Health Insurance in Japan: Complete Guide for Expats

Key Takeaways

• Japan's health insurance premiums are rising in 2025 as costs grow – planning ahead is crucial.
• Public health insurance covers about 70% of medical costs (patients pay ~30% co-pay).
• 14-day deadline: New residents (or anyone switching jobs) must enroll within 14 days to avoid full medical bills.
• Typical premiums: A Tokyo full-time worker with a ¥470,000 monthly salary pays ~¥23,300/month (employee share), while a ¥3,000,000/year freelancer's NHI bill is ¥331,380/year (¥27,615/month).
• 2025 updates: National Health Insurance (NHI) caps and some rate changes take effect. For example, Tokyo's basic NHI cap rises to ¥660,000, and several prefectures increased their insurance rates.

Why Healthcare Costs Matter in 2025

Japan's universal healthcare system faces soaring costs as the population ages (≈29% are 65 or older) and medical spending grows. To keep the system solvent, the government has repeatedly raised premium limits – e.g. the NHI annual cap was set to ¥1.06M in 2024 and is up again for 2025. At the same time, Japan's foreign population hit a record high (~3.58M mid-2024), and all residents (Japanese and eligible foreigners alike) must join insurance. In contrast to past decades of stability, recent years have seen premium hikes and rule changes every year, so understanding the 2025 rules is critical. For comparison, major markets like the US use private insurance; Japan's public insurance system spreads costs across everyone.

Shakai Hoken (Employee Health Insurance)

Shakai Hoken is the mandatory social health insurance for full-time employees (and many part-timers). It bundles health coverage, pension, unemployment, etc. with premiums split 50/50 between employee and employer. The premium is calculated from your salary ("standard monthly remuneration") at the local rate. For example, Tokyo's 2025 Shakai hoken rate is 9.91% of salary. A worker earning ¥470,000/month sees a total premium of ¥46,577, half of which (¥23,288) comes from their paycheck.

Key points:

• Who pays: You and your company each pay half the premium.
• How it's calculated: Based on your monthly pay (and bonuses). The insurer (Association of Social Insurance) publishes rate tables each year. Tokyo's rate fell slightly from 9.98% to 9.91% in 2025.
• Example: A ¥400,000 salary in Tokyo yields an employee health insurance premium ~¥20,460/month (half of ¥40,918).
• Pitfall: If you leave your job (or start working), notify HR immediately. Once you start a new company job, you switch from NHI to Shakai. Failing to do so (or forgetting to cancel Shakai when unemployed) can lead to unpaid premiums.

Employees also have a small co-pay at the clinic: usually 30% of costs (20% for children or seniors). Shakai Hoken covers standard treatments (see Coverage below) in the same way NHI does.

National Health Insurance (Freelancers & Self-Employed)

NHI (Kokumin Kenko Hoken) is for self-employed people, students, unemployed spouses, etc. It is managed by local governments (city/ward) in Japan. You pay the full insurance premium yourself (no employer share). The annual NHI bill combines three portions – basic (medical), elderly-support, and long-term care – each with an income-based component and a fixed per-person component. Premium rates and caps vary by municipality, but Tokyo's 2025 example (Chuo Ward) is illustrative:

• Basic (medical) portion: Income rate 7.71% (down from 8.69%), plus ¥47,300 per person, capped at ¥660,000.
• Elderly-support portion: Income rate 2.69%, ¥16,800 per person, capped at ¥260,000.
• Long-term care (age 40–64 only): Income rate 2.25%, ¥16,600 per person, capped at ¥170,000.

For example, a single 30-year-old in Tokyo earning ¥4,000,000/year would pay about ¥660,000 (medical) + ¥160,000 (support) = ~¥820,000 total. Caps then apply. The effective rates tend to be high: e.g. a ¥3M income yields ~¥331,380/year in Tokyo (≃¥27,615/month). NHI premiums are paid by household and often billed in 10 installments from June–March.

Tip: Always report your actual income when enrolling. Most municipalities offer steep discounts for low earners or students. For instance, a student with ¥0 income in Tokyo can reduce a ~¥30,000 base to just ~¥10,000/year by filing a reduction form.

