PUBLISHED AUGUST 20267 MIN READ健康保険法 · 高額療養費 · 選定療養
TWO BENEFIT SYSTEMS · 給付の二系統WHO EACH ONE REACHES IS NOT THE SAME
REACHES THE INSURED AND DEPENDENTS
Medical benefits医療給付
Treatment itself, mostly in kind at the counter: 療養の給付 (care in kind), 療養費 (Medical Expenses — reimbursement where you paid in full), and 高額療養費 (the monthly ceiling).
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INCOME REPLACEMENT: INSURED PERSON ONLY
Cash benefits現金給付
傷病手当金 and 出産手当金 replace lost earnings and attach to the insured person alone. 出産育児一時金 and 埋葬料（費）reach the family but are not income replacement.
NEVER FOR A DEPENDENTAn 傷病手当金 or 出産手当金 is never paid to a dependent. The dependent flag does not fund an income-replacement benefit.
Benefits split into two systems. Medical benefits pay for the treatment itself — mostly in kind, at the counter — and reach the insured and their dependents alike. Cash benefits are paid in cash; some replace earnings lost while unable to work.
Within cash benefits, the income-replacement benefits attach to the insured person only. And before any of that, two gates: is this even a health-insurance matter, and can the person’s coverage be confirmed at the counter at all?
1
Two gates before benefits
給付の前に二つの入口
01 · HEALTH INSURANCE, OR 労災? そもそもどちらの制度か
Injury or illness from work or commuting goes to Industrial Accident Compensation Insurance, not health insurance. Non-work-related sickness and injury is a health-insurance matter. Use health insurance for a work injury and the treatment is later transferred onto 労災.
02 · CAN COVERAGE BE CONFIRMED? 資格確認ができるか
A My Number Card is not, in itself, a health insurance card. It works as one only once registered for that use — then called a マイナ保険証. Those without it are issued a 資格確認書 (Health Insurance Eligibility Confirmation Document) by the insurer. The old paper card stopped being newly issued in Dec 2024 and expired by Dec 2025.
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High-cost medical expenses, in three steps
高額療養費の3段階
1
You pay your share自己負担
At the counter you pay your co-payment — 30% for most.
2
A monthly ceiling月額上限
A cap set by age and income limits what you bear in a calendar month.
3
The excess is refunded高額療養費
Eligible insured co-payments above the applicable ceiling are reimbursed. Show a 限度額適用認定証 or マイナ保険証 in advance and the counter is capped from the start — no waiting for a refund.
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The cash benefits, separated
現金給付の内訳 — 所得補填かどうかで分かれる
傷病手当金 INJURY AND SICKNESS ALLOWANCENon-work-related sickness. From day 4 after 3 consecutive days off, about two-thirds of pay, up to 1.5 years. Insured person only.
出産手当金 CHILDBIRTH ALLOWANCEPaid around childbirth. Insured person only.
出産育児一時金 LUMP-SUM ALLOWANCE FOR CHILDBIRTH AND CHILDCAREA lump sum on childbirth. Reaches the family; not income replacement.
埋葬料（費） BURIAL CHARGESA payment on death. Reaches the family; not income replacement.
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Selective treatment
選定療養 — 紹介状なしの大病院受診
THE RULE
Visit a large hospital without a referral and a special charge applies on top of the ordinary bill — a representative floor is around ¥7,000 at first visit (medical), less on return.
WHY IT COSTS EXTRA
This 選定療養 charge is outside insurance — paid in full, with no 30% co-payment applied. It steers routine care to clinics and keeps large hospitals for referrals.
WHO IT APPLIES TO
Specified hospitals under the national referral system, including specified-function hospitals and certain 200+-bed regional or referral-focused hospitals. A referral letter avoids it.
The trap: “free at the counter” does not mean “an insurance benefit.” Free or subsidised care for children and free cancer screening are usually local-government schemes — funded and decided by the municipality, not paid by health insurance. Move to another city and they can change or vanish. Conversely, the 選定療養 surcharge is a cost that insurance deliberately does not cover.
FOUR EQUATIONS THAT DO NOT HOLD成り立たない四つの等式
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My Number Card ≠ health-insurance credential カード自体は保険証ではない（要利用登録）
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Work injury ≠ health insurance 業務・通勤災害は労災
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Dependent ≠ income benefits 傷病・出産手当金は本人のみ
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Free at counter ≠ insurance benefit 窓口無料＝保険給付とは限らない
FOR THE ENGINE
An income-replacement benefit must never resolve for a dependent.
Model benefits as two broad forms: medical benefits and cash benefits. Within cash benefits, distinguish income-replacement benefits (insured person only) from other cash benefits such as childbirth and burial benefits — the dependent flag does not fund the former. Gate access on confirmation of coverage, not on possession of a “card”: a My Number Card qualifies only when registered, else a 資格確認書 does the same job. High-cost benefit is a three-stage function — pay, then a ceiling keyed to age × income, then a refund of the excess — and an advance certificate collapses it to a capped counter. And keep a “free at the counter” value separate from “insurance benefit”: the first can be a municipal scheme or an outside-insurance charge, neither of which health insurance pays or reads.
WHO WRITES THESE
Wakana Chiba, Tokutei Sharoushi
Licensed Labor and Social Security Attorney in Japan
Wakana Chiba is a Tokutei Sharoushi — a nationally qualified and registered Labor and Social Security Attorney in Japan. She advises employers on Japanese employment law, workplace rules, working time, employment documentation, and labor and social insurance procedures, translating complex statutory requirements into policies and operations that work in practice.
Legal analysis and review of Japanese primary sources are performed by Wakana Chiba. English terminology is checked against the Japanese Law Translation Database and official MHLW materials. While AI may be used to draft initial texts, all published conclusions have been reviewed by the author.
TSUKURU-HR.COM / GLOBAL · COOKIE POLICY労災 = INDUSTRIAL ACCIDENT COMPENSATION INSURANCE · 高額療養費 = HIGH-COST MEDICAL EXPENSES (JLT) · CO-PAYMENT RATES, CEILINGS AND THE 選定療養 SURCHARGE CHANGE OFTEN; FIGURES ARE REPRESENTATIVE · AS OF AUGUST 2026 · GENERAL INFORMATION, NOT LEGAL ADVICE
