Benefits provided when using your health insurance card for examinations or treatment
This section explains the benefits (benefits in kind) provided when you use your health insurance card for examinations or treatment, explaining why costs are lower when you present your health insurance card at a medical institution. It also provides basic information on health insurance benefits, including the circumstances under which you can obtain additional benefits from Sony Health Insurance.

"Medical care benefits" and "dependent medical expenses"
"Medical care benefits" refers to benefits in kind received by "the insured individual" when he or she uses his or her health insurance card to receive care.
If you present your health insurance card at a medical institution, you will be charged only for part of the medical costs incurred (referred to as "the copayment"). By paying the copayment you can receive all medical care services to which health insurance can be applied. Sony Health Insurance pays the remaining costs (to the medical institution) as "medical care benefits."
"Dependent medical expenses" refer to benefits provided to "the insured individual's dependents." "These benefits" are the same as those provided to the insured.

The "copayment amount" charged at the medical institution varies according to the age of the patient (or to income levels, in the case of the elderly). However, there is no difference between the copayment amounts charged to insured individuals and those charged to their dependents.
For individuals aged 69 and younger
The copayment paid by individuals aged 69 and younger is 30% for both inpatient and outpatient care. However, the copayment is 20% for children under 3 years of age.

Elementary
school
student
– up to
age 69

Copayment amount
<<the copayment>>
30%
Amount paid by Sony Health Insurance
《Medical care benefits/dependent medical expenses 》
70%
Preschool 20% 80%

Partial cost sharing through March 2008 (for those younger than 70 years of age)
Patients receiving both inpatient and outpatient services pay a copayment of 30% of total medical costs to the medical institution. However, the copayment for children less than three years of age is 20%.
3 – 69
years
Copayment
<<Partial cost sharing>>
30%
Paid by Sony Health Insurance Society
《Medical benefits, family medical costs 》
70%
Less than
3 years
20% 80%

For individuals aged 70 through 74
In principle, the copayment paid by individuals aged 70 to 74 is 10% for both inpatient and outpatient care. However, the copayment is 20% for insured individuals with incomes over a certain level and for their dependents.
* Sony Health Insurance will specifically notify "individuals whose incomes are above this level.
Persons with
general income
Copayment
《the copayment》
20%
10% through March 31, 2009*1
Amount paid by Sony Health Insurance
《Medical benefits, family medical costs 》
80%

Individuals
earning
the same
amount
as active
workers *2

30% 70%
*1 Although copayment for those aged 70-74 was scheduled for revision to 20% effective April 2008 , this revision has been postponed until April 2009. Under exceptional measures for FY 2008, the difference from this copayment of 20% is covered by the Japanese government.
*2 Persons with standard monthly remuneration of 280,000 yen or above and taxable income of 1,450,000 yen or above
Partial cost sharing through March 2008 (for those aged 70-74 years)
Persons with
general income
Copayment
10%
Paid by Sony Health Insurance Society
90%
Individuals
earning
the same
amount
as active
workers *1
30% 70%
*1 Persons with standard monthly remuneration of 280,000 yen or above and taxable income of 1,450,000 yen or above


Additional benefits from Sony Health Insurance "copayment reimbursement" and "dependent medical costs"
Additional benefits are provided by Sony Health Insurance in the form of "copayment reimbursements (for the insured)" and "dependent medical care additional sums (for dependents)" when "copayments" exceed a certain amount.
These benefits are provided to insured individuals or dependents when the total amount of "copayments" paid by an individual to medical institutions exceeds 20,000 yen during one calendar month.

When the total amount of "copayments" paid by an individual to medical institutions exceeds 20,000 yen during one calendar month, the amount exceeding 20,000 yen is returned (approximately 4 months after medical care was received) as a "copayment reimbursement" or as a "dependent medical care additional sum." In principle, these benefits are paid automatically, and no procedures need to be completed to receive these benefits. Figures are rounded down to the nearest 100 yen.

These benefits are provided no matter how much was paid by the individual. For this reason, the maximum amount paid by any individual in a single month is 20,099 yen.

•t‰Á‹‹•t‚ĚŽd‘g‚Ý
* Individuals eligible for elderly healthcare insurance benefits cannot receive additional benefits from the Sony Health Insurance Society.