Pitfall: Unlike Shakai, NHI has no employer to split the cost. Many freelancers are shocked by their first bill. Plan your finances and apply for any low-income exemptions (they exist for children, unemployed, etc.).

International Students and Dependents

Foreign/International students: If you hold a student visa (3+ months) and are living in Japan, you are required to have health insurance and must enroll in NHI within 14 days of moving in. You register at the local city or ward office (bring passport, residence card, student ID, MyNumber). Students typically have very low income, so almost all of them qualify for huge premium reductions. For example, after declaring zero income, a Tokyo student might pay only ~¥10,000–¥15,000/year instead of ¥30–¥40k. If you work part-time, keep earnings under ¥1,300,000 (so you can stay a dependent) or report it properly. Some schools even offer private gap insurance to cover the 30% co-pay.

Domestic students/dependents: Usually remain on a parent's Shakai insurance if eligible (earning <¥1.3M). But if you live separately (e.g. university dorm), you often must join NHI yourself. The rules mimic those above: sign up quickly, file for reductions, and pay the minimal premium.

Tip: Always submit the income-report form when enrolling as a student. Municipal offices then apply automatic discounts (often 70–90% off the standard NHI fee).

Pitfall: Missing the deadline (14 days) or forgetting to re-apply after summer break can trigger retroactive charges. Keep an eye on your enrollment status if you change addresses or visas.

Coverage & Copays (What's Covered vs Not)

Japan's public health insurance covers most routine medical care under fixed co-pay rules.

Covered (70% paid by insurance): Doctor visits, hospital stays, surgeries, prescriptions, and basic dental (fillings, etc.). Common treatments like emergency care, X-rays, and lab tests are included. Preventive child vaccinations (the national schedule) are free.

Not covered (you pay 100%): Cosmetic or elective procedures (e.g. plastic surgery), most advanced dental (braces, dentures), non-prescription drugs, routine health checkups or vaccines not in the national program (e.g. travel shots). Maternity delivery costs are not billed through insurance – instead the insured mother receives a lump-sum ¥420,000 childbirth allowance. Elective infertility treatments, private-room fees, vision/hearing aids, and overseas care are also excluded.

Co-pays: Patients pay a fixed share at the counter. Generally: 30% for ages 6–69 (unless high-income), 20% for children (6–15) and seniors (70–74), and 10% for 75+. For example, a ¥10,000 clinic bill costs a ¥3,000 copay (if under 70). Importantly, high-cost protection caps your monthly out-of-pocket: once your co-pays exceed ~¥80–100k in a month, the rest is refunded (known as the 高額療養費 benefit). Always save receipts to claim this if needed.

In short: Japan's healthcare system handles illness and injury comprehensively, but you may need private health insurance or savings for non-covered services and the 30% share.

Best Practices (Avoid These Pitfalls)

Missing the 14-Day Deadline
Impact: You become technically uninsured. Any care in that gap is 100% your cost, and you'll be billed retroactively for missed premiums (often with interest).
Avoid by: Marking "住民登録＋NHI enrollment" on your moving-in checklist. Go to the ward office immediately after moving or job changes.

Underreporting Income
Impact: Your NHI premium is based on last year's income. Declaring less income than you earn (or not filing for discounts) can cause huge bills.
Avoid by: Always submit accurate income reports/forms at sign-up or yearly. Take advantage of automatic discounts for low-income households (most cities cut fees 50–80% for near-zero income).

Overlooking Dependent Coverage
Impact: You or a family member may pay twice. For example, a spouse could be covered as a dependent (no extra cost) or separately on NHI (costly).
Avoid by: Check eligibility: if you have a working spouse, verify if you can be added to their plan. If not (both self-employed), make sure you're listed under the same NHI household to combine benefits.

Optional table:

Risk/Mistake	Impact	How to Avoid
Delaying enrollment	No coverage; full-cost bills + back-pay penalties	Enroll within 14 days of moving/job change.
Failing to declare low income	High premiums (missed discounts)	File income report + reduction application.
Not verifying family coverage	Paying separate premiums unnecessarily	Check spousal/dependent status with HR or ward.
Ignoring coverage limits	Surprise out-of-pocket costs (e.g. maternity)	Plan for excluded costs; use special allowances.

