# health insurance back payments



## shallots

Not expecting an exact answer here but some kind of ballpark. Being a male in my 50s, having lived in Japan for many years and never joined the health insurance system, and making about 5,000,000 yen a year, and living in the Kansai area, my question is this: what can I expect to get out of a negotiation with the city in terms of monthly payments? People say you can negotiate the back payments. I've heard you've 3 years of back payments to make. I've heard you are looking at something around 10% of your salary for normal payments plus back payments. This sounds like a crazy amount of money to owe. Can anyone offer a clue to how to understand what might happen to me if I walk into a city office and ask them about this? And once I start asking, is it too late to back out? What's the range of fees people have negotiated or heard about? 
Finally, would I be better off with private insurance at this point? The only thing I worry about are big things.


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## BBCWatcher

Just to clarify, are you currently insured through an employer's plan? Did you recently stop working? If you're off, how long have you been off the employer's plan?

Also, what's your household size? If more than just you, is anyone else insured? If insured, how?


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## shallots

BBCWatcher said:


> Just to clarify, are you currently insured through an employer's plan? Did you recently stop working? If you're off, how long have you been off the employer's plan?
> 
> Also, what's your household size? If more than just you, is anyone else insured? If insured, how?


Thanks so much for your reply. I've been an "independent contractor" for years and, as such, I believe I was required to join the system for that category. So I've not been on any plan here. I am alone and uninsured. I'm thinking of joining a private plan. But the biggest concern I have is the long-term and the big issues. I don't have a retirement plan either, but that's another story. If I join the Japanese plan, maybe I'm covered until I'm old and it will be adjusted according to what I make when I get old. Whereas maybe a private plan will eventually become unaffordable? I've no idea how this works. I'be no head for this sort of thing. I ignored it, thinking it would go away. Now I'm starting to think it's no or never to resolve it. Of course, I also realize if something bad happened to me in Japan, they'd cover me and charge me the back payments anyway. What to do? I'm not willing to pay thousands of dollars a month to the Japanese government. At least right now.


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## shallots

"I've no head" "it's now or never"


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## larabell

This is just a guess but... in theory, at least... I would expect National Health Insurance to be cheaper than a private plan specifically because it's more-or-less mandatory. Everyone pays in rather than just those who figure they're at higher risk for getting sick. But it's worth comparing the two anyway. You should be able to get a ballpark figure for your salary range from your local ward office. I'd try to get the estimate first, before telling them your situation, just in case you do decide to go private.

Also make sure you look at benefits. In my case (covered through my employer but I believe the NHI basic plans work the same way) there's no annual deductible and I only pay my portion in cash at the time and the rest gets billed directly. Some (if not all) private plans would have you pony up the money when you receive the treatment, fill out some claim forms, and wait to be reimbursed. Unless the private plan is a lot cheaper, that seems like too much hassle. Your choices for health care may be limited if you have to search for a provider who can deal directly with your private insurance carrier.

As for anything big happening here... it's hard to imagine doctors would leave you to die after an accident simply because you don't have insurance. But it's not hard to imagine that they might simply bill you for 100% of the cost and *then* you'd still be stuck having to make those back payments in order to initiate coverage going forward. I think the back payment is more of a penalty than for retroactive coverage. Remember... the goal is to motivate people to sign up like they're supposed to so I doubt the government is going to let you slide for years and than only pay up once you've already incurred some huge medical bill you want them to pay.

One more catch is that, from what I've read, you're still required to sign up for NHI even if you're covered by a non-Japanese private plan so if you ever do decide to switch over to NHI, you may get stuck with those back payments anyway.


