## Detailed Information 1 Outline of High-Cost Medical Care Benefit System

The high-cost medical care benefit system is for use in avoiding co-payments made for medical costs becoming too expensive for family budgets. Under this system, households pay co-payments for medical costs at the reception desks of medical institutions but then get reimbursed by insurers for any amount exceeding the monthly maximum amount. (*1) In case of hospitalization, a benefit in kind system has been introduced in which the monthly payment at the reception desks of medical institutions is limited to the maximum co-payment

(*2) In case of outpatient treatment, a benefit in kind system was introduced in April 2012 for use when the monthly payment exceeds the maximum co-payment at the same medical institution

○ The maximum co-payment amount is divided into three categories, namely general, high income, and low income, and thus according to the income of the insured person concerned.

Co-payment at reception

desks ¥300,000

Medical costs ¥1,000,000

High-cost medical care benefits ¥300,000 - ¥87,430 = ¥212,570

Maximum co-payment ¥80,100 + (¥1,000,000 - ¥267,000*) × 1% = ¥87,430

* 80,100 / 0.3 = 267,000

(Note) Per-household addition system

For cases where co-payments are paid multiple times in the same month by the same household (for example, a insured person receives medical treatment at medical institutions A and B and one of their dependents at medical institution C), co-payments are added for the individual household (for those younger than 70, co-payments paid at medical institutions A, B, and C must respectively be ¥21,000 or more: per-household standard amount) and if the amount exceeds the maximum co-payment, it will be the subject of high-cost medical care benefits.

## Detailed Information 2 Response to Benefit in Kind for Outpatient Treatment

A method (benefit in kind) of reducing the burden of patients paying high drug costs will be introduced for outpatient treatment in addition to conventional hospital treatment (enforced in April 2012). The method involves that when a patient receives outpatient treatment at the same medical institution and their monthly co-payment exceeds the maximum co-payment the insurer then makes the payment to the medical institution rather than the patient applying for the high-cost medical care benefits and receiving the benefits later, thus ensuring that the patient is only required to pay an amount which is capped at the maximum co-payment.

Case of general income earners (younger than 70) with medical expenses of ¥500,000 (30% co-payment)

[3] Present the maximum payable amount certificate and only pay an amount that is capped by the maximum co-payment (approximately ¥80,000)

Insured persons

[1] Apply for maximum payable amount certificate

[2] Issue maximum payable amount certificate

Medical institution* (outpatient)

* Including dispensing pharmacies, dental services, and home-visit nursing care stations

[4] Apply for high-cost medical care benefits (with submission of receipts)

Insurers

[5] Payment of high-cost medical care benefits (approximately ¥70,000)

(Reference) Percentage of receipts subjected to benefit in kind for outpatient treatment (medical services)

→ Younger than 70: Approx. 0.3%

70 or older: Approx. 0.1%

Basic mechanism of benefit in kind

[1] Insured persons, etc. apply to insurers, etc. for a maximum payable amount certificate to be issued. (Same treatment as with inpatient treatment)

[2] Insurers issue insured persons with maximum payable amount certificates according to the income category of their household. (On an individual basis)

[3] Insured persons present the maximum payable amount certificates at the counters of medical institutions. Medical institutions calculate the amount of the co-payment of insured persons, etc. on an individual basis and do not collect the amount exceeding the maximum co-payment, etc.

* Co-payment for the 1% addition must be made even if the maximum co-payment has been exceeded.

[4] Medical institutions will require from insurers the amount of high-cost medical benefits in addition to receipts.