Employees’ Health Insurance

The Employees’ Health Insurance is a workplace-based insurance system which provides financial assistance to salaried workers of companies and to their dependent family members by paying insurance benefits in the event of sickness, injury, childbirth and death.
Within the system, Society-managed Health insurance is for large-scale companies while other companies are covered by the Government-managed Health Insurance. The outline of Government-managed system is explained here. Under the Society-managed system, each society may manage its own health insurance program with its own benefits and contributions, within the government regulations.

	Coverage
		Compulsory Coverage
			You must be covered by the Employees’ Health Insurance if you work for a company or factory which employs 5 workers or more, or if you work for a HOJIN corporation, irrespective of your age or nationality. Specifically, a company or a factory here means one in business specified by law, such as manufacture or health and medical services. You must be also covered if you are a part-time worker and if both your work days and your work hours are more than 3/4 of the regular workers in your workplace.
			How to Enroll in the System
			For your enrollment to the Employees’ Health Insurance, your employer must submit the “Application to Enroll in the Employees’ Health Insurance / Employees’ Pension Insurance” (SHIKAKU SHUTOKU TODOKE - KENKO HOKEN / KOSEI NENKIN) to local Social Insurance Office (including one in a Social Insurance Bureau) within 5 days since you are hired.
		Coverage of Your Dependents
			Your dependent family members can apply for coverage if they are your first, second or third level of your family members or relatives (see the chart below). The condition is that substantial portion of his/her financial support comes from you.
				When your dependent has an income, he/she is applicable if :
					-	he/she lives with you and has an income of less than \1.3* million AND less than half of your annual income.
					-	he/she does not live with you and has an income of less than \1.3* million AND less than the total financial support amount provided by you.
					*	\ 1.8 million if he/she is aged 60 or older or has disability
			Your First, Second and Third Level of Family Members or Relatives
							To qualify for coverage, your family members in in the chart below need to be financially supported by you.  Those in need to be living with you in addition to financial dependence on you.
			How to Enroll in the System
			When your dependants become eligible for coverage or disqualified for coverage, your employer must submit the “Application for Dependant’s Coveage”(HIFUYOSHA IDO TODOKE) to the Social Insurance Office (including one in a Social Insurance Bureau) within 5 days since the day of change.
		Voluntary Coverage
			You may be covered as voluntary status if you have at least 2 consecutive months covered under the Employees’ Health Insurance just before your retirement/resignation from work.
			How to Enroll in the System
			If you opt for this type of coverage, you need to submit the “Application for Voluntary and Continuous Coverage” (KENKO HOKEN NIN-I KEIZOKU HIHOKENSHA SHIKAKU SHUTOKU SHINSEISHO) to the Social Insurance Office (including one in a Social Insurance Bureau) within 20 days after your retirement. You can not apply after that date unless Social Insurance Agency admits that you have a good reason.*
			*	The good reasons for delayed payments include such as disaster, strike on transportation systems.
			(Note)
				Under this type of coverage, you are covered for up to 2 years, and your coverage ends when the 2 years has passed. It is one time only and it can not be renewed. As for the contribution, you pay full amount of contribution instead of half amount of contribution (your employer has paid the other half before retirement). If you fail to pay your first contribution by the date designated by the Social Insurance Office (including one in a Social Insurance Bureau) without good reasons, your application for coverage may be considered invalid. Likewise, if you fail to pay the contribution by the designated date, your coverage ends the following day of the designated payment date. The contribution payment deadline is usually 10th day of each month. Without good reasons, therefore, you may lose your coverage on the next day if you fail to pay. You may opt for the advance payment of contribution for either six months or for one year in a lump. You will have some discount depending on the amount of advance payment. In this arrangement, the contribution for each month is considered to be made on the first day of due month.