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## shallots

larabell said:


> This is just a guess but... in theory, at least... I would expect National Health Insurance to be cheaper than a private plan specifically because it's more-or-less mandatory. Everyone pays in rather than just those who figure they're at higher risk for getting sick. But it's worth comparing the two anyway. You should be able to get a ballpark figure for your salary range from your local ward office. I'd try to get the estimate first, before telling them your situation, just in case you do decide to go private.
> 
> Also make sure you look at benefits. In my case (covered through my employer but I believe the NHI basic plans work the same way) there's no annual deductible and I only pay my portion in cash at the time and the rest gets billed directly. Some (if not all) private plans would have you pony up the money when you receive the treatment, fill out some claim forms, and wait to be reimbursed. Unless the private plan is a lot cheaper, that seems like too much hassle. Your choices for health care may be limited if you have to search for a provider who can deal directly with your private insurance carrier.
> 
> As for anything big happening here... it's hard to imagine doctors would leave you to die after an accident simply because you don't have insurance. But it's not hard to imagine that they might simply bill you for 100% of the cost and *then* you'd still be stuck having to make those back payments in order to initiate coverage going forward. I think the back payment is more of a penalty than for retroactive coverage. Remember... the goal is to motivate people to sign up like they're supposed to so I doubt the government is going to let you slide for years and than only pay up once you've already incurred some huge medical bill you want them to pay.
> 
> One more catch is that, from what I've read, you're still required to sign up for NHI even if you're covered by a non-Japanese private plan so if you ever do decide to switch over to NHI, you may get stuck with those back payments anyway.


Thanks. From what I've heard, to join, you have to make back payments. The estimates vary wildly. Many people say you just negotiate it. But who knows how much that could end up being. My fear is that once I flag myself, then they will go ahead and enforce the mandatory provision. Some wards, in desperate straights, have been pretty draconian about collecting debts. But those cases involve families of people using the insurance and falling behind on payments. I've never heard of someone being reamed who's not actually signed up. But who knows as things continue to deteriorate financially in Japan. In any case, many people say the back payments are negotiable. I could see myself paying something like 6 or 7 man, painful as it is, if push comes to shove. But with three years of back payments I've no idea what they negotiating would be. I'm looking to hear from someone who's actually gone into the office and negotiated back payments. If I go in there, I'll need to pony up my information to get a quote. I don't want to give them a thousand dollars a month of my money. it's so high. On the other hand, I've no idea what my real options are. Private insurance is a heck of a lot cheaper. But yeah, it's more red tape and who knows what it covers when push comes to shove. My concern is what if something really bad happens. And, what if I needed expensive medication some day. And what happens when I get old? ON the other other hand, if I moved to another country some day then I'll need new coverage anyway...


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## BBCWatcher

larabell said:


> As for anything big happening here... it's hard to imagine doctors would leave you to die after an accident simply because you don't have insurance. But it's not hard to imagine that they might simply bill you for 100% of the cost and *then* you'd still be stuck having to make those back payments in order to initiate coverage going forward.


That's also my understanding of how it works. There's no retroactivity in coverage, only retroactivity in payments to get covered going forward. Which makes sense, of course, otherwise _everyone_ would do what you're (not) doing.

Shallots, are you planning to leave Japan relatively soon (within the next couple years, say)? In that case, private catastrophic medical insurance might make sense. If not, I'd go on national coverage now. Yes, that'll cost some money.


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## shallots

BBCWatcher said:


> That's also my understanding of how it works. There's no retroactivity in coverage, only retroactivity in payments to get covered going forward. Which makes sense, of course, otherwise _everyone_ would do what you're (not) doing.
> 
> Shallots, are you planning to leave Japan relatively soon (within the next couple years, say)? In that case, private catastrophic medical insurance might make sense. If not, I'd go on national coverage now. Yes, that'll cost some money.


The question is: how much? I'm hoping someone who's been through it could give me some idea. Everyone says you negotiate. I can't get myself to walk in the door if I've no idea what will happen.


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## BBCWatcher

Well, let's look at something similar to the "worst case." Let's assume:

1. Current premium rates with no penalties or interest. (A safe assumption, I think.)
2. Steady 5 million yen per year income.
3. You're starting from at least age 40. (Premiums are lower below age 40.)

With those assumptions, and also with the assumption my math is correct, the premium is/was 513,546 yen per year. So if you've got 10 years of back premiums to cover, _with the above assumptions_ it'd be about 5.1 million yen to get caught up -- equivalent to one year of income, roughly.

I don't think there are too many people who have waited as long as you have, so you're probably in seldom navigated waters especially within your locality. And really nothing else will matter except the amount you're asked to pay to get caught up. It won't particularly matter what somebody else was quoted somewhere else. The law _allows_ collecting per the above. (And this is a tax. In principle, as I understand it, the law appears to allow asset seizure to collect the unpaid tax.)

