Japan's National Health Insurance (NHI) Explained: The Complete Guide for Foreigners (2026)

Moving to Japan comes with a long checklist. Apartment hunting, residence card registration, opening a bank account — and somewhere in that first week, a trip to your local ward office to sign up for National Health Insurance. For many foreigners, this is where the confusion starts.

What exactly is NHI? Do you have to join? How much will it cost? And what does it actually cover when you walk into a Japanese clinic?

This guide answers all of those questions in plain English. Whether you just arrived in Japan, recently left a company job and lost your employer coverage, or you are a freelancer trying to figure out the self-employed path — this is the complete breakdown you need.

What Is National Health Insurance (NHI)?

Japan runs a universal healthcare system. Every resident — Japanese citizen or foreign national — is required to be enrolled in some form of public health insurance. The two main systems are:

• Employees' Health Insurance (EHI / 健康保険, Kenkō Hoken): For people employed full-time by a company. Your employer handles enrollment and splits the premium cost with you.

• National Health Insurance (NHI / 国民健康保険, Kokumin Kenkō Hoken): For everyone else — the self-employed, freelancers, students, part-time workers, people between jobs, and dependent family members not covered under a company plan.

NHI is administered at the municipal level, meaning your city or ward office manages your enrollment, calculates your premiums, and issues your insurance card. The national government sets the rules, but the details vary slightly by location.

The core promise of NHI is simple: when you receive medical treatment at a covered facility, you pay only a portion of the bill (typically 30%), and NHI pays the rest directly to the provider.

Who Is Required to Enroll?

This is one of the most common questions among new arrivals, and the answer is straightforward: if you live in Japan on a valid residence status and are not covered by Employees' Health Insurance or another public scheme, you are legally required to enroll in NHI.

In practical terms, this means you must enroll if you are:

• Self-employed or a freelancer with no employer-based coverage

• A student on a student visa staying more than three months

• Between jobs — if you leave a company and lose EHI coverage, you must switch to NHI

• A part-time worker whose employer does not provide health insurance

• A dependent spouse or family member not certified under an EHI plan

• Newly arrived and not yet employed by a company that provides coverage

The minimum threshold for eligibility is a visa stay of more than three months. Tourists and short-stay visitors are not eligible. As of 2025, foreigners on a valid residence card who plan to stay longer than three months are included in Japan's Basic Resident Registration System and are subject to the same enrollment obligations as Japanese nationals.

Who is excluded from NHI?

You do not need to join NHI if you are already covered by Employees' Health Insurance through your employer, enrolled in the Late-Stage Elderly Medical Care System (age 75+), or if your home country has a social security agreement with Japan and you hold a valid Certificate of Coverage exempting you from enrollment.

The 14-Day Rule: Why Timing Matters

Once you have a qualifying reason to join NHI — arriving in Japan, leaving a company job, losing EHI coverage — you are legally required to complete enrollment at your ward or city office within 14 days.

This deadline is strict and has real financial consequences. If you delay, your enrollment can be backdated to the date you became eligible. That means you may receive a bill for retroactive premiums covering every month you should have been enrolled but were not. You will also have been uninsured during that gap, meaning any medical costs you incurred during that time would be your responsibility to pay in full.

The practical advice is simple: go to your ward office as soon as possible after you register your address. NHI enrollment is typically done at the same office on the same visit.

Step-by-Step: How to Enroll in NHI

The process is not complicated, but knowing what to bring and what to expect will save you time.

Step 1: Register Your Address First

Before enrolling in NHI, you must register your address at your local ward or city office (住民票, jūminhyō registration). This is your residential registration in Japan and is required before any other municipal services can be set up.

Step 2: Go to the NHI Counter

At the same ward office, locate the NHI counter — often labeled as the National Health Insurance Division or Insurance and Pension Section (保険年金課). During busy periods, there can be a wait, so arriving in the morning on a weekday is advisable.