	Benefits
		Medical Care Benefits / Dependents’ Medical Care Expenses / Medical Care Expenses with no Insurance Applied Medical Care
			When you or your dependents become sick or injured by non-occupational causes, you can receive medical treatment under the insurance system at any insurance hospitals/clinics by presenting your Certificate of Employees’ Health Insurance. When you receive medical treatment, you pay your cost-sharing to the hospitals/clinics as discribed in the chart below;
			Cost-sharing
				Insured persons General insured persons 30% of the medical care expenses Elderly insured persons* 10% of the medical care expenses (30% for higher income persons) Dependents Children under age 3 20% of the medical care expenses Persons aged 3-69 30% of the medical care expenses Elderly insured persons* 10% of the medical care expenses (30% for higher income persons)
				*	Persons aged 70 or older who are not subject to the Health and Medical Services for the Elderly (they should present their Certificates of Employees’ Health Insurance as well as the Employees’ Health Insurance Certificate for Elderly insured persons)
					Persons subject to the Health and Medical Services for the Elderly: 10% of the medical care expenses (30% for higher income persons)
		Meal Service Benefits
			If you/your dependents are hospitalized in insurance hospitals/clinics, you can receive your meal service by paying a standard cost-sharing to the hospitals. The amount of a standard cost-sharing is \260 per meal (If your household is tax-exempted, you can apply for lower rate.).
		Medical Care Expenses / Dependents Medical Care Expenses
			If you/your dependents can not help but have to receive medical treatment at non-insurance hospitals/clinics due to unavoidable reasons or difficulties, you can receive the Medical Care Expenses.
			Benefit Amount
			The designated total of standard medical care expenses minus your cost sharing. Please note that it is not the actual cost you paid to the non-insurance hospital.
			How to Claim Your Benefit
			To claim your benefit, you need to file the “Application for Medical Care Expenses” (RYOYOHI SHINSEISHO) together with the receipt of itemized medical costs, to the Social Insurance Office (including one in a Social Insurance Bureau) within 2 years from the next day that you paid the medical costs.
		Transportation Expenses / Dependents’ Transportation Expenses
			You/your dependents can receive the Transportation Expenses when you can not walk due to sickness or injury and pay for the transportation to the insurance hospitals/clinics, provided that such expenses are deemed to be reasonable and appropriate.
			Benefit Amount
			Amount calculated based on the cost of most economical route/method of transportation.
			How to Claim Your Benefit
			To claim your benefit, you need to file the “Application for Transportation Expenses / Dependents” Transportation Expenses’ (ISOHI (KAZOKU ISOHI) SHIKYU SHINSEISHO) together with the note of your doctor's comments and the receipt of transportation costs, to the Social Insurance Office (including one in a Social Insurance Bureau) within 2 years from the next day of the day that you paid for the transportation.
		Benefits for High-cost Medical Care
			If you/your dependents’ co-payments exceed the specified limits, you can apply for the reimbursement of the excess over the limit.
			Amount of Reimbursement and Co-payment Limits

	�@	If your/your dependents’ total co-payments to an insurance hospital/clinic in a same month exceeds over the payment limit as shown in “Case �@” on the table below, the excess over the limit will be reimbursed (co-payments for outpatient service, inpatient service, medical service or dental service are calculated individually).
	�A	If you or your dependents have received the reimbursement for 3 months in a year, the total excess over the payment limit shown in “Case �A” on the table below will be reimbursed for and after the forth month.
	�B	If two or more members of your household have paid more than \21,000 of co-payments each, the total medical care expenses less the sum of individual payments limit shown in both “Case �@” and “Case �A” below will be reimbursed.
		Individual co-payment limit: Case �@ Individual co-payment limit: Case �A Low income persons *1 \35,400 \24,600 General \80,100＋(Medical care expenses - \267,000) x 1% \44,400 Higher income persons *2 \150,000 + (Medical care expenses - \500,000) x 1% \83,400
			*1	The Public Assistance beneficiaries and persons of municipal tax exempted households
			*2	The insured persons with Monthly Standard Remuneration of more than \530,000, and their dependents
				The individual payment limit and high medical treatment expenses for those aged 70 and older are otherwise specified.

			How to Claim Your Benefit
			To claim your benefit, you need to file the “Application for high-cost medical care benefit” (KOGAKU RYOYOHI SHIKYU SHINSEISHO) to the Social Insurance Office (including one in a Social Insurance Bureau) within 2 years from the first day of the next month that you paid the medical care expenses. If you are a low-income person, please attach the certificate of municipal tax exemption. You need to file the application within 2 years from the first day of the next month of your medical treatment. In case you paid your cost-sharing in the next month of the medical treatment, you need to file the application within 2 years from the next day that you pay your cost sharing.
		Sickness and Injury Allowance
			If you become unable to work due to medical treatment for sickness or injury and lose salary paid by the employer, you can receive the Sickness and Injury Allowance. The waiting period is 3 days.
			Benefit Amount
			Approximately two-thirds of daily standard remuneration is paid for period of up to 1 year and 6 months. However, the Allowance is suspended or reduced when:

	a.	you receive a part or all of the remuneration from your employer.
	b.	you receive the Disability Basic Pension, the Disability Allowance, or the Disability Employees’ Pension deriving from the same injury or sickness.
	c.	you receive the Old-age Employees' Pension, the Old-age Basic Pension, or the Retirement Mutual Aid Pension after your retirement.

