"If I get cancer, how much will the medical bills be?" The answer is greatly changed by the High-Cost Medical Expense Benefit. Public health insurance has a monthly cap on out-of-pocket costs — about ¥80,000–90,000 a month for those earning ¥3.7–7.7 million a year. Even if medical costs reach ¥1 million, you pay only up to the ceiling, not the ¥300,000 that a 30% out-of-pocket share would be. This system, which sparked a major debate in 2025 over "freezing the increase," will begin a phased increase from August 2026. Here we summarize the current ceilings, how to use them, and the details of the reform.
- Monthly ceiling: For an annual income of ¥3.7–7.7 million (category "u"), about ¥87,000. Even with ¥1 million in medical costs, you pay only up to the ceiling, not ¥300,000 at the counter.
- Procedure: With a My Number health insurance card, no advance procedure is needed and your counter payment is capped at the ceiling (the eligibility certificate for the ceiling amount can also be used).
- Even lighter: Household aggregation (combining family members' costs of ¥21,000 or more) and the multiple-time provision (from the 4th time, ¥44,400 for category "u").
- Increase from August 2026: Category "u" rises to ¥85,800 + 1%. In exchange, an annual ceiling (¥530,000 for the category "u" equivalent) is newly created[MHLW expert committee materials].
- Not covered: Extra-bed charges, the technology fees for advanced medical treatment, meals during hospitalization, and free (non-insured) treatment are outside the ceiling. This is where private medical insurance should be considered.
List of out-of-pocket ceilings (under age 70, for treatment through July 2026)
| Category | Rough annual income | Monthly ceiling | Multiple-time provision (from 4th) |
|---|---|---|---|
| a | about ¥11.6 million and up | ¥252,600 + (medical costs − ¥842,000) × 1% | ¥140,100 |
| i | about ¥7.7–11.6 million | ¥167,400 + (medical costs − ¥558,000) × 1% | ¥93,000 |
| u | about ¥3.7–7.7 million | ¥80,100 + (medical costs − ¥267,000) × 1% | ¥44,400 |
| e | up to about ¥3.7 million | ¥57,600 | ¥44,400 |
| o | residence-tax exempt | ¥35,400 | ¥24,600 |
Example: for a category "u" person in a month with ¥1 million in medical costs (30% at the counter = ¥300,000) → the ceiling is 80,100 + (1 million − 267,000) × 1% = ¥87,430. The difference of about ¥210,000 comes back as the High-Cost Medical Expense Benefit (those aged 70 and over have a separate category table).
The increase from August 2026 (the confirmed reform)
- The increase that had been scheduled for August 2025 was fully frozen for the time being due to a public backlash. Afterward, a revised plan was finalized in December 2025, and with the passage of the FY2026 budget, implementation from August 2026 is confirmed[MHLW: On the review of the High-Cost Medical Expense Benefit].
- Example: category "u" goes from ¥80,100 to ¥85,800 (the base amount for the +1% portion also changes from ¥267,000 to ¥286,000) — an increase of about ¥5,700 a month. The other categories are raised similarly (a ¥270,300; i ¥179,100; e ¥61,500; o ¥36,900). The multiple-time provision (category "u" ¥44,400) is left unchanged.
- Together with the increase, a new "annual ceiling" is created. For people in long-term treatment who do not reach the multiple-time provision, an annual cap on patient burden (category "u" equivalent: ¥530,000 a year; residence-tax exempt: ¥290,000 a year) is established, and the excess is reimbursed by the insurer (for the time being, operated on the individual's application basis).
- As a second stage, a subdivision of income categories is planned for August 2027 (for example, splitting category "u" into three by income band). Please check the MHLW materials for the latest confirmed amounts.
- Because the impact is greater for those in long-term treatment, it becomes even more important to make full use of the multiple-time provision, household aggregation, and additional benefits (top-ups unique to a health insurance society).
How to use it (in fact, almost no procedure is now needed)
- See a doctor with a My Number health insurance card: through online eligibility verification, your ceiling information is linked, and your counter payment is capped at the ceiling with no advance procedure.
- If you do not use a My Number health insurance card: obtain an "eligibility certificate for the ceiling amount" from your insurer in advance and present it. Even after the fact, if you apply, the amount exceeding the ceiling is refunded about three months later (statute of limitations: 2 years).