Step 3: Bring the Right Documents

The standard documents required for enrollment are:

• Residence card (在留カード, zairyū kādo) — your primary ID

• Passport

• My Number card or notification slip — if you have received your My Number (個人番号)

• Proof of address — if not yet reflected in the system, your lease agreement or a utility bill can help

• Certificate of insurance termination (資格喪失証明書) — required only if you are switching from Employees' Health Insurance after leaving a job

• Move-out certificate (転出証明書) — if you recently moved from another municipality within Japan

If you have not yet received your My Number card, most offices will still process your enrollment and update the details later. Do not let the absence of a My Number card delay your application.

Step 4: Complete the Enrollment Form

The ward office will provide you with the NHI enrollment form (国民健康保険加入届). Staff are generally helpful, and many ward offices in major cities have multilingual support or English-speaking staff available. Fill out the form carefully, including details for all household members who will be enrolled.

Step 5: Receive Your Insurance Card

After processing — which is typically done the same day — you will receive your NHI card (国民健康保険証). This is one of your most important documents in Japan. Carry it with you whenever you visit a clinic, hospital, or pharmacy.

Important 2025 update: As of December 2, 2024, Japan stopped issuing traditional health insurance cards. Going forward, your My Number card functions as your health insurance card. If you do not have a My Number health insurance card set up, you will receive a Qualification Confirmation Notice that can be used at medical facilities in the meantime.

How NHI Premiums Are Calculated

NHI premiums are not a flat fee. They are calculated annually by your municipality using a formula based on your previous year's income and your household size. Rates are updated each fiscal year and vary from city to city, so the exact numbers below are illustrative rather than universal.

Your NHI premium is made up of three separate portions:

1. Medical portion (基礎分): The core premium that funds general medical care. Calculated using your income and a per-person flat rate.

2. Support portion (支援分): A contribution to the fund that supports the Late-Stage Elderly Medical Care System. Also income-based plus per-person rate.

3. Long-term care portion (介護分): Only applies to members aged 40 to 64. Funds nursing care services.

Each portion has a maximum cap. For Tokyo (2025), the caps are approximately ¥660,000 for the medical portion, ¥260,000 for the support portion, and ¥170,000 for the long-term care portion, bringing the total annual cap to around ¥1,090,000.

2025 Premium Example (Tokyo)

Note: Rates are based on Tokyo ward data for 2025. Premiums vary significantly by municipality. Use your city's official NHI calculator for an accurate estimate.

NHI premiums are billed to the head of household, even if the head of household is not personally enrolled in NHI. Payment is typically spread across 10 installments running from June through March of the following fiscal year. You can pay at a bank, post office, convenience store, or set up automatic bank transfer (口座振替), which is the most convenient method.

If you enroll mid-year, you will only be billed from the month you became eligible — not from the start of the fiscal year.

Premium Reductions: How to Lower Your NHI Bill

This is one of the most overlooked aspects of NHI, particularly among new arrivals. Japan has an official system for reducing premiums for low-income households, and many foreigners — especially students and people in their first year with low declared income — qualify for significant discounts.

Standard Low-Income Reduction

If your household's total income falls below certain thresholds, the per-capita and flat-rate portions of your premium are automatically reduced. The reductions are tiered:

• 70% reduction applies to households where total income does not exceed ¥430,000 plus ¥100,000 multiplied by the number of salary or pension earners

• 50% reduction for slightly higher income thresholds

• 30% reduction for households above those but still within qualifying ranges

These reductions are applied automatically when you declare your income. If you do not declare your income — even if it was zero — the office cannot calculate the reduction and will charge you the full base amount. Always declare your income, even if you earned nothing.

Students with Zero or Low Income

If you are a student with zero income, filing the income report when you enroll can reduce your premium dramatically. In Tokyo, a student with zero declared income can see the NHI annual cost reduced from around ¥30,000–¥40,000 down to approximately ¥10,000–¥15,000 per year.

Involuntary Unemployment

If you lost your job involuntarily — through redundancy, company closure, or the end of a fixed-term contract — you may be eligible for a special premium reduction. The income levy portion of your NHI premium can be calculated using 30% of your previous year's employment income rather than the full amount, which can dramatically reduce your bill for the year following job loss. Bring documentation of your unemployment status and the reason for leaving (such as a departure notice or employment termination letter) to your ward office.

