Medical Treatment Benefit Using the Membership Card

Members and their dependents (excluding those under the late-stage geriatric medical plan) who fall ill or get injured for causes not related to official duties can receive necessary medical treatment upon presentation of the Mutual Aid Association membership card to any hospital or clinic that accepts insurance plans.

Treatments for illnesses and injuries related to official duties are eligible for compensation under as stipulated in the Government Employees' Accident Compensation Act and other government-related laws, and the Mutual Aid Association does not pay the benefits.

1Medical Treatment Benefit and Family Medical Treatment Benefit

Category Association Pays: Member Pays: 70 – 74 Years Old (Early-Stage Senior Recipients) General 80% 20% Income Earners Above a Specified Level* 70% 30% Younger than 70 Years Old 70% (80% for children before entering elementary school) 30% (20% for children before entering elementary school)

	∗1	For members who (1) are 70 years of age or older, (2) have the standard monthly salary of 280,000 yen or more, and (3) have a dependent or dependents who are early-stage senior recipients, the specified amount is 5,200,000 yen or more, including the income of the dependent or dependents (3,830,000 yen or more if all members are early-stage senior recipients). Dependents 70 years old or older and younger than 75 years old who are supported by a member younger than 70 years old are categorized as general.
	∗2	Individuals who were born between April 2, 1939 and April 1, 1944 are eligible for special treatment for reduced responsibility.

2Inpatient Dietetic Treatment Benefit and Inpatient Resident Treatment Benefit

Inpatient Dietetic Treatment Benefit
	1.	Members pay a flat amount for meals while they or their dependents are hospitalized. The Mutual Aid Association will pick up the rest of the costs.
	ii.	The meal copayment amounts per meal per person are as follows (the standard copayment).

Who Standard Copayment General 460 yen Up to 90 days of hospitalization for low-income earners 210 yen ∗1 Hospitalization exceeding 90 days 160 yen ∗2 Senior welfare pension recipients residing in low-income households 100 yen ∗3

	Notes:	The patient’s responsibility (the standard responsibility amount) is not eligible for high-cost medical treatment costs, reimbursement of the partial cost benefits, or supplementary benefits for family medical treatment benefit. *1 through *3 apply to the member and his/her dependents only when the member himself/herself falls under the low-income earner category.
Inpatient Resident Treatment Benefit
	Elderly recipients hospitalized in a long-term care facility*1 pay a flat amount for meals and living expenses. The Mutual Aid Association will pick up the rest of the costs as inpatient resident treatment costs. The standard copayment amounts for inpatient resident treatment costs are as follows.
	Income Category Meal Cost (per Meal) Living Cost (per Day) General 460 yen (420 yen∗2) 370 yen Low-Income Earners II 210 yen Low-Income Earners I 130 yen
	∗1	Ask your healthcare institution if the facility qualifies as a long-term care facility.
	∗2	The amounts differ depending on healthcare institutions. Ask your healthcare institution which amount applies to you.
	(1)	Patients who require a respirator, central venous feeding, or patients who have spinal injuries (with quadriplegia) or intractable diseases pay only the amounts equivalent to the cooking ingredients (the standard inpatient dietetic copayment).
	(2)	Standard copayments are not eligible for high-cost medical treatment benefits, partial reimbursement of the cost of benefits, or supplementary benefits for family medical treatment costs.

3Home Visit Nursing Care Benefit and Family Home Visit Nursing Care Benefit

Members or their dependents who continue to receive treatment at home (i.e., the primary physician confirms that the home care requirements comply with the criteria stipulated by the Ministry of Health, Labour and Welfare) can receive home visit care services of the nurses dispatched from qualified home visit nursing care organizations.

Notes:

The criteria stipulated by the Ministry of Health, Labour and Welfare include patients with intractable diseases, terminal cancer patients, severely disabled patients (e.g., muscular dystrophy and brain paralysis), and middle-aged cerebral stroke patients.

Home Visit Nursing Care Benefit

The member who receives home visit care pays 30% of the costs, with the remainder paid by the Mutual Aid Association.

Family Home Visit Nursing Care Benefit

The dependent who receives home visit care pays 30% of the costs, with the remainder paid by the Mutual Aid Association.

4Transportation Benefit and Family Transportation Benefit

When the member or his/her dependent who is non-ambulatory due to the severity of his/her illness is incapable of using public transit and is transported via a bed-equipped car or taxi by the physician’s order, the Mutual Aid Association will, at a later date, pay the transportation costs that the Association approves if it receives a request from the member.

	i.	If the accompaniment of a caretaker (other than relatives such as parents and siblings) is needed, the transportation costs for that caretaker will also be paid.
	ii.	Transportation costs for regular hospital visits are not paid.

