What is Medical Care for Self-Support? A Clear Guide to Eligible Individuals and Application Methods for Reducing Medical Expenses!

Are there many people with disabilities who are worried that "medical expenses are high and it's hard on the household budget"?

Having a disability often means needing to visit the hospital regularly, which can be a significant financial burden.

To alleviate such medical expenses, there is a system called "Medical Aid for Self-Support."

Medical Aid for Self-Support is a system designed to reduce the out-of-pocket medical expenses for those with physical or mental disabilities through public funding.

This time, we will clearly explain the eligibility, application process, and points to note when using the Medical Aid for Self-Support system.

Additionally, the personal experience of the author who actually uses this system is also included, so please use it as a reference.

1. What is Medical Aid for Self-Support?

As mentioned at the beginning, Medical Aid for Self-Support is a public funding medical system designed to reduce the out-of-pocket expenses for medical treatment and hospital visits for people with disabilities.

Previously, public medical funding systems were divided into three categories: rehabilitation medical care, developmental medical care, and mental outpatient medical care, each with different burden amounts and income-based limits.

This led to issues with uniformity due to differences in the types of disabilities and disparities between systems.

Therefore, based on the Act on the Independence of Persons with Disabilities, effective April 1, 2006, the Medical Aid for Self-Support system was implemented to unify the public medical funding system across different types of disabilities, setting the out-of-pocket expense as 10% in principle, with a monthly cap based on household income.

The Medical Aid for Self-Support system seeks fairness in medical expenses for people with disabilities and stability for long-term hospital visits by unifying the public funding ratio to 10%.

2. Types and Eligible Conditions for Medical Aid for Self-Support

While Medical Aid for Self-Support generally standardizes medical expenses to a 10% burden, the eligible disabilities and conditions are categorized into the following three types.

Let's take a look at the types of Medical Aid for Self-Support and the representative conditions that qualify.

2-1. Mental Outpatient Medical Care

Mental outpatient medical care is for those with mental disorders such as schizophrenia as stipulated in Article 5 of the Mental Health and Welfare Act, who require ongoing outpatient mental health care.

It can also be used for day care and home nursing visits, in addition to outpatient visits.

However, note that mental outpatient medical care does not cover hospitalization costs or medical expenses other than mental outpatient care.

Representative conditions and disabilities eligible for mental outpatient medical care include:

• Schizophrenia
• Depression
• Bipolar disorder
• Drug addiction and dependency
• Intellectual disabilities
• Developmental disorders
• Alzheimer's type dementia
• PTSD and other stress disorders
• Epilepsy

The above are representative conditions, and if long-term treatment is recognized as necessary for conditions like schizophrenia or depression, individuals may qualify as "severe and continuous" cases. In such cases, those from households subject to municipal tax can have a separate monthly cap to reduce their burden.

Reference: About Medical Aid for Self-Support (Mental Outpatient Medical Care) | Ministry of Health, Labour and Welfare

2-2. Rehabilitation Medical Care

Rehabilitation medical care is for individuals aged 18 or older who have received a physical disability certificate under the Act on Welfare of Physically Disabled Persons, and for whom surgery or treatment is expected to reliably remove or alleviate the disability.

Conditions and disabilities eligible for rehabilitation medical care include:

• Visual impairments
• Physical disabilities
• Hearing and balance disorders
• Heart function disorders
• Small intestine function disorders
• Speech, language, and chewing function disorders
• Immune function disorders (such as HIV or leukemia)

For example, cataract lens extraction surgery for visual impairments and tympanoplasty for hearing impairments are covered treatments.

Treatments for internal organ disorders related to the heart or small intestine are also eligible for rehabilitation medical care.

The disabilities introduced here are merely examples, and eligibility for rehabilitation medical care may vary depending on the disability status and treatment plan.

Even if a condition or treatment example applies, it does not necessarily mean it will qualify for rehabilitation medical care, so please be cautious.