			If the daily amount of remuneration / pension benefit in a. to c. is higher than the daily amount of the Sickness and Injury Allowances, the Allowance is not paid. If lower, the difference is paid.
			How to Claim Your Benefit
			To claim your benefit, you need to file the “Application for Sickness and Injury Allowance” (SHOBYO TEATEKIN SHIKYU SHINSEISHO) to the Social Insurance Office (including one in a Social Insurance Bureau). We need certification by your employer and comment by your doctor on the Application form. For your first application, you need to submit photocopy of evidence such as your “payroll book” (CHINGIN DAICHO) and “attendance book” (SHUKKINBO). The deadline to file the claim is determined for each benefit payable day. You need to file a claim within 2 years from the next day of the day for which your benefit is payable.
		Maternity Allowances
			If you are absent from work in order to give birth to a baby and lose income from the employers, you can receive the Maternity Allowance.
			Benefit Amount
			Approximately two-thirds of the daily standard remuneration is paid. This allowance is payable from 42 days preceding the delivery date until 56 days after the delivery. In case of twins or more, it is payable from 98 days preceding the delivery date. If the baby is born later than the expected delivery date, it is payable from 42 days preceding the expected delivery date.
			How to Claim Your Benefit
			To claim your benefit, you need to file the “Application for Maternity Allowance” (SHUSSAN TEATEKIN SHIKYU SHINSEISHO) to the Social Insurance Office (including one in a Social Insurance Bureau). We need certification by your employer and comment by your doctor on the Application form. For your first application, you need to submit photocopy of evidence such as your “payroll book” (CHINGIN DAICHO) and “attendance book” (SHUKKINBO). The deadline to file the claim is determined for each benefit payable day. You need to file a claim within 2 years from the next day of the day for which your benefit is payable.
		Midwifery Expenses / Dependents’ Midwifery Expenses
			If you/your dependents give birth to a baby after 4 months of pregnancy, you can receive the Midwifery Expenses. It is also payable for stillbirth or miscarriage.
			Benefit Amount
			￥350,000
			How to Claim Your Benefit
			To claim your benefit, you need to file the “Application for Midwifery Expenses / Dependents’ Midwifery Expenses “(SHUSSAN IKUJI ICHIJIKIN / KAZOKU SHUSSAN IKUJI ICHIJIKIN SHIKYU SHINSEISHO) to the Social Insurance Office within 2 years from the next day that you give birth to your child. You need to attach certification by either doctor/midwife or Mayor of your municipality on the Application form.
		Funeral Expenses / Actual Funeral Costs / Dependents' Funeral Expenses
			If an insured person of the Employees’ Health Insurance system dies, any person who is financially supported by the deceased person can receive the Funeral Expenses. If there is no one eligible for the Expenses, the deceased person’s employer or a friend who arranged the funeral can receive the Actual Funeral Costs. If a dependent of an insured person dies, the insured person can receive the Dependents' Funeral Expenses.
			Benefit Amount
			Funeral Expenses: \50,000 Actual Funeral Costs: Equivalent to the actual cost of funeral up to                          the Funeral Expenses amount Dependents' Funeral Expenses: ￥50,000
			How to Claim Your Benefit
			To claim your benefit, you need to file the “Application for Funeral Expenses / Actual Funeral Costs / Dependents' Funeral Expenses” (MAISORYO (MAISOHI) / KAZOKU MAISORYO SHIKYU SHINSEISHO) to the Social Insurance Office (including one in a Social Insurance Bureau). You need to include either the employer’s certification on his/her death on the Application form, or attach doctor’s certification on his/her death to the form. To claim the Actual Funeral Costs, you need to attach the original receipt of the funeral costs. You need to file the claim within 2 years from the next day of the death.

Contributions

Your insurance contribution is shared by you and your employer equally. Your employer is responsible for paying your share of contribution and employer’s share of contribution to the Social Insurance Office.

			Contribution for regular months (without bonus payment)
			Contribution amount = Your Standard Monthly Remuneration* × Contribution rate ***
			Contribution for bonus months (regular salary + bonus)
			Contribution amount = Your Standard Monthly Remuneration* × Contribution rate ***                                        + Your Standard Bonus Amount**× Contribution rate***
				* Standard Monthly Remuneration
					The Standard Monthly Remuneration serves as the basis for calculating the benefits and insurance contributions for Employees’ Health Insurance and the Employees' Pension Insurance. Your actual remuneration paid from the employer is classified into the prescribed remuneration table, and your Standard Monthly Remuneration is determined. Your remuneration includes every payment such as salary, wage and any allowance which you receive from your employer in return of your service performed. However, the bonus and such received at intervals of more than 3 months are excluded.
				** Standard Bonus Amount
					The Standard Bonus Amount is the amount of bonus you receive from your employer at intervals of more than 3 months, rounded down to the nearest \1,000. The maximum of the Standard Bonus Amount for the purpose of contribution calculation is a total of \5.4 million in bonus payments per one fiscal year (from 1 April to 31 March).
				*** Contribution rate (as of September 2007)
					The contribution rate for the Government-managed Health Insurance (SEIFUKANSHO KENKO HOKEN) is 82/1000. If you are aged 40 or over but under 65, the contribution rate is 94.3/1000 including the contribution for Long-term Care Insurance.
			(Note)
			-	If you take childcare leave from work, you and your employer may be exempt from contribution payment for the duration of the leave, upon application.
			-	If you opt for the Voluntary and Continuous Coverage after retirement, you pay the whole contribution: employer’s share and your share. For this coverage purpose, the Standard Monthly Remuneration is either \280,000 or your Standard Monthly Remuneration at retirement, whichever the lower.

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