|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.
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%.
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.
*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)
*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.
|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
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.
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]
|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
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
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
for which the statement was prepared). (This is referred to
as "a release of detailed statements.") However, the contents of these
are generally quite difficult to understand. Please consider
carefully whether such release is necessary and the reasons for requesting
a release before submitting a request.
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.|