A person in their 70s, identified as A, was hospitalized for three months at a university hospital last year due to a spinal fracture. The total medical bill, excluding noncovered services, reached 92.09 million won. Of this, the National Health Insurance Service covered 76.03 million won, but A still had to pay 16.06 million won out of pocket.However, thanks to the out-of-pocket maximum program, the actual burden fell significantly. As the out-of-pocket payments at the same hospital during the admission exceeded the then-maximum cap of 8.26 million won, the excess 7.8 million won was paid directly by the insurer to the hospital. A initially paid only 8.26 million won.Later, in August this year, the post-settlement of the out-of-pocket maximum confirmed A's cap at the lowest level of 890,000 won based on A's income level. Accordingly, A was set to receive a refund of 7.37 million won, the difference between the 8.26 million won already paid and the 890,000 won cap.
About 2.26 million people who paid high out-of-pocket medical costs covered by health insurance last year will receive a total refund of 3.07 trillion won. The average refund per person is about 1.36 million won.
The Ministry of Health and Welfare and the National Health Insurance Service said they have finalized individual out-of-pocket caps for 2025 medical services and will begin the process of paying the excess starting on the 31st.
The out-of-pocket maximum program refunds the excess when a patient's health insurance-covered medical expenses over a year exceed the individual cap. Noncovered services and selective benefits are excluded. For 2025, the individual cap ranges from 890,000 won to 10.74 million won depending on income level and other factors.
This year's refund-eligible population is 2,262,605, up 5.9% from 2,135,776 in 2024. The payout is 3.07 trillion won, up 10.2% from 2.792 trillion won the previous year. Beneficiaries of the out-of-pocket maximum program have steadily increased from 1,749,831 in 2021 to 2,262,605 in 2025.
In particular, benefits concentrated on low-income and older adults.
Those in the bottom 50% by income numbered 2,016,503, accounting for 89.1% of the total. The amount paid to them is 2.3556 trillion won, or 76.6% of the total.
People ages 65 and older numbered 1,310,761, or 57.9% of all recipients. The excess paid to them totals 2.0596 trillion won, accounting for 67% of the total payout.
If the cap had already been exceeded at a medical institution, the insurer also paid the excess directly to the institution. A total of 27,742 people had out-of-pocket costs at the same provider exceeding the then-maximum cap of 8.26 million won, and the insurer made advance payments of 184.6 billion won to providers in connection with this.
The remaining eligible recipients can apply after receiving guidance from the insurer.
Starting on the 31st, the insurer will sequentially send guidance letters on applying for payment of excess out-of-pocket amounts to eligible recipients. Beginning this year, electronic documents are sent first via Naver, KT (PASS app), and KakaoTalk; those who do not use or view electronic documents are notified by mail.
Those who pre-registered a consent-to-payment account do not need to go through a separate application process. Of the 2,261,271 confirmed recipients, 1,312,819 (58%) will automatically receive excess payments to their pre-registered accounts starting Sept. 2, in stages.
Those who receive the notice can apply to have the payment sent to an account in their name through the insurer's website or the mobile app "Health Insurance 25 Hours," or via fax, phone, mail, or in person.
However, the program will change in part starting Oct. 8 this year. Under the revised National Health Insurance Act, if insurance premiums or health insurance-related charges are in arrears, the arrears may be deducted from the excess out-of-pocket payment before disbursement.