5Partial Reimbursement of the Cost of Benefits and Supplementary Benefit for Family Medical Treatment Costs

If the member’s or his/her dependent’s copayment amount to the same hospital or pharmacy exceeds 25,000 yen (50,000 yen for combined household high-cost medical treatment benefits) per event per person per month, the Mutual Aid Association will, at a later date, pay the excess amount as partial reimbursement of the cost of benefits to the member, and as supplementary benefit for family medical treatment costs to the dependent. However, the Association will not pay any excess amount less than 1,000 yen, and the payment amounts will be rounded down to the nearest 100 yen.

	∗	Members whose standard monthly salary is 530,000 yen and more (high-income earners) and their dependents have new responsibility amounts starting with medical treatments in October 2013, as follows:
		High-Income Earners' Maximum Responsibilities for Supplementary Benefits
		Month of Treatment Partial reimbursement for the cost of benefits Supplementary benefit for family medical treatment costs Supplementary benefit for high-cost home nursing care combined household costs October 2013 - March 2014 30,000 yen 60,000 yen April 2014 - March 2015 40,000 yen 80,000 yen April 2015 - 50,000 yen 100,000 yen
		The provision applies to the supplementary benefit for family home visit nursing care costs.

	1.	The amount of copayment does not include the standard copayment due for hospitalization. If high-cost medical treatment benefits are paid for, the Association will pay the amount after deducting the reimbursement amount for high-cost medical treatment.
	2.	These benefits will not be available when the municipal government subsidizes the member’s partial copayment to healthcare organizations. In this case, the member should inform the Association.
	3.	The Association calculates supplementary benefits and other benefits based on the itemized statement of medical treatment fees. For this reason, the Association’s benefit amounts may be slightly different from those calculated based on the amounts paid at the cashiers of healthcare organizations.

6High-Cost Medical Treatment Benefit

If the copayment amount that the member or his/her dependents pays for services by the same healthcare organization in the same month exceeds a specified amount (the copayment cap), the Mutual Aid Association will pay the patient, as a high-cost medical treatment benefit, any amount exceeding the copayment cap.

	1.	High-cost medical treatment benefits are calculated based on each monthly invoice (itemized statement of medical treatment fees) per patient created by the healthcare organization. Thus, these costs are calculated separately for medical and dental, and also separately for inpatient and outpatient services.
	2.	The amount of copayment does not include the standard copayment due for hospitalization.

(1)

When a patient younger than 70 years old pays a copayment exceeding the upper limit in any given month for an insured medical treatment, the Association will pay the amount exceeding the amount calculated based on Table 1 (the copayment cap). Elderly recipients receive the amount exceeding the amount calculated based on Table 2 (the copayment cap).

	Table 1: Patients Younger Than 70 Years Old
	Standard monthly salary: 830,000 yen or higher 252,600 yen If the medical treatment cost exceeds 842,000 yen, add 1% of the excess amount. (140,100 yen) Standard monthly salary: 530,000 yen to 790,000 yen 167,400 yen If the medical treatment cost exceeds 558,000 yen, add 1% of the excess amount. (93,000 yen) Standard monthly salary: 280,000 yen to 500,000 yen 80,100 yen If the medical treatment cost exceeds 267,000 yen, add 1% of the excess amount. (44,400 yen) Standard monthly salary: 260,000 yen or lower 57,600 yen (24,600 yen) Low-Income Earners∗ 35,400 yen (24,600 yen)
	∗ Members exempt from resident tax   The amounts in parentheses in the above table indicate the patient’s copayment cap applied to the fourth month and thereafter where benefit payments for high-cost medical treatment benefits have been paid for at least three months (multiple medical cost statements) within the past year in the same household.   (1) The base amount for a combined household calculation is 21,000 yen or more (10,500 yen or more for the month in which the insurance plan switches to the late-stage geriatric medical care plan).   (2) The amount of the patient’s copayment cap is 10,000 yen for specific diseases, e.g., dialysis (20,000 yen for high-income earners who require dialysis and their dependents younger than 70 years old).   (3) For the month in which the insurance plan switches to the late-stage geriatric medical care plan, the patient’s copayment is 1/2 of his/her regular copayment amount.