Checklist: Enrolling & Managing Health Insurance in Japan

• Determine your coverage: Are you a full-time employee (Shakai Hoken) or else? If you work ≥20 hours/week for an employer, you get employer-based insurance. Otherwise plan to join NHI at your ward office.
• Gather documents: Passport, Residence Card, My Number card, proof of income (or last tax return), and if applicable, 資格喪失証明書 (insurance termination certificate) from your old job.
• Register promptly: Within 14 days of moving to Japan or changing jobs, visit your local city or ward office's insurance section. Complete the NHI enrollment form or inform HR for Shakai insurance.
• Submit income & claim discounts: Declare last year's income honestly. As a student or low earner, apply for reduction forms to cut your NHI fee. Many municipalities do automatic discounts once declared.
• Receive your health insurance card: You should receive your health insurance card (国民健康保険証 or 社会保険証) immediately. Check it for correct personal info.
• Pay premiums on schedule: NHI bills typically come in June (for previous year) then monthly until March. Choose a payment plan (lump sum or installments). Avoid late fees by using bank transfer or credit card.
• Keep your card handy: Whenever you visit a clinic or hospital in Japan, show your insurance card and pay only the copay (30% or less).
• Report changes: If your income changes significantly, or you leave/start a job mid-year, update the city/HR immediately. Premiums may be recalculated. Also report address or family changes (adding a child or spouse).
• Monitor bills: Verify your premium amount on the bill. Use online calculators or ask the ward office if uncertain. Confirm that children (under 6) and the unemployed are getting any waivers.

FAQ

Q: Are all foreign residents required to have health insurance?
A: Yes. Any foreigner with a proper visa (typically 3+ month stay) must enroll in either employer-based insurance or NHI. Health insurance is mandatory by law. If you work, your company signs you up. Otherwise, you must join NHI at your city office.

Q: What's the difference between Shakai Hoken and Kokumin Kenko Hoken?
A: Shakai Hoken (社保) is for employees of companies; the employer and you share the premium. It also covers health and pension and unemployment. Kokumin Kenko Hoken (国保) is for others (self-employed, students, non-working families). You pay the full premium based on your income and household. Both provide similar healthcare coverage, but NHI is managed by local governments while Shakai is via your employer's insurance provider.

Q: What if I miss the 14-day enrollment deadline?
A: If you delay enrollment, the law treats you as uninsured during that gap. You could be billed for the entire cost of any medical care you received and retroactively for the missed premium months. To avoid this, always notify the ward office (or HR) immediately when your situation changes.

Q: How are health insurance premiums calculated?
A: For Shakai insurance, premiums = standard salary × (premium rate) ÷ 2 (half borne by employee). For NHI, premiums = (income-based levy at ~7–9%) + (per-person flat fee) for each household member. Each portion has annual caps. Municipal websites often have simulators. For example, a ¥300万 income in Tokyo leads to about ¥331,380 yearly NHI (after household discounts).

Q: What medical expenses does insurance not cover?
A: Routine cosmetic services (e.g. elective cosmetic surgery, non-essential laser treatments) and many dental/orthodontic procedures are excluded. Vaccines outside the national schedule (like travel shots) and most vision/hearing aids also aren't covered. Maternity is covered by a lump-sum allowance, not pay-as-you-go. For any non-covered care, you must pay 100% out of pocket (or via private insurance).

Q: Can I add my family to my insurance?
A: If you're an employee, minor children and non-working spouses can often be listed as dependents under the company plan (no extra premium). If you're on NHI, your spouse and children must be part of your NHI household. Either way, you cannot arbitrarily switch – e.g. an adult spouse with own income cannot become your dependent. Always check with HR or the ward office to apply dependents correctly.

Conclusion

Japan's public health insurance (either via your employer or National Health Insurance) ensures access to medical care at reasonable cost, but it requires timely enrollment and accurate income reporting. By understanding the 2025 rates, deadlines, and coverage rules, international students, freelancers and full-time workers alike can avoid fines and minimize premiums – while still receiving the 70% coverage Japan's healthcare system guarantees.