The High-Cost Medical Expense Reimbursement System is changing starting in August 2026!
Nmya~chi! Tuna (@miyakojimalife_) (*’▽’)
Even if you’ve heard the term “High-Cost Medical Expense Relief System,” many of you may still be wondering, “How much will my medical expenses be reduced?” and “What will change starting in August 2026?”
The High-Cost Medical Expense Reimbursement System is a public health insurance program that reimburses out-of-pocket expenses exceeding a certain threshold when medical costs become prohibitively high.
However, against the backdrop of an aging population and rising medical costs, the system is set to be revised starting in August 2026.
In this article,
- How the High-Cost Medical Expense Reimbursement System Works
- Changes Effective August 2026
- Comparison with the Current System
- Frequently Asked Questions (FAQ)
We’ll explain it all in an easy-to-understand way.
What is the High-Cost Medical Expense Reimbursement System?
The High-Cost Medical Expense Reimbursement System is a program whereby, if your out-of-pocket expenses for insured medical treatments paid within a single month (from the 1st to the last day of the month) exceed a certain cap, the amount exceeding that cap is reimbursed.
For example,
- Cancer Treatment
- Heart Surgery
- Joint Replacement Surgery
- Long-term hospitalization
This can help alleviate the financial burden on households, even in cases where high medical expenses are incurred.
Please note that cosmetic surgery, private medical services, private room surcharges, and meal costs are not covered.
I also used the High-Cost Medical Care Support Program.
Our family also relied on the High-Cost Medical Expense Assistance Program when our twins were born.
Since I ended up being admitted to the hospital earlier than planned, the hospital staff explained the admission fees to me.
As expected, it’s ridiculously expensive…
However, since I was familiar with the High-Cost Medical Expense Reimbursement System, I wasn’t worried at all.
The explanation provided by the hospital was also reassuring.
However, at that time, the Myna health insurance card system had not yet been introduced, so the process involved paying at the counter first and then receiving a refund later.
It goes without saying that you should save money in case of unforeseen circumstances!
How the High-Cost Medical Expense Reimbursement System Works
医療費100万円
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▼
健康保険が約70万円負担
│
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患者負担30万円（3割負担）
│
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高額療養費制度を適用
│
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自己負担限度額（約8～9万円程度※所得により異なる）
│
▼
超えた分が払い戻される
In other words, although you’ll pay at the counter initially, you’ll be reimbursed later for any amount exceeding your out-of-pocket maximum. Additionally, by using a “Certificate of Application of the Out-of-Pocket Maximum” or your My Number health insurance card, you can limit your payment at the counter to the out-of-pocket maximum.
Why is the system being revised?
The background to the system reform is the rise in medical costs in Japan.
There are three main reasons:
- Rising Medical Costs Due to an Aging Population
- The Widespread Adoption of Expensive New Drugs and Advanced Medical Treatments
- The Need to Sustain the Health Insurance System for the Future
Although the revision was originally scheduled to take effect in August 2025, it was postponed due to numerous concerns raised by patient advocacy groups and others—including that “it would become difficult to continue treatment.” After the details of the system were reevaluated, the new system is now scheduled to begin in August 2026.
[Comparison Table] Differences Between the Current System and the System Effective August 2026 and Beyond
| Comparison Criteria | Current System | August 2026 and later |
|---|---|---|
| Out-of-Pocket Maximum | Set by income category | Increases across many income brackets |
| Income Category | Current Classification | Classify in more detail |
| Multiple instances | Yes | Continued |
| Annual Limit | None | New |
| Support for Long-Term Patients | Applies only when multiple instances are present | Annual limit added |
Change #1: The out-of-pocket maximum has been raised
The most significant change resulting from this system reform is the increase in the monthly out-of-pocket maximum.
For example, for those with an annual income of approximately 3.7 million to 7.7 million yen,
Current System
Approximately 80,100 yen + 1%
↓
August 2026 and later
Approximately 85,800 yen + 1%
As a result, your out-of-pocket expenses will increase by approximately 5,700 yen.
The higher the income, the larger the expected increase is expected to be.
| Estimated Annual Income | Out-of-Pocket Maximum Current |
Out-of-Pocket Maximum August 2026– |
|---|---|---|
| Approximately 11.6 million yen and up | 252,600 yen + 1% | 270,300 yen + 1% |
| Approximately 7.7 million to 11.6 million yen | 167,400 yen + 1% | 179,100 yen + 1% |
| Approximately 3.7 million to 7.7 million yen | 80,100 yen + 1% | 85,800 yen + 1% |
| ~Approximately 3.7 million yen | 57,600 yen | 61,500 yen |
| Exempt from resident tax Under 70 years old |
35,400 yen | 36,900 yen |
| Exempt from resident tax 70 years of age or older |
24,600 yen | 25,700 yen |
| Income below a certain level 70 years of age or older |
15,000 yen | 15,700 yen |
Source:Revision of the High-Cost Medical Expense Reimbursement System
Change #2: Starting in August 2027, income brackets will be further subdivided.