- Household aggregation: out-of-pocket costs of family members on the same medical insurance (for those under 70, items of ¥21,000 or more per person) are combined to judge against the ceiling. Note that when a dual-income couple has separate insurance, the costs cannot be combined.
- The month-straddling trap: the ceiling is "per calendar month." A hospital stay that straddles the end of a month incurs the ceiling for two months, so if you can choose the timing of a planned admission, starting from the beginning of the month is advantageous.
What is not covered, and the relationship with other systems
- Where to file an after-the-fact application: your insurer. Company employees file with their health insurance society or the Japan Health Insurance Association; the self-employed and those after retirement file at their municipality's National Health Insurance counter (this is stated on the insurance card / eligibility confirmation document).
- Not covered: extra-bed charges (private-room fees), meal costs during hospitalization (¥550 per meal, revised June 2026), the technology fees for advanced medical treatment, and free (non-insured) treatment. Because these have no upper limit, one way to frame it is that this is precisely what private medical insurance should cover.
- Difference from the medical expense deduction: the High-Cost Medical Expense Benefit is a "refund from insurance," while the medical expense deduction is a "reduction of tax." You can use both, but in calculating the medical expense deduction you must subtract the amount returned via the High-Cost Medical Expense Benefit.
- If you take time off work due to illness, also consider injury and sickness allowance (2/3 of salary). In a year when your income falls, you may become eligible for the spousal deduction.
- The High-Cost Medical Expense Benefit can likewise be used with National Health Insurance for the self-employed and freelancers (no additional benefits, though).
Do this today
- Check your income category and monthly out-of-pocket ceiling on Mynaportal or the like
- Register to use your My Number health insurance card (counter payments above the ceiling become in principle unnecessary)
- Look back through your medical expense notices for any month within the past 2 years that exceeded the ceiling
More actions: the Take-Home Boost Checklist.
FAQ
If medical costs come to ¥1 million, what is the actual burden?
For an annual income of ¥3.7–7.7 million (category "u"), the monthly ceiling is ¥80,100 + (¥1 million − ¥267,000) × 1% = about ¥87,430 (for treatment through July 2026; from August, around ¥93,000). Extra-bed charges and meal costs are separate.
What changes from August 2026?
The out-of-pocket ceilings are raised. For example, category "u" goes from ¥80,100 to ¥85,800 (the +1% base also changes), an increase of about ¥5,700 a month. Meanwhile the multiple-time provision (category "u" ¥44,400) is left unchanged, and an annual ceiling (¥530,000 for the category "u" equivalent) is newly created for those in long-term treatment. A subdivision of income categories is planned for August 2027.
Is an advance procedure required?
If you see a doctor with a My Number health insurance card, in principle it is not needed, and your counter payment is automatically capped at the ceiling. If you do not use one, obtain the eligibility certificate for the ceiling amount in advance, or file an after-the-fact application and receive a refund about three months later (statute of limitations: 2 years).
Does this mean cancer insurance or medical insurance is unnecessary?
It cannot be said flatly. Thanks to public insurance, out-of-pocket treatment costs are held to around ¥80,000–90,000 a month, but extra-bed charges, advanced medical treatment, income loss from a prolonged illness, and meal costs are not covered. It is reasonable to consider it not as covering "the part above the ceiling" but as a design to fill "the part not covered and the loss of income."
Data sources
- Review of the High-Cost Medical Expense Benefit (the increase from August 2026): Ministry of Health, Labour and Welfare — Social Security Council Health Insurance Committee / Expert Committee on the State of the High-Cost Medical Expense Benefit, materials (December 25, 2025) (in Japanese)
- Current out-of-pocket ceilings, household aggregation, multiple-time provision: Ministry of Health, Labour and Welfare — On the review of the High-Cost Medical Expense Benefit (Health Insurance Committee materials) (in Japanese) and MHLW "To everyone using the High-Cost Medical Expense Benefit"
* The categories for those aged 70 and over, additional benefits of health insurance societies, and municipal medical cost subsidies differ from the table in this article. Please confirm the confirmed amounts for each category from August 2026 with your insurer and the latest MHLW materials before they take effect.