Hence my question about whether you plan to leave Japan relatively soon or not. If not, I'm not sure what else you can do except see what catch up offer you get.


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## shallots

BBCWatcher said:


> Well, let's look at something similar to the "worst case." Let's assume:
> 
> 1. Current premium rates with no penalties or interest. (A safe assumption, I think.)
> 2. Steady 5 million yen per year income.
> 3. You're starting from at least age 40. (Premiums are lower below age 40.)
> 
> With those assumptions, and also with the assumption my math is correct, the premium is/was 513,546 yen per year. So if you've got 10 years of back premiums to cover, _with the above assumptions_ it'd be about 5.1 million yen to get caught up -- equivalent to one year of income, roughly.
> 
> I don't think there are too many people who have waited as long as you have, so you're probably in seldom navigated waters especially within your locality. And really nothing else will matter except the amount you're asked to pay to get caught up. It won't particularly matter what somebody else was quoted somewhere else. The law _allows_ collecting per the above. (And this is a tax. In principle, as I understand it, the law appears to allow asset seizure to collect the unpaid tax.)
> 
> Hence my question about whether you plan to leave Japan relatively soon or not. If not, I'm not sure what else you can do except see what catch up offer you get.


Thanks for your reply. From my understanding, this is not the way it works. For Japanese and foreigners, they want something like 3 years back payments but it's negotiable. I think quite a few people have been in the same predicament, actually. I'm hoping someone can give their story to provide us insight into how the negotiation might work and what kind of bill one could conceivably get stuck with. The first commenter here is probably right that they want to get people in the system. It isn't treated as a tax, as far as I know, via a vis something they will go after in the same way. I believe there was a directive some years back to deliberately not seek penalties from foreigners as a condition of visa even though insurance is a requirement by law. Many people are in flux and there has been some leniency. That could change and it's up to them. I am planning to be here for a while.


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## larabell

It's not likely you'll find anyone on the forum who has been through the process because most ex-pats are here on assignment and get their health insurance through their company. And there doesn't seem to be much official information on the web about back payments (which isn't surprising in Japan since situations that don't conform to convention always seem to be handled on a case-by-case basis). But poking around on the web a bit yielded a couple of interesting points.

First, most places seem to cap the back payments at 2~3 years. However, it also seems that the time period depends on where you live. Premiums are determined by your local ward/city office so you aren't likely to get an exact amount for either the back payments or the premiums going forward without visiting your local ward/city office. There doesn't seem to be a rule specifying how many years they can ask you to pay so that may be where the "negotiation" comes in. You should be able to get an estimate from them without telling them who you are. I believe the computation is based on your inhabitant's tax from the previous year so go in with that information and they probably won't have to look you up to find it.

Some have also reported better luck when first moving into an area. Apparently some officials don't care when you can to Japan... only when you first became eligible in their ward/city. I'm not entirely sure I believe those reports, but... it also wouldn't surprise me too much if it were actually possible to reset the clock by moving to a different ward/city. Until recently, these sorts of records were not centralized. However, the Japanese government is making moves to consolidate all this record keeping and associate it with a unique number that sticks with you no matter where you move (or, in theory, how many times you leave Japan and come back) so I don't see any upside to waiting any longer than necessary to get this straightened out.

But I agree with BBCWatcher... if you're planning on leaving soon, you could get by with simple coverage for any big medical issues that come up. If you're going to be here long-term, you probably want to get squared away with the system before they start putting two-and-two together and come looking for you.

It also might be worth noting that there was a plan a few years back to require proof-of-coverage in order to extend one's period of stay but that got shot down. However, it does suggest that the J-government knows there are holes in the system and that they're trying to close them over time.


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## BBCWatcher

I think we're all mostly in agreement, really. To reiterate, I was describing the "worst case" -- what the law _allows_, not your most likely outcome. I can't actually find where the law _requires_ a 3 year limitation on back NIH premiums, but obviously that'd be great if somebody could find such a provision since that'd constrain the "worst case."