Starting in August 2027, income brackets will be divided into more detailed categories than they are now.
| Estimated Annual Income | Out-of-Pocket Maximum August 2027– |
|---|---|
| Approximately 16.5 million yen and up | 342,000 yen + 1% |
| Approximately 14.1 million to 16.5 million yen | 303,000 yen + 1% |
| Approximately 11.6 million to 14.1 million yen | 270,300 yen + 1% |
| Approximately 10.4 to 11.6 million yen | 209,400 yen + 1% |
| Approximately 9.5 to 10.4 million yen | 194,400 yen + 1% |
| Approximately 7.7 million to 9.5 million yen | 179,100 yen + 1% |
| Approximately 6.5 to 7.7 million yen | 110,400 yen + 1% |
| Approximately 5.1 to 6.5 million yen | 98,100 yen + 1% |
| Approximately 3.7 to 5.1 million yen | 85,800 yen + 1% |
As a result,
- A burden commensurate with income
- Increased Burden on High-Income Earners
- Consideration for low-income individuals will continue
This is how the system works.
Even so, I think the majority of people in the so-called “main income bracket”—those earning between 3.7 million and 7.7 million yen annually—would find it impossible to spend 80,000 to 110,000 yen per month.
That’s why the new annual cap being introduced this time is a lifesaver!
Change #3: A new annual limit has been introduced
With this revision,A new “annual cap” will be introduced..
Under the previous system, while there was a “monthly cap,” individuals receiving expensive treatment every month faced a significant financial burden when viewed on an annual basis.
As a result, an annual cap is set on out-of-pocket expenses, creating a system where individuals do not have to pay any additional costs for amounts exceeding that cap.
It is expected to provide significant support to patients undergoing long-term treatment, such as for cancer or intractable diseases.
| Estimated Annual Income | Annual limit | |
|---|---|---|
| August 2026– | August 2027– | |
| Approximately 11.6 million yen and up | 1.68 million yen | 1.68 million yen |
| Approximately 7.7 million to 11.6 million yen | 1.11 million yen | 1.11 million yen |
| Approximately 3.7 to 7.7 million yen | 530,000 yen | 530,000 yen |
| Approximately 2 million to 3.7 million yen | 530,000 yen | 530,000 yen |
| ~Approximately 2 million yen | 410,000 yen | |
| Exempt from resident tax Under 70 years old |
290,000 yen | 290,000 yen |
| Exempt from resident tax 70 years of age or older |
290,000 yen | 290,000 yen |
| Income below a certain level 70 years of age or older |
180,000 yen | 180,000 yen |
Change #4: Multiple occurrences remain unchanged
The High-Cost Medical Expense Reimbursement System includes a provision known as “multiple occurrences.”
If you use the High-Cost Medical Expense Assistance Program three or more times within the past 12 months, your out-of-pocket maximum will be further reduced starting with the fourth use.
This program will continue beyond August 2026.
Key Points for Using the High-Cost Medical Expense Reimbursement System
When using this program, please keep the following points in mind.
✅ Treatments not covered by insurance are excluded.
✅ Calculated on a monthly basis (from the 1st to the end of the month)
✅ In some cases, household incomes may be combined
✅ There are cases where the “multiple occurrences” rule applies
✅ By using your Myna health insurance card or your Certificate of Eligibility for the Out-of-Pocket Maximum, you can limit your payments at the counter to your out-of-pocket maximum.
Frequently Asked Questions (FAQ)
Q1. Are reimbursements under the High-Cost Medical Expense Reimbursement System processed automatically?
No. You may receive application instructions from your health insurance provider, but you will need to submit an application. Please check with your provider.
Q2. Are all hospitalization costs covered?
This applies only to services covered by health insurance.
Additional bed charges, meal costs, technical fees for advanced medical treatments, and cosmetic medical procedures are not covered.
Q3. Can I combine my family’s medical expenses?
If family members are enrolled in the same health insurance plan, their coverage can be combined under a single household.
However, if both spouses work and are enrolled in separate public health insurance plans, their coverage will not be combined.
Q4. Is the annual income threshold for the High-Cost Medical Expense Program based on household income or individual income?
This is an individual’s annual income.
Therefore, if both spouses work and are enrolled in separate public health insurance plans, they are considered separate households and their benefits are not combined.
Q5. Is a Certificate of Eligibility for the Spending Limit required?
When using a Myna health insurance card, a certificate of eligibility for the coverage limit is generally not required.
If you do not plan to use your Myna health insurance card, applying in advance can help you minimize the amount you have to pay at the counter.
Summary
The High-Cost Medical Expense Assistance Program is an important public program designed to protect households from high medical costs.
Starting in August 2026, while measures such as raising the out-of-pocket maximum and revising income brackets will be implemented, new support measures—including the introduction of an “annual cap” to support patients requiring long-term care—will also be incorporated.
To summarize the key points of the regulatory reforms,
- The monthly out-of-pocket maximum has been raised
- Income categories have been further subdivided
- The multiple-use system will continue
- Annual cap newly established
- Support for Long-Term Patients Is Being Strengthened
The system may be revised in the future. It is important to check for the latest information and ensure you have a clear understanding of the High-Cost Medical Expense Program in case of an emergency.
I hope this article helps put someone’s mind at ease.
Thanks for reading all the way to the end, Tandy-ga (´･ω･)(´_ _) Tandy♪