	Table 2: Elderly Recipients
	A Individual: Outpatient B Household: Outpatient and Inpatient Standard monthly salary: 280,000 yen or higher 57,600 yen 80,100 yen If the medical treatment cost exceeds 267,000 yen, add 1% of the excess amount. (44,000 yen ∗2) Standard monthly salary: 260,000 yen or lower 14,000 yen Annual ceiling amount is 144,000 yen 57,600 yen (44,000 yen ∗2) Low-Income Earners II *1 8,000 yen 24,600 yen Low-Income Earners I *2 15,000 yen
	∗1 Members exempt from resident tax   ∗2 Members exempt from resident tax who reside in the household where the household income is not exceeding a specified level.   The amounts in parentheses in the above table indicate the patient’s copayment cap which applies to the fourth month and thereafter where there are multiple-medical expense statements (excluding the times where the member/dependent receives a benefit payment based solely on the patient’s copayment cap in “A” above).   (1) Add only the patients’ copayment amounts for outpatient services individually for the member and each dependent, and apply the appropriate copayment cap in “A” to each individual.   (2) Add the patients’ copayment amounts for both inpatient and outpatient services (deduct the high-cost medical treatment benefits received under (1)) for the entire household, and apply the appropriate copayment cap in “B.”   (3) For combined household maximum amounts, there are no criteria for amounts to be combined. Add all amounts paid by the member or dependent, including medical treatment fees.   (4) The patient’s copayment cap for specific diseases, e.g., dialysis, is 10,000 yen.   (5) Inpatient medical expenses that exceed the patient’s copayment cap per each medical expense statement are directly paid to healthcare facilities (in this case as well, high-price cost medical treatment benefits are deemed to be paid out).   (6) For the month in which the insurance plan switches to the late-stage geriatric medical care plan, the patient’s copayment cap is 1/2 of each applicable copayment cap.

(2)

When a patient younger than 70 years old has received two or more invoices, each with the monthly copayment amount of 21,000 yen or more per event: When the same household has two or more invoices, each with the copayment amount of 21,000 yen (10,500 yen for the month in which the insurance plan switches to the late-stage geriatric medical care plan) or more per event in a single month, the Association will pay the amount exceeding the amount calculated based on Table 1 if the total of the copayment amounts of family members (called the combined household amount) exceeds 81,000 yen (150,000 yen for high-income earners). Elderly recipients receive the amount calculated based on Table 2. For the combined household of elderly recipients and recipients younger than 70 years old, the amount exceeding the calculated amount based on Table 3 will be paid. All amounts of copayments borne by elderly recipients can be included in the combined household amounts.

	Table 3: Combined Household Amounts of Elderly Recipients and Recipients Younger Than 70 Years Old
	C Combined Household Elderly Recipients A Individual: Outpatient B Household: Outpatient and Inpatient Standard monthly salary: 280,000 yen or higher 57,600 yen 80,100 yen If the medical treatment cost exceeds 267,000 yen, add 1% of the excess amount. (44,000 yen) Standard monthly salary: 830,000 yen or higher 252,600 yen If the medical treatment cost exceeds 842,000 yen, add 1% of the excess amount. (140,100 yen) Standard monthly salary: 530,000 yen to 790,000 yen 167,400 yen If the medical treatment cost exceeds 558,000 yen, add 1% of the excess amount. (93,000 yen) Standard monthly salary: 280,000 yen to 500,000 yen 80,100 yen If the medical treatment cost exceeds 267,000 yen, add 1% of the excess amount. (44,000 yen) Standard monthly salary: 260,000 yen or lower 57,600 yen (24,600 yen) Standard monthly salary: 260,000 yen or lower 14,000 yen 57,600 yen (44,400 yen) Low-Income Earners II 8,000 yen 24,600 yen Low-Income Earners 35,400 yen (24,600 yen) Low-Income Earners I 15,000 yen
	The amounts in parentheses in the above table indicate the amounts which apply to the fourth month and thereafter for multiple-medical expense statements   (1) Add only the elderly recipients’ copayment amounts for outpatient services individually for the member and each dependent, and apply the appropriate copayment cap in “A” to each individual.   (2) Add the elderly recipients’ copayment amounts for both inpatient and outpatient services (deduct the high-cost medical treatment benefits received under (1)) for the entire household, and apply the appropriate copayment cap in “B.”   (3) Combine the copayment amounts for patients under 70 years old (only the copayments in the medical expense statements that meet the minimum combinable amounts or more) and the copayment amounts for elderly recipients (deduct the high-cost medical treatment benefits received under (2)) for the entire household, and apply the copayment cap in “C.”   (4) For the month in which the insurance plan switches to the late-stage geriatric medical care plan, the patient’s maximum responsibility is 1/2 of each applicable copayment cap.