If I were to speculate a bit, I suspect that a local authority would be less inclined, other things being equal, to limit the back premiums to 3 years (or less) when a particularly high income individual is getting caught up. The premiums are capped and don't increase once you hit a certain income level. Consequently I could easily imagine that any forbearance would be progressively less forthcoming as the individual's/household's income rises. At your relatively moderate ~5 million yen (roughly equivalent to US$42,220 as I write this) of income per year one would think forbearance would be relatively forthcoming if it exists, and it seems to be pretty common.

One point where we might disagree is in calling these NIH premiums (past or present) taxes. As far as I can determine, they fit at least the colloquial definition: obligatory payments to government that may or may not vary depending on individual circumstances and that are legally enforceable and collectible. It's a legal obligation to carry some form of medical insurance -- either _kenko hoken_ or _kokumin kenko hoken_ -- if you reside in Japan (as the applicable law defines residence). I consider such payments taxes, just as I would consider social security contributions to be taxes (the domestic/obligatory ones), but I suppose reasonable people can disagree. Note that a "tax" is not incompatible with personal benefit. When you pay NIH premiums you get public medical insurance coverage and benefits. Likewise, when you pay social security taxes you qualify for social security retirement benefits (among other benefits). "Tax" is not a pejorative term here.


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## shallots

Thanks Larabell and BBC both for taking by the time. I'll read over your posts more carefully this evening. If I thought I could get out of the back payments by moving, I just might do it - much as I'd hate to. The question of tax is interesting. If I'm not mistaken, the Supreme Court in the US considered this very point in its decision on "Obama-care." But my only point was I don't think the Japanese government is going after it like that yet.


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## larabell

shallots said:


> ... The question of tax is interesting. If I'm not mistaken, the Supreme Court in the US considered this very point in its decision on "Obama-care." But my only point was I don't think the Japanese government is going after it like that yet.


The opinion of the US Supreme Court isn't really relevant since the US has only enacted their version of NHI recently and a lot of the fine points of enforcement are still open for debate. In Japan, this system is pretty well entrenched. According to a number of sources I've read, NHI actually is considered a tax. Here's a quick quote from one such source:



> EHI premiums are split between you and your employer wherein you pay in the form of a monthly fixed premium deducted from your paycheck before taxes. However, if you are on the NHI program, your payments are classified as a tax. This is an important distinction because you are obligated to pay the tax on your own without your employer to deduct it from your pre-tax earnings. If you opt to skip out the tax for whatever reason city/prefectural government you can go to court and ask for a draft or lien on your bank account.


Of course, this isn't from an official government source -- most of the official sources are based on the assumption that people will simply sign up if they're told where and how. I have read accounts of ex-pats who signed up and then stopped making payments later being barred from extending their visas until they were caught up on back payments. That's in contrast to, for example, NHK license fees which, from what I've read, are almost never an issue when dealing with visas and Immigration. Of course, there's a difference between someone who has already joined the system and someone who has fallen through the cracks. But that's a subtle distinction, at best. It's widely believed that some of the more recent rule changes, like the Zairyu-card system and My Number, are attempts on the government's part to shake the tree, as it were, and find people who have slipped through the cracks when it comes to mandatory payments. It's interesting to note that of the limited things the J-government already admits will be linked to the My Number system initially, Social and Medical insurance are already on the list.

So while it's not likely that the government is enforcing NHI with as much vigor as they currently enforce income tax, there is no doubt in my mind that they can and, judging from recent systemic changes, that they intend to at some point.


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## shallots

larabell said:


> The opinion of the US Supreme Court isn't really relevant since the US has only enacted their version of NHI recently and a lot of the fine points of enforcement are still open for debate. In Japan, this system is pretty well entrenched. According to a number of sources I've read, NHI actually is considered a tax. Here's a quick quote from one such source:
> 
> 
> 
> Of course, this isn't from an official government source -- most of the official sources are based on the assumption that people will simply sign up if they're told where and how. I have read accounts of ex-pats who signed up and then stopped making payments later being barred from extending their visas until they were caught up on back payments. That's in contrast to, for example, NHK license fees which, from what I've read, are almost never an issue when dealing with visas and Immigration. Of course, there's a difference between someone who has already joined the system and someone who has fallen through the cracks. But that's a subtle distinction, at best. It's widely believed that some of the more recent rule changes, like the Zairyu-card system and My Number, are attempts on the government's part to shake the tree, as it were, and find people who have slipped through the cracks when it comes to mandatory payments. It's interesting to note that of the limited things the J-government already admits will be linked to the My Number system initially, Social and Medical insurance are already on the list.
> 
> So while it's not likely that the government is enforcing NHI with as much vigor as they currently enforce income tax, there is no doubt in my mind that they can and, judging from recent systemic changes, that they intend to at some point.


