Catastrophic Medical Expense Support Is Decided by Your Insurance Premium, Not Your Income — the July 2026 Tables and the 100,000-Won, 180-Day and 50-Million-Won Limits

This is not the out-of-pocket ceiling programme

The two get conflated, but they work differently. The out-of-pocket ceiling system is a retrospective settlement: if your covered co-payments over a calendar year exceed a personal ceiling, the excess is refunded the following year. That one is covered separately in the piece on the out-of-pocket ceiling refund deadline.

Catastrophic medical expense support is different. It counts non-covered charges and full self-pay amounts as well, and pays a share of bills you cannot absorb now. It rests on the Act on Support for Catastrophic Medical Expenses, and the National Health Insurance Service administers it. Eligible care is any condition for inpatient treatment; outpatient care qualifies only for serious conditions — cancer, cerebrovascular and cardiac disease, rare disease, severe intractable illness and severe burns.

The cut is made on premiums, not income

This is where most people go wrong. The Service does not compute an income percentile. It takes your premium and checks it against a table indexed by household size. The thresholds in Schedule 3 of the notice are these.

Household size	Employee-insured household	Self-employed-insured household	Mixed household
1 person	92,180 won or less	20,950 won or less	-
2 people	150,960 won or less	87,970 won or less	153,910 won or less
3 people	192,650 won or less	137,180 won or less	197,190 won or less
4 people	233,480 won or less	177,040 won or less	240,450 won or less
5 or more	271,660 won or less	226,340 won or less	280,990 won or less

There is also an asset test. The household's combined property tax base for the relevant assets must be 700 million won or less. Note that this is the assessed tax base, not the published price or the market value.

Exceeding the threshold is not automatically the end. Schedule 3-2 of the notice creates an "additional eligible person" category that roughly doubles the premium ceiling, with support granted after deliberation by the catastrophic medical expense support committee. The catch is the spending threshold, which is far higher — see below.

How large the bill has to be

"15% of annual income" is the common explanation, but the notice actually fixes dedicated amounts by household size and premium band (Schedule 1). For a single-person household on employee insurance: the threshold is 1.2 million won at a premium of 46,090 won or less, 2.3 million won up to 64,520 won, 2.6 million won up to 78,350 won, and 3.3 million won up to 92,180 won. The lower your premium, the lower the bar.

Schedule 2, which applies to the additional eligible category, starts at 7.7 million won for the same single-person household. Before assuming that a near miss on the premium test will be rescued by individual review, look at that gap.

The payment rate is 80, 70, 60 or 50 percent

Not one figure either. Article 11(1) of the Enforcement Decree sets 80 percent for basic livelihood security recipients, the near-poor, people approved for reduced co-payments as rare or intractable disease patients, disability pension supplementary benefit recipients, and recipients of the disability allowance or disabled child allowance.

Everyone else falls under Article 11(2) and Schedule 4 of the notice, at 70, 60 or 50 percent. The determinant is again the premium. For a single-person employee-insured household, 46,090 won or less gives 70 percent, up to 92,180 won gives 60 percent, and the additional eligible band above that gives 50 percent. That is why two people with identical bills receive different amounts.

Three ceilings that rarely get mentioned

• Nothing under 100,000 won is paid. That is the proviso to Article 11(1) of the Decree. If the calculation lands below 100,000 won, no payment is made at all.
• Only 180 treatment days a year are counted. Article 11(3)1 limits support to care where inpatient days plus outpatient days total 180 or fewer in the year. For a long admission, this constraint binds first.
• The annual cap is 50 million won. The figure everyone quotes is not in the statute — it sits in Article 6(3) of the notice. Amend the notice and the number moves.

A fair amount is excluded from the total

Counting non-covered charges does not mean the whole receipt goes in. Article 2 of the notice lists the exclusions; these are the ones that bite in practice.

• Single-occupancy room charges — the cost of a room with one bed for one patient is excluded.
• Selective benefits — costs for selective benefit items under Article 18-4 of the National Health Insurance Act Enforcement Decree are left out.
• Charges incurred at convalescent hospitals — excluded as a rule, with an exception only where the care meets the highest-acuity benefit standard and the committee resolves that support is warranted.
• Cosmetic and elective procedures and other services, drugs and materials falling outside covered benefits.

Under Article 13(2) of the Decree, amounts already received or receivable from private indemnity insurance or another programme are also deducted. That is why the application asks for documentation of insurance enrolment and claims paid. If a convalescent admission is running long, it is worth checking the long-term care grading process at the same time.

180 days to apply — and three days before discharge

The deadline is in Article 2(1) of the Enforcement Rule: within 180 days from the day after the final treatment date, or the discharge date for an admission. Miss it by a day and the application is not accepted regardless of eligibility.

The step before that matters more. Article 5 of the Rule lets a patient still in hospital ask that payment go directly to the hospital, and sets the deadline at three days before discharge (or seven days for those qualifying under the general premium test). The Service notifies the outcome within the same number of days. Use this route and the money is deducted from the bill instead of being paid up front and reclaimed later. That is why the question belongs at the admissions desk or an NHIS branch before you start discharge paperwork.

If you disagree with the decision, you can file an objection with the Service, which must decide within 60 days (extendable by 30 where unavoidable). Different programmes have different desks for the same bill, so it is worth checking whether items with their own separate insurance coverage apply as well.

In order

Work through it like this. First, find this month's health insurance premium and your household size. Second, check it against the table above. Third, confirm the household's combined property tax base is 700 million won or less. Fourth, add up the out-of-pocket medical costs so far and see whether they clear the Schedule 1 amount. Fifth, if you are still admitted, request direct payment to the hospital three (or seven) days before discharge; if you have already been discharged, apply at an NHIS branch within 180 days of the day after discharge.

This article summarises the notice in force from 1 July 2026 together with the underlying statutory provisions. It does not determine any individual's eligibility or entitlement. Premium tables and payment rates change when the notice is amended, and the standard applied depends on the date of treatment, so confirm your own position with the National Health Insurance Service (1577-1000) or a local branch. Decisions about diagnosis and treatment belong to your medical team.