Benefits for high-cost medical care
High-cost medical care benefits are statutory benefits intended to reduce the financial burden on patients imposed by high copayments for medical care. If the copayments paid exceed a certain amount, they are reimbursed as "high-cost medical care benefits."

Under Sony Health Insurance, when the total copayments paid by an individual exceeds 20,000 yen during one calendar month, the amount exceeding 20,000 yen is reimbursed as additional benefits. This also applies to high-cost medical care. For this reason, any amount over 20,000 yen paid by an individual in a single calendar month (figures are rounded down to the nearest 100 yen) will be reimbursed as benefits.

(Note: This applies only to "Medical care for which health insurance can be used.")

High-cost medical care benefits and Sony Health Insurance additional benefits are calculated automatically based on the detailed statements received by Sony Health Insurance from the medical institutions in question. The amount covered by "high-cost medical care benefits" and "additional benefits" will be paid approximately 4 months after the month in which medical care was received. In other words, no matter how much an individual pays at the medical institution, totals exceeding 20,000 yen per person per month will be returned as benefits some 4 months later. For this reason, the maximum amount paid by an individual in a given month is 20,099 yen.
In general, these benefits are processed automatically, and no procedures are required.


High-cost medical care benefits related to hospitalization of persons less than 70 years of age
Persons hospitalized April 1 or later can receive benefits in kind for high-cost medical care benefits, by submitting a Health Insurance Maximum Copayment Amount Eligibility Certificate issued in response to an application submitted in advance and paying to the administering hospital no more than the maximum personal cost burden (see “Terminology” below) corresponding to his or her income category.
Notes:
1. Persons desiring to receive benefits in kind for high-cost medical care benefits must apply in advance.
2. Additional benefits will continue to be paid automatically.

[How to apply for benefits in kind for high-cost medical care benefits]
Documents to submit Application for Health Insurance Maximum Copayment Amount Eligibility Certificate
Documents to attach Certificate of non-taxation (required only from persons exempt from local income tax)
Eligible persons Insured persons and dependents
Term of validity From the first day of the month in which the application was received at the Health Insurance Society through July 31
Submit documents to Attn:Benefits, Health Insurance Group, Social Insurance Center, Sony Human Capital Corp. 11th Floor, Shinagawa Intercity B
Note Please return your Health Insurance Maximum Copayment Amount Eligibility Certificate promptly after its term of validity has expired or when you have lost qualification as an insured person (or dependent) "

Explanation of terminology

High-cost medical care benefits for the insured and for dependents

When the copayments paid at the medical institution during one calendar month exceed the maximum copayment amount per detailed statement from the institution, the surplus amount is reimbursed as "high-cost medical care benefits for the insured" or "for dependents."

* This maximum copayment amount refers to the amount stipulated by law to protect patients against excessive medical expenses.
【Maximum copayment (monthly) for persons less than 70 years of age 】
General income earners  80,100 yen + (Medical costs - 267,000 yen) x 1%
High-income individuals
(Individuals with incomes of 530,000 yen or more per month)
150,000 yen + (Medical costs - 500,000 yen) x 1
Low-income individuals
(Individuals exempted from residence tax)
 35,400yen

Maximum copayment (monthly) for persons over 70 years of age 】
Persons with general income ●Outpatient (per individual)
   24,600 yen
●Outpatient/inpatient (per household)
   62,100 yen

Maximum copayment amount through March 2008 (for Persons with general income aged 70-74 years)】
Persons with general income ●Outpatient (per individual)
   12,000 yen
●Outpatient/inpatient (per household)
   44,400 yen
Persons receiving income at the same level as before retirement
●Outpatient(per individual )
  44,400yen
●Outpatient/inpatient(per individual)
  8,000yen+(medical cost -267,000yen)×1%
Low-income individuals
(Individuals exempted from residence tax)

●Outpatient(per individual )
  8,000yen*1
●Outpatient/inpatient(per individual)
Low-income individualsI:15,000yen
Low-income individualsII:24,600yen
*2

 

*1・・・Persons with standard monthly salaries of 280,000 yen or higher and annual taxable incomes of 1,450,000 yen or higher .
*2··· There are two categories of low-income individuals: Category I includes those with pension incomes of 650,000 yen or less and Category II includes other individuals with incomes below a certain level.

Since Sony Health Insurance also provides additional benefits for the portion up to this maximum copayment amount, the maximum amount paid by the individual in a given month is always 20,099 yen.