Yes, I wasn't suggesting it was relevant. That would be ridiculous. Just that it's interesting that so much controversy in the States came of the question. 
Yes, I'm already terrified by My Number and my situation. That's one of the reasons I'm throwing this out there. I was hoping to get some answers here. I've noted the opinion above that it's unlikely a member here will have experience with this. Yet, I'm still holding out hope someone might have had a brush with this process and can add specifics. Unlikely as it is, this is the internet... While most people have resolved this issue, I also know I am not the only one like this. Let's see. Maybe someone will come along who went through it. We might get lucky. In any case, I appreciate the effort from you and the other posters to add context.


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## BBCWatcher

larabell said:


> The opinion of the US Supreme Court isn't really relevant since the US has only enacted their version of NHI recently and a lot of the fine points of enforcement are still open for debate.


I quite agree. It really doesn't help to compare two different legal systems here.

But if you really want to compare, the better comparison is with U.S. Medicare, also a single payer system, also limited to particular cohorts of individuals on both the contribution and benefit sides. _Different_ cohorts than the Japanese National Health Insurance system, of course. U.S. Medicare contributions are taxes, too. They're compulsory (for those who owe them, and most workers in the U.S. owe them), they're collectible, they're enforceable -- including via tax liens and such.

I've seen much the same information Larabell has, and from multiple sources, with respect to the not-so-pleasant aspects of NIH tax enforcement (e.g. legally permitted, government imposed tax liens and such). I tend to believe that information.

"Obamacare" is quite different than the Japanese system. Unlike Japanese law, the Patient Protection and Affordable Care Act ("Obamacare") doesn't require anybody to carry medical insurance of any sort. (It may be imprudent or even downright foolish to go without insurance at least if it's affordable, but it's not _illegal_ in the U.S. to go without.) However, the PPACA adds a higher rate of income tax called the Shared Responsibility Payment, administered and collected by the IRS, if you fail to have Minimum Essential Coverage (as the PPACA defines it) and if you don't have a qualified exception. Paying the Shared Responsibility Payment does not buy you medical insurance coverage. If you fail to pay your Shared Responsibility Payment if you owe it, then the IRS has some power to collect it. However, Congress somewhat limited the IRS's power to collect that part of tax owed. Unlike the Japanese system, the IRS does not have the legal authority to impose a tax lien on your assets if you only owe the Shared Responsibility Payment. The IRS can, however, deduct the Shared Responsibility Payment from your tax refunds, and it can assess interest and penalties on the outstanding balance.

One similarity is that _legally_ the tax owed can run forever (unless you've filed, and then the statute of limitations kicks in), even into your estate when you depart the planet. I can't actually find a 3 year or 2 year limit in the law, but like Larabell I've seen several references to that being a common forbearance offer. The IRS is fairly similar in that way: it _can_ agree to collect less than the law allows, but it doesn't have to.

Anyway, cross country comparisons really don't mean much here -- Japan is free to do as Japan does, and Japan is unique in so many ways -- but if you want to make such comparisons, that's a start.


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## shallots

Thanks BBC. I'm just hoping someone might stop by who knows someone who , or who them-self, has had to solve this problem. Perhaps I will get on the phone with the ward office and see if I can ask hypothetically. My pay fluctuates year to year and it'd probably be better for me to work this out based on last year than this year. I do worry that My Number will mean they'll eventually get into my bank account, although a Japanese friend of mine seems to believe it's impossible (I don't know why). I gather the rate is quite high in one's 50s. Anyway, again, I'd love to hear from anyone who has joined the "independent worker" system, especially someone who had to negotiate payments.


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