2-3. Developmental Medical Care

Developmental medical care is for individuals under 18 years of age with physical disabilities, as stipulated in Article 4, Paragraph 2 of the Child Welfare Act, for whom surgery or other treatments are expected to reliably remove or alleviate the disability.

The eligible conditions and disabilities are the same as for rehabilitation medical care, but a physical disability certificate is not a requirement for developmental medical care.

Developmental medical care primarily aims to prevent future disabilities from remaining by addressing congenital disabilities or conditions that, if left untreated, could result in long-term disabilities.

For more detailed information on allowances and financial support available to children with disabilities under 18, please refer to

Reference:

3. Medical Aid for Self-Support Has Income-Based and "Severe and Continuous" Out-of-Pocket Expense Caps

The out-of-pocket expense for Medical Aid for Self-Support is generally 10%, but for low-income households and individuals with disabilities classified as "severe and continuous," a monthly cap is set to prevent an increase in out-of-pocket medical expenses.

The categories for the monthly cap are as follows:

Reference: Basic Framework of Patient Burden for Medical Aid for Self-Support | Ministry of Health, Labour and Welfare
Reference: Medical Aid for Self-Support | Tokyo Metropolitan Welfare Bureau

As a supplement, for those in the middle-income category using developmental medical care, even if they are not classified as high-cost treatment continuers ("severe and continuous"), transitional measures are in place until March 31, 2027, with the following monthly cap:

Income Tax-Exempt: 5,000 yen
Income Tax Less Than 300,000 yen: 10,000 yen

Additionally, for those with an income tax of 300,000 yen or more, who are generally not eligible for Medical Aid for Self-Support, if classified as "severe and continuous," a monthly cap of 20,000 yen is set as a transitional measure until March 31, 2027.

4. How to Apply for Medical Aid for Self-Support

4-1. Required Documents for Application

The documents required to apply for Medical Aid for Self-Support (in the case of mental outpatient medical care) are as follows:

• Application for Certification of Medical Aid for Self-Support
• Medical Aid for Self-Support Diagnosis Form ※Diagnosis by the attending physician (within 3 months from the application date)
• Consent Form and Household Situation Declaration
• Proof of health insurance (for national insurance, for the same household)
• My Number Card
  ※In addition to the above documents, a seal is also required.

The Application for Certification of Medical Aid for Self-Support can be downloaded from the website of each local government.

For those without a printer or internet access, application forms can also be obtained at municipal offices.

The diagnosis form must be created by the attending physician using the format specified by each local government.

Note that the diagnosis form used for the Medical Aid for Self-Support application is limited to those issued within 3 months, so please be careful.

Also, the issuance of the diagnosis form is not covered by health insurance, so it will be a full payment.

If applying as a "high-cost treatment continuer (severe and continuous)," a separate opinion form must be attached.

The Consent Form and Household Situation Declaration is a consent form for investigating the income of the individual and the household.

This can also be downloaded from the municipal website or obtained at the counter.

Proof of health insurance refers to any of the following:
(Please check the website of your local government as it may vary.)

・Traditional health insurance card
・Eligibility certificate or notification of eligibility information
・Printed screen showing health insurance card information from My Portal

Additionally, while it varies by municipality, it is advisable to bring your My Number Card as it is the most effective form of identification. If you do not have a My Number Card, bring a notification card with your individual number, a disability certificate, a driver's license, or other identification.

Reference: Tokyo Metropolitan Welfare Bureau | Changes to Applications for "Medical Aid for Self-Support (Mental Outpatient Medical Care)" Due to Abolition of Health Insurance Cards
Reference: About Medical Aid for Self-Support (Mental Outpatient Medical Care) | Tokyo Metropolitan Welfare Bureau

4-2. Application Process

The process for applying for Medical Aid for Self-Support is as follows:

1. Confirm that the hospital is a "designated medical institution for Medical Aid for Self-Support"
2. Request the attending physician to create a diagnosis form
3. Fill out the necessary documents at the municipal office (such as the social welfare department) and apply
4. Once the application is approved, a "Medical Aid for Self-Support Recipient Certificate" and a "Self-Payment Cap Management Form" will be issued

First, confirm whether the hospital is applicable to the Medical Aid for Self-Support system, then request the attending physician to create a diagnosis form.