Total high-cost medical care
When two or more individuals in the same household each pay 21,000 yen or more for medical care within a single calendar month and the total amount exceeds the maximum copayment amount, the amount exceeding the maximum copayment amount will be reimbursed as "total high-cost medical care benefits."
In addition, when the same individual receives treatment in two or more areas of medicine within a single calendar month, paying 21,000 yen or more for treatment in each area, and the total amount exceeds the maximum copayment amount, this amount exceeding the maximum copayment amount will be reimbursed as "total high-cost medical care benefits."
In either case, since Sony Health Insurance also provides additional benefits in addition to the total high-cost medical care benefits, the maximum amount paid by the individual in a given month is always 20,099 yen.


Reductions of costs for households with high-cost medical care over several months
When a household undergoes high-cost medical care four or more times in a single year, the maximum copayments amount will be reduced as follows beginning with the fourth time.
【Maximum copayment (montly) for persons less than 70years of age】
General income earners 44,400yen
High-income individuals
(Individuals with income of 530,000 yen or more per month)

83,400yen


【Maximum copayment (montly) for persons over 70years of age】
General income earners No reduction
Persons receiving income at the same level as before retirement  44,400yen
Low-income individuals
(Individuals exempted from residence tax)
No reduction
Reductions for individuals with specific conditions
The maximum copayment amount for hemophiliacs, individuals infected with HIV through blood coagulation factor medicines, and long-term patients with chronic kidney conditions are as follows.However, this maximum amount does not include pharmaceuticals obtained outside the hospital (i.e., from dispensing pharmacies).
The high-income individuals aged less than 70 who are long-term patients with chronic kidney conditions requiring dialysis (those with monthly incomes of 530,000 yen or above) 20,000yen
other people 10,000yen

In order to obtain these benefits, the patient must first obtain a Certificate of Special Condition from Sony Health Insurance and present it at the hospital together with his or her health insurance card. Be sure to conduct the related procedures if they apply.



Questions & Answers
Q1 What does "the total amount per individual on detailed statements" mean?

Medical institutions send "detailed statements of medical care" to Sony Health Insurance when requesting payment. They prepare these detailed statements for medical care costs for each area of medicine incurred during each month (from the first through the last days of the month). For example, assume you received internal medicine and surgical care from a hospital during one calendar month. In such cases, the hospital will prepare a detailed statement for each area of medicine for each month (i.e., a total of two detailed statements will be prepared) and send them to Sony Health Insurance.
The detailed statements sent to Sony Health Insurance also cover hospitalization and dispensing pharmacy prescriptions for each month.
Sony Health Insurance totals the medical costs per month per person based on these detailed statements for the calculation of additional benefits. Even if you did not pay more than 20,000 yen for a single visit, if the total of 2 or 3 of these detailed statements exceeds 20,000 yen, you will be eligible for additional benefits.


Q2 It says here that copayment reimbursements (for the insured) and dependent medical care additional sum (for dependents) are paid automatically and that no special procedures are generally required. How do I receive these benefits?

They are paid automatically with your salary. A "Notice of Payment Decision" sent to the insured about 4 months after medical care was received will indicate to which copayments and to which hospitals these benefits apply, how much was paid, and other specifics.

Q3 Are patients permitted to view these detailed statements?

If the insured or dependent patient requests, Sony Health Insurance will decide whether to allow provision of a copy of the detailed statement, based on the judgment of his or her physician (the physician for which the statement was prepared). (This is referred to as "a release of detailed statements.") However, the contents of these detailed statements are generally quite difficult to understand. Please consider carefully whether such release is necessary and the reasons for requesting such a release before submitting a request.

Procedural flow for release of detailed statements
1. Request by the patient for release of detailed statements
Contact Sony Health Insurance. We will send a request form.
2. Verification of release with the physician
Based on this request, Sony Health Insurance will confer with the physician concerning whether to release "all," " part," or "none" of the detailed statements.
3. Release (or non-release)
We will notify the patient based on the physician's decision.


Requests for release from individuals other than the patient
Requests for release of detailed statements will not be accepted from any individual other than the patient covered by the statement . Detailed statements for a dependent cannot be released to the insured individual.


Copyright 2003 Sony Health Insurance Society All Rights Reserved.