Cutting Medical Costs: The Out-of-Pocket Cap and Catastrophic Medical Expense Support

The diagram below is a self-made illustration, not a real screen.

If you paid a lot in hospital bills this year, check whether some of it can come back. Only information from official sources such as the National Health Insurance Service (NHIS) is included. For treatment decisions, talk to your doctor.

Who this suits

• People (and families) with high inpatient or outpatient costs this year
• People who received an NHIS refund notice
• People whose medical costs are large relative to income

Part 1: Out-of-pocket cap (본인부담상한제)

If your covered out-of-pocket costs from Jan 1 to Dec 31 exceed the cap for your income bracket, NHIS pays the excess.

2026 caps
| Income bracket | Cap | Long-term care hospital, 120+ days |
|—|—|—|
| 1st | 0.90M won | 1.43M won |
| 2nd–3rd | 1.12M | 1.81M |
| 4th–5th | 1.73M | 2.45M |
| 6th–7th | 3.26M | 4.04M |
| 8th | 4.46M | 5.80M |
| 9th | 5.36M | 6.98M |
| 10th | 8.43M | 10.96M |

Not counted: non-covered services, selective coverage, full self-pay items, implants, 2–3 bed room fees, Chuna therapy, minor outpatient care at tertiary hospitals, and the 90% self-pay portion for minor ER visits and outpatient visits over 365.

How it’s paid

• Advance: at a single hospital, once the year’s total exceeds the top cap (8.43 million won), the hospital bills NHIS for the rest. Long-term care hospitals excluded since 2020.
• Refund: if totals across hospitals exceed your personal cap, NHIS sets the cap around August of the next year after premium settlement and pays you the excess.

How to claim
1. Check the notice NHIS mails you.
2. Submit the claim via the NHIS website (after login), the 건강보험25시 app, phone 1577-1000, a branch, fax, or mail.
3. Payment to a family member’s or another person’s account requires a branch visit with a power of attorney, both IDs, and a family relation certificate.
4. Register a consent account so future refunds arrive automatically.

Part 2: Catastrophic medical expense support (재난적의료비)

Supports part of the costs for people who meet all criteria: illness, income, assets, and cost burden.

| Group | Threshold (out-of-pocket) | Rate |
|—|—|—|
| Basic livelihood recipients / near-poor | over 800k won | 80% |
| ≤50% of median income | over 1.2M (1 person) / 1.6M (2+) | 70% |
| 50–100% of median income | over 10% of annual income | 60% |
| 100–200% of median income | case review | case review |

• Assets: 700 million won or less.
• Limits: 180 days a year (inpatient + outpatient), up to 50 million won a year. Nothing is paid if the calculated amount is under 100k won.
• Excluded: cosmetic procedures, private rooms, caregiver fees, etc. Government aid and private indemnity insurance payouts are deducted first.
• For care from July 1, 2026: minor conditions (e.g., hypertension, diabetes, colds) excluded; 2–3 bed room fees excluded except for the 7 major severe diseases; managed-coverage items excluded; bills under 100k won excluded.

How to apply
1. Within 180 days after discharge (last treatment day), you or a proxy applies at an NHIS branch.
2. For direct payment to the hospital while admitted, apply 7 days before discharge (3 days for recipients/near-poor).
3. Documents: application, consent form, family relation certificate, private insurance papers, admission/discharge confirmation.
4. Contact: 1577-1000, 129.

Common mistakes

• Ignoring the refund notice
• Assuming non-covered costs count toward the cap
• Missing the 180-day deadline
• Forgetting to report private insurance payouts

Checklist

• ☐ Find your bracket’s cap
• ☐ Check the NHIS notice and claim
• ☐ Register a consent account
• ☐ Large bills? Check catastrophic support criteria
• ☐ Apply at a branch within 180 days with documents

For more money you may be missing, see our guide to finding hidden money.

We also have a $4.99 PDF guide that collects more everyday money-saving tips. Take a look if it’s useful →