National Health Insurance in Japan: who joins, what it costs, what it covers

Forget open enrollment, networks and surprise bills. In Japan, if you live here for more than three months, you're in, and the government caps what a hospital stay can cost you.

The short version

• Foreign residents staying more than three months must join public health insurance: your employer's plan if you qualify, otherwise National Health Insurance (NHI) through your ward office [1][2].
• At the doctor or pharmacy you generally pay 30% of the bill; children and older people may pay less [1].
• NHI premiums are set by each ward. In Shinjuku for fiscal 2026, they're about 10.6% of last year's income (after a ¥430,000 deduction) plus per-person charges, with a household cap of ¥1.13 million a year [3].
• The high-cost medical expense benefit caps your monthly out-of-pocket costs; for many middle-income households in Tokyo it's about ¥85,800 plus 1% since August 2026 [4].
• NHI and the National Pension go together: if you're on NHI and between 20 and 59, you'll usually owe pension contributions too [5].

USD conversions use the Federal Reserve H.10 rate of October 30, 2026 (USD 1 = JPY 157.47), rounded.

NHI or employee insurance: which one are you on?

Japan has two main tracks [1]:

If you're working full time for a Japanese company, you'll almost certainly be on the employer plan and the payroll office will handle it. NHI is for people who aren't. That includes many Americans who freelance, teach privately, run their own business, study or retire here.

What about a US employer sending you over?

Under the US–Japan social security agreement, a worker temporarily sent to Japan by a US employer can be exempted from Japanese social security taxes, including health insurance in some cases [6]. The catch: the employer has to certify that you and your family have employer-sponsored or other private health insurance while in Japan, and if you're exempt you can't use the Japanese health insurance system [6]. Without that private coverage, you pay into the Japanese plan [6]. Talk to HR before you assume you're out.

How to join NHI in Tokyo

1. Register your address at the ward office first. See our guide to the residence card and My Number.
2. Ask to join NHI at the insurance and pension counter, usually at the same visit. Bring your residence card and My Number.
3. Declare your income. New arrivals with no Japanese tax record should fill in the ward's income declaration, which some wards use to apply low-income reductions to the per-person charge [7].
4. Get your proof of coverage. Japan stopped issuing old-style insurance cards on December 2, 2024 [8]. You'll use your My Number card at the clinic if you've registered it for health insurance, or a card-type eligibility certificate if you haven't [8].
5. Pay by bank transfer, convenience store slip or other options the ward offers.

Don't let premiums slide. An official NHI leaflet warns that long-term nonpayment can mean seized property, paying full costs at the clinic, and having your payment record considered when you renew your period of stay [2].

What it costs in Tokyo: FY2026 premiums

Each ward sets its own rates every April. Here are Shinjuku's for fiscal 2026 (April 2026 to March 2027), as an example [3]:

The income rate applies to your previous year's total income minus a ¥430,000 basic deduction (for incomes up to ¥24 million) [3]. Add up the caps and a household tops out at ¥1.13 million (about USD 7,180) a year [3].

Two quick examples

These are our own illustrative calculations from Shinjuku's published rates [3]:

• Your first year, no Japanese income on record, age under 40: the per-person charges alone come to about ¥67,000 (about USD 430) for the year, before any low-income reduction.
• Age 35, with ¥4 million of total income last year: about ¥378,000 in income-based premiums plus ¥67,000 in per-person charges, or roughly ¥445,000 (about USD 2,830) a year. Turn 40 and the long-term care portion adds more.

Notice the lag: premiums follow last year's income. If you had a big final year at a US job, you may find out what Japan thinks of it when your second-year bill arrives. Ask your ward which income it's counting.

What NHI covers, and the 30% co-pay

NHI covers doctor visits, hospital stays, prescriptions and most standard dental work at any clinic or hospital in Japan that takes public insurance, which is nearly all of them. There are no networks. You show your My Number card or eligibility certificate and pay 30% of the bill [1]. Young children and older people may pay a lower share [1].

What's not covered, in general: cosmetic procedures, checkups that aren't tied to an illness, and hospital extras such as a private room. Normal childbirth isn't treated as an illness either, so ask your ward what support it offers for having a baby.

The high-cost medical expense benefit

This is the safety net Americans tend to love most. If your out-of-pocket costs in a month pass a limit based on your age and income, the excess comes back to you [1].

The limits rose on August 1, 2026, and Japan added a new annual cap. Here's Minato Ward's NHI table for people 69 and under [4]:

Example: a ¥1 million hospital bill in the middle bracket. Your 30% share is ¥300,000 (about USD 1,900), but the cap is ¥85,800 plus 1% of ¥714,000, or about ¥92,900 (about USD 590). Minato says the limits will change again in August 2027 [4]. Before a planned hospital stay, ask your ward how to have the cap applied at the counter, so you don't front the full 30% and wait for a refund.

The pension link

When you join NHI, the ward will usually sign you up for the National Pension too, if you're 20 to 59 and not on an employer plan [5]. That's a separate bill on top of NHI: ¥17,920 a month (about USD 114) in fiscal 2026 (April 2026 to March 2027), according to the Japan Pension Service [9]. See our pension guide for the lump-sum refund when you leave.

The American angle

Japan's coverage doesn't follow you home, and Medicare generally doesn't follow you abroad, so think about the gap before you move back. Whether your Japanese premiums or medical bills count for anything on your US return depends on the usual IRS rules; a US expat tax preparer can check your situation. For English-speaking clinics and real-world experiences with ward offices, ask in our community group for Americans in Japan.

Sources

1. Tokyo Metropolitan Government, Bureau of Public Health: Medical insurance (English)
2. Ministry of Health, Labour and Welfare: National Health Insurance leaflet for foreign residents (English, PDF)
3. Shinjuku City: How NHI premiums are calculated, FY2026 (Japanese, updated April 1, 2026)
4. Minato City: High-cost medical expense limits from August 2026 (Japanese)
5. Japan Pension Service: National Pension (English)
6. Social Security Administration: US–Japan social security agreement
7. Chuo City: NHI income declaration (Japanese)
8. Inagi City: Use of the health insurance card with the My Number card
9. Japan Pension Service: National Pension premium, fiscal 2026 (Japanese)

Keep reading

• Healthcare and health insurance in Tokyo
• Japan's pension and the lump-sum withdrawal
• Your residence card and My Number in Tokyo
• Medicare when you live abroad