee material indicates each bracket other than the residence-tax-exempt one would be split into three. For multiple occurrence, the figure for those under ¥2 million a year is to fall from ¥44,400 to ¥34,500.
This article does not give the monthly caps that will apply from August 2027. I looked at the ministry's comparison table and could not read the per-bracket figures reliably. I will add them once I can confirm them.
8. What is outside the benefit, and how to claim
Not covered
"Meal costs" and "accommodation costs", together with charges for services received at the patient's own request such as "private room charges" and "costs of advanced medical treatment", are not covered by the high-cost medical expense benefit.
MHLW, "For those using the high-cost medical expense benefit" (my translation)Leaving these out of an estimate for a hospital stay is how the figure ends up not matching the bill.
How a month is counted, and what can be added together
A "month" is a calendar month. A stay spanning two months is calculated separately for each. Medical and dental, inpatient and outpatient are separate claims. What can be combined depends on age.
- Aged 69 and under: only amounts of ¥21,000 or more at a single institution can be combined
- Aged 70 and over: amounts can be combined regardless of size
What you pay at a dispensing pharmacy is added to the institution that issued the prescription.
Avoiding the up-front payment
An eligibility certificate (gendogaku tekiyō ninteishō) keeps the counter payment down to the cap. There is now a second route.
If you use your My Number card as a health insurance card, then even without an "eligibility certificate" you do not need to pay the amount above the cap for care covered by public medical insurance.
MHLW, "Benefits of using a My Number card as a health insurance card" (my translation)A certificate is still needed at institutions that have not introduced online eligibility verification, and for the reduced-rate certificate where the household is residence-tax exempt.
The deadline for claiming afterwards
Under Article 193 of the Health Insurance Act, the right to receive insurance benefits is extinguished by prescription after two years. On when the clock starts, the ministry says two years from the first day of the month following the month of treatment. Paying the full amount at the counter does not close the door, so long as you are within that window.
Closing
The easiest thing to get wrong here is stopping at "the increase was shelved". What was shelved was the version planned for August 2025. After that the expert committee met nine times, and a different version has been running since August 2026.
What changed is not only the monthly figure. The multiple-occurrence caps were held, an annual ceiling was added, and a line about "a person receiving continuous treatment over a long period" went into the statute. The monthly burden went up; something else was put in place for the people carrying it over years.
What is written here is one way of looking at it. Cabinet Orders get amended, and procedures differ between insurers. If you notice something, I would be glad to hear it through the contact form.
Sources
- Health Insurance Act (Act No. 70 of 1922), Articles 115, 115-2 and 193 e-Gov (Japanese)
- National Health Insurance Act (Act No. 192 of 1958), Article 57-2 e-Gov (Japanese)
- Health Insurance Act Enforcement Order (Imperial Order No. 243 of 1926), Articles 41, 41-2, 42 and 43 e-Gov (Japanese)
- MHLW, "On the revision of the high-cost medical expense benefit (from August 2026 treatment)" PDF (Japanese)
- MHLW, "For those using the high-cost medical expense benefit" page (Japanese)
- MHLW, "The medical insurance reform act has passed" page / outline of Act No. 31 of 2026 PDF
- MHLW, 1st Expert Committee on the High-Cost Medical Expense Benefit, document 2 PDF / list of meetings page
- MHLW, "Basic thinking on the revision of the high-cost medical expense benefit (draft)" PDF / 9th committee material PDF
- MHLW, "Benefits of using a My Number card as a health insurance card" page
- Japan Health Insurance Association, "High-cost medical expense benefit" page / "Eligibility certificate" page / "The scheme is revised from August 2026" page