Hardship and Disaster Exemptions

Municipalities also allow temporary reductions or exemptions in cases of financial hardship due to natural disasters, serious illness, or a sharp unexpected drop in income. These require an application and supporting documents, and decisions are made on a case-by-case basis.

What Does NHI Actually Cover?

NHI covers the majority of medically necessary treatment in Japan. The standard co-payment rate for most adults (ages 6 to 69) is 30% — meaning you pay three-tenths of the bill at the counter, and NHI pays the remaining 70% directly to the provider.

Co-payment rates by age

What is covered

NHI covers a broad range of services at registered clinics and hospitals:

• Doctor visits and consultations

• Hospitalization and surgery

• Prescription medications dispensed at registered pharmacies

• Emergency treatment

• Basic dental care (fillings, extractions, standard treatments)

• Lab tests, X-rays, and standard diagnostic procedures

• Prenatal check-ups (to a degree — see below)

• Childbirth lump-sum allowance (出産育児一時金): a one-time payment to offset delivery costs

What is not covered

NHI does not cover everything. Costs you will pay in full out of pocket include:

• Cosmetic procedures and plastic surgery

• LASIK and elective vision correction

• Routine dental procedures such as orthodontics, whitening, and implants

• Normal (uncomplicated) childbirth delivery costs (though the lump-sum allowance partially offsets this)

• Health check-ups and general physical examinations (unless medically necessary)

• Injuries sustained during work (these are covered by Workers' Accident Compensation Insurance instead)

• Traffic accident injuries (special procedures apply)

If you anticipate needing dental or vision care beyond basic coverage, supplemental private insurance is worth considering.

The High-Cost Medical Care Benefit (高額療養費)

One of the most important protections in the NHI system is the High-Cost Medical Care Benefit (高額療養費, Kōgaku Ryōyō Hī). This is a cap on how much you are required to pay out of pocket in a single calendar month, regardless of how large your medical bills are.

For a standard-income adult in 2025, the monthly cap is calculated as approximately ¥80,100 plus 1% of the amount by which the total bill exceeds ¥267,000. In practice, for most people facing serious illness or major surgery, total out-of-pocket costs in a given month will not exceed roughly ¥80,000–¥90,000, even if the medical bills run into the hundreds of thousands of yen.

To use this benefit effectively, apply at your ward office for a Maximum Ceiling Amount Applicable Certificate (限度額適用認定証). Presenting this certificate at the hospital or clinic at the time of treatment means you will only be charged up to your ceiling amount at the counter, rather than paying the full 30% upfront and applying for reimbursement afterward.

If you do not have the certificate, you can still apply for a refund after the fact — but the paperwork takes several months to process, and you need to front the money in the meantime. Getting the certificate in advance is strongly recommended for anyone facing planned surgery, hospitalization, or ongoing expensive treatment.

How to Use Your NHI Card at a Clinic or Hospital

Using your insurance in Japan is straightforward once you understand the process.

At a clinic or general practice:

Walk in (or book an appointment), present your NHI card at the reception counter, and confirm your co-payment category. After your consultation, you pay your share (30% in most cases) at checkout. Most clinics do not require advance payment or complex pre-authorization.

Picking up prescriptions:

If the doctor issues a prescription (処方箋, shohōsen), take it to any registered pharmacy. Present your NHI card again. You will pay 30% of the medication cost, and the pharmacy handles the rest.

Keeping receipts:

Hold onto your medical receipts (領収書, ryōshūsho) and itemized treatment statements. You may need them when applying for the High-Cost Medical Care Benefit reimbursement or when claiming medical expense deductions on your annual tax return.

Finding English-speaking care:

Major urban areas including Tokyo, Osaka, Kyoto, and Nagoya have clinics and hospitals with English-speaking staff. Smaller cities and rural areas generally do not. If you are in a city with limited English medical support, keeping your NHI card and a simple Japanese phrase card explaining your symptoms can go a long way.

Leaving a Job: Switching from EHI to NHI

This is one of the most common situations foreigners encounter and one that catches people off guard financially.