	(3)	When the same household has multiple high-cost medical treatment benefits: When the same household has received high-cost medical treatment benefits for three months or longer (multiple medical expense statements) during the one-year period prior to the month in which a patient or patients receive treatment, the benefit amount for the fourth month and beyond is subject to reduction.(For details, see Table (1), Table (2) and (3).) However, the number of coverage provided solely under the outpatient copayment cap rule applicable to publicly subsidized medical treatments, specific diseases, and elderly recipients are excluded from the count.
		Note: For the month in which the insurance plan switches to the late-stage geriatric medical care plan, the patient’s copayment cap is 1/2 of the applicable copayment cap.
	(4)	Special cases for patients who require high costs medical care for a prolonged period If the patient has hemophilia or is under dialysis treatment for chronic renal failure, and his/her copayment amount exceeds 10,000 yen (20,000 yen for high-income earners and any dependents 70 years old or younger on dialysis who are supported by a member (regardless of his/her age) who earns a standard monthly salary of 530,000 yen or more, and 1/2 of each applicable cap for the month in which the insurance plan switches to the late-stage geriatric medical care plan), the Association pays the excess amount as a high-cost medical treatment benefit.

	1.	To be qualified for these special cases, the “certificate of special disease treatment qualification,” issued by the Association, should be presented to the healthcare organization along with the membership card or dependent card.
	2.	To receive the “certificate of special disease treatment qualification,” complete the form “Application for certificate of special disease treatment qualification” and submit it to the Association.

Certificate of Application of Copayment Cap For high-cost medical treatment benefits, the member or his/her dependent usually pays the entire amount of his/her copayment to the cashier of the healthcare organization at the time the patient uses the services of that organization for the illness or injury covered by the insurance. The Association will pay the patient the amount exceeding the patient’s copayment portion after a specified length of time. With the patient temporarily paying the entire amount of his/her copayment, the financial burden is not small. For this reason, the Association issues a certificate of application of copayment cap upon request. By presenting this certificate with the membership card or dependent card to the healthcare organization, the patient can pay only up to his/her copayment cap directly to the healthcare organization, with the Association paying the remainder directly to that organization. If you or your dependents desire the issuance of this certificate because of the possibility of high treatment costs suggested by your healthcare organization, or because of your financial situation, please inquire at the mutual aid department of your local branch.

7High-Cost Nursing Care Combined Household Treatment Benefit

If there is a member of the household who is receiving the benefit of a nursing care insurance, and if the combined household costs of the patients’ annual (from August 1 to July 31 of the following year) responsibility amounts for the medical insurance and the home nursing care insurance become significantly high, the Mutual Aid Association will pay the amount exceeding the patients’ maximum responsibility amounts according to the ratio of the patients’ responsibility amounts for the medical and home nursing care insurances, in order to ease the financial burden.

Note:

The home nursing care insurance pays the benefit as a “high-cost medical treatment benefit combined household nursing care service fee.”

8Payments of Differences by Patients for Medical Treatment Costs and Medical Treatment Costs Combined With Non-Insured Costs

Payments of differences by patients for medical treatment costs include the following. The benefit payments are the same as for regular insurance-covered treatments. However, the differences are not part of the benefits.

	(1)	Hospital Room Upgrade If the patient upgrades his/her hospital room to one with a better condition (individual room or room for two patients), he/she is responsible for the difference in the cost.
	(2)	Dental Treatments Certain limits are in place for each material used in dental treatments. If the patient wishes to use materials such as gold alloy and platinum, he/she is billed for the excess cost of materials incurred beyond the scope of the coverage, subject to the treatment method.
	(3)	Advanced Technology Treatments When the patient receives advanced technology treatment, the insurance will cover the basic treatment (e.g., initial consultation and lab tests) part of that treatment as medical treatment cost combined with uninsured care costs.

Treatment Benefit When You Did Not Use Your Membership Card for Treatment Medical

As a general rule, patients should present their membership cards or dependent cards to the healthcare organization for treatment of illness and injury. If they are not able to use their cards, however, for emergency or other unforeseen circumstances, including those stated below, they should pay the full charge to the healthcare organization. If the Association approves the reason for the non-use of the card, it will pay the medical treatment benefit at a later date.