The format of the diagnosis form varies by local government, so check with the municipal office or website in advance.

When applying, specify the hospital for outpatient visits and the pharmacy for prescriptions from the "designated medical institution for Medical Aid for Self-Support" set by each local government and fill in the necessary information.

Once the application is approved, a "Medical Aid for Self-Support Recipient Certificate" and a "Self-Payment Cap Management Form" for managing the monthly self-payment cap will be issued.

Once the amount recorded on the Self-Payment Cap Management Form reaches the monthly cap, any further medical expenses will be covered by public funding, and no payment will be required.

5. Points to Note When Using Medical Aid for Self-Support

5-1. Can Only Be Used at Pre-Designated Medical Institutions and Pharmacies

Medical Aid for Self-Support can only be used at pre-designated medical institutions and pharmacies.

For example, if you visit a hospital not designated at the time of applying for Medical Aid for Self-Support, the window will not charge 10%, but the usual 30%.

Also, if you visit for conditions or disabilities unrelated to Medical Aid for Self-Support, it will not apply, so be careful.

5-2. Documents Must Be Submitted Before Each Payment

To use Medical Aid for Self-Support, you must submit the "Medical Aid for Self-Support Recipient Certificate" and the "Self-Payment Cap Management Form" before each payment.

If you forget to submit the documents, the 10% burden will not apply, so make sure to bring them.

If you forget, consult with the hospital's reception to either pay after verifying the recipient certificate later or apply for a refund with the municipality.

When applying for a refund with the municipality, a receipt is required, so be sure to obtain one from the medical institution.

5-3. Has an Expiration Date (Renewal Required)

Medical Aid for Self-Support has a maximum validity of one year.

Additionally, the certification period for rehabilitation medical care is generally three months, but it can be extended up to one year based on the treatment progress and the appropriateness of the condition.

As the expiration date approaches, a renewal notice will be mailed to the address provided at the time of application by your local municipality.

5-4. Renewal Takes About Two Months After Application

The validity of Medical Aid for Self-Support is up to one year, but renewing it allows for continued reduction of out-of-pocket expenses.

Renewal requires gathering the necessary documents, just like a new application, and completing the procedure at the municipal office.

Regarding the physician's diagnosis form, submission is required once every two years for renewals.

Renewal takes about two months after application, which is quite a long period.

Renewal applications can be submitted starting three months before the expiration date, so it's best to apply as early as possible.

5-5. What to Do If the New Recipient Certificate Hasn't Arrived Before Your Appointment

Until the new recipient certificate arrives, present the copy of the Medical Aid for Self-Support application at the reception.

It takes about two months for Medical Aid for Self-Support to be approved.

During this time, a copy of the application will be issued at the municipal office, and many medical institutions and pharmacies will arrange to collect medical expenses after the recipient certificate is issued.

In other words, until the new recipient certificate arrives, the payment of medical expenses is deferred.

6. What the Author Using Medical Aid for Self-Support (Mental Outpatient Medical Care) Wants to Convey

The author of this article is a user of the Medical Aid for Self-Support system (mental outpatient medical care).

I learned about this system about three years after I started visiting a psychiatrist.

Although I knew about the system, I thought, "The application seems cumbersome," and "Even if the 30% burden is reduced to 10%, it might not make much difference," so I didn't apply.

However, when I finally decided to apply, thanks to the detailed explanation from the city hall staff, the application process was surprisingly smooth.

Now, I truly feel that the financial burden has significantly eased.

For those who visit frequently, the benefits of Medical Aid for Self-Support are even greater.

I recommend consulting with your doctor to see if your disability or condition qualifies