When you leave a company job in Japan, your Employees' Health Insurance coverage ends. Your employer will issue a Certificate of Insurance Termination (資格喪失証明書). You have two options at that point:

Option 1: Enroll in NHI. Go to your ward office with your termination certificate within 14 days and switch to NHI. Your premiums will be based on your previous year's income — which may be relatively high if you were earning a full salary. If you left your job involuntarily, apply for the reduced premium calculation described above.

Option 2: Continue your previous EHI plan voluntarily (任意継続). Under certain conditions, you can remain on your former company's health insurance plan for up to two years. The catch is that you now pay both your own share and the employer's share of the premium — meaning the cost roughly doubles compared to what was deducted from your salary. In some cases this is still cheaper than NHI for the first year if you had high income. Compare both options before deciding.

Moving Within Japan

If you move to a new city or ward, you must withdraw from your current municipality's NHI and enroll in the NHI of your new location. This is handled at the ward offices of both your old and new addresses as part of the standard move-out (転出) and move-in (転入) procedures. Your coverage continues without interruption as long as you complete the paperwork promptly.

Your NHI member number may change when you move, and your premiums will be recalculated based on the new municipality's rates.

Leaving Japan

When you leave Japan permanently or for an extended period without plans to return, you must notify your ward office and cancel your NHI enrollment. Failure to do so means premiums will continue to be charged as long as your resident registration remains active in Japan's system. Retroactive bills can accumulate, and unpaid NHI premiums can affect your ability to return to Japan on a new visa.

If you are leaving temporarily but plan to return, the procedures differ. Check with your ward office before departure.

Common Mistakes to Avoid

Waiting too long to enroll. The 14-day rule is not a suggestion. Backdated enrollment means backdated premiums and a period of uninsured risk.

Not declaring income. Even zero income must be declared to receive premium reductions. Skipping this step means paying the full base rate.

Assuming your card works everywhere. NHI works at registered (保険適用) medical facilities. Unregistered clinics, cosmetic clinics, and most dental specialty services operate outside the NHI system and charge full private rates.

Forgetting to cancel when you leave a job or move. Both situations require action at the ward office. Ignoring it leads to billing confusion and potential retroactive charges.

Not applying for the High-Cost Medical Care Certificate in advance. If you know you are going to hospital, apply for this certificate first. It prevents the need to pay large upfront sums and wait months for a reimbursement.

Frequently Asked Questions

Do I have to join NHI if I have private health insurance? Yes. Private health insurance — whether Japanese or international — does not substitute for NHI enrollment. They are not alternatives; they are supplements. Enrollment in NHI is mandatory for eligible residents regardless of other coverage.

Can I add my spouse or children to my NHI? Under NHI, each household member enrolls individually and is billed as a household unit. There is no "dependent certification" system like EHI. Your spouse and children will each be enrolled in NHI, and their per-person rate will be added to the household premium.

What if I miss the 14-day deadline? Go as soon as possible. The sooner you enroll, the less exposure you have for retroactive charges. Delaying further only increases the potential backdated premium bill and the uninsured gap.

Does NHI cover dental care? Basic dental treatments — fillings, standard extractions, root canals — are covered under NHI. Orthodontics, implants, teeth whitening, and most cosmetic dental work are not. For covered dental services, your co-payment is the standard 30%.

What happens if I cannot afford to pay my premiums? Contact your ward office proactively. Municipalities have hardship deferral and reduction programs. Ignoring unpaid bills is the worst option: continued non-payment can result in your insurance benefits being suspended, and eventually in wage or asset seizure.

Summary: Key NHI Facts at a Glance

Japan's National Health Insurance system is genuinely one of the best deals available to residents in the country. Access to a doctor visit for a few hundred yen, hospitalization with a hard monthly cost ceiling, and prescriptions at a fraction of their true cost — the coverage is broad and the out-of-pocket costs are predictable. The paperwork can feel overwhelming at first, but the enrollment process itself takes less than an hour at your ward office. Do it early, declare your income honestly, and check whether you qualify for a reduction. Your health — and your wallet — will thank you.

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