	(1)	When the patient receives medical treatment in an area where no insured medical care facility is available
	(2)	When the patient receives medical treatment in the nearest medical care facility providing uninsured care due to an accident or sudden illness
	(3)	When the patient has purchased blood for transfusion, or therapeutic apparatus such as a prosthetic arm or leg, and corset.
	(4)	When the patient receives medical treatment overseas

1Upfront Payment of Full Charge for Medical Treatment Costs

The Association pays back to the patient the amount after deducting the patient’s responsibility from an amount obtained from a specified criterion as a medical treatment cost (medical treatment cost for a dependent or family).

	1.	Medical costs are higher when you pay the full charge upfront than when you use your insurance. Because the benefit amount that the Mutual Aid Association pays is calculated using insurance points, it may be lower than the actual amount you paid upfront.
	2.	To claim your benefit, a receipt for medical treatment charges and an itemized statement are required. Please do not forget to obtain these from the healthcare organization

2Temporary Upfront Payment of Full Charge for Acupuncture, Moxacautery, and Massage

When the patient suffers a fractured bone, bone dislocation, or sprain that requires treatment and receives treatment from an acupuncture, moxacautery, or massage therapist upon approval of a physician, the Mutual Aid Association will, at a later date, pay the treatment cost(s) that it approves based on a specific criterion.

3Temporary Upfront Payment of Full Charge for Therapeutic Apparatus

When the patient purchases therapeutic apparatus such as prosthetic joints, a corset, or other therapeutic apparatus that the physician approves as necessary, the Mutual Aid Association will, at a later date, pay the cost of that apparatus based on a specific criterion.

The Association pays for therapeutic apparatus necessary for treatment purposes only. It will not pay for devices that remedy inconveniences in daily life or at work, or for those worn for cosmetic reasons (e.g., eyeglasses and hearing aids).

4Temporary Upfront Payment of Full Charge for Transfusion

When the patient pays for blood for transfusion, the Mutual Aid Association will pay that cost as a treatment benefit at a later date.

The Association will not pay for the blood provided by a relative.

5Temporary Upfront Payment of Full Charge for Treatments Received Overseas

If the patient receives and pays for treatment at an overseas healthcare organization for illness or injury, the Mutual Aid Association will pay the medical treatment benefit at la later date. The Association will not pay the benefit for the medical treatment that the patient received and paid for overseas when the patient travels there for the purpose of treatment.

	1.	Because the benefit amount that the Mutual Aid Association pays is calculated based on a Japanese domestic criterion (using insurance points), the benefit is almost always lower than the actual amount you paid out of pocket due to differences in healthcare practices between Japan and overseas.
	2.	To claim your benefit, an itemized statement of medical treatments and an itemized receipt, and a receipt (issued locally) are required. Please do not forget to obtain these from the healthcare organization.
	3.	You may submit an itemized statement of medical treatments and an itemized receipt Issued by the local healthcare organization. However, we recommend that you obtain specific forms before you travel. If you will be overseas for a long time, please inquire at the mutual aid department of your local branch in advance.
	4.	When traveling overseas, we recommend that you purchase, for reassurance, an overseas travelers' personal accident insurance, which compensates for costs incurred due to an unexpected accident, as well as illness and injury.

Treatments Not Covered by the Membership Card

While members and their dependents can receive medical treatment by presenting their membership card or dependent card at a healthcare organization, the card cannot be used for the following services.

Simple Procedures for Disease Prevention or Relief of Fatigue

Physical examinations, immunization shots for influenza, dysentery, and other diseases, and vitamin shots as a procedure for relief of fatigue

Cosmetic Surgery

Cosmetic surgery (e.g., rhinoplasty, double-fold eyelids), procedures for gray hair, hirsutism, and atrichia, and removal of age spots and moles

Artificial Abortion

Artificial abortion for economical reasons

Normal Child Delivery

The benefit for child delivery (or family child delivery) is paid for pregnancy of four months (85 days) or longer whether or not the pregnancy ends in normal birth, stillborn, miscarriage, premature birth, or artificial abortion. However, the benefit will not be paid for expenses related to the treatment provided by a physician in the course of normal delivery.

		Short-Term benefits

	Outline of Short-Term benefits
	Illnesses and Injuries
	Childbirth
	Absence from Work
	Disasters
	Death
	Restrictions on Benefits
	Injury Caused by Others
	Benefits after Retirement
	Healthcare Treatment after Retirement
	Geriatric Medical Care Plans
	Long-Term Care Insurance Act