Will the 2025 Out-of-Pocket Limit Change? Key Points on Refund Criteria and Income Levels

What is the co-payment limit?

The out-of-pocket maximum system is the annual medical expenses paid by the individual (based on medical expenses covered by health insurance).
This is a system in which the Ministry of Health and Welfare and the National Health Insurance Corporation refund the excess amount if it exceeds the individual limit.

The upper limit varies depending on your income level, with lower incomes receiving faster and greater benefits.

 

 

What will change from 2025?

Starting in July 2025, the reimbursement criteria and upper limit for the out-of-pocket maximum will be completely revised.

The upper limit for high-income earners will be raised, while the upper limit for middle- and low-income earners will be maintained or slightly reduced.
It is adjusted to strengthen equity and sustainability.

 

📈 Comparison of maximum amounts by income bracket

Income bracket	2024 cap	2025 cap
1~2nd quartile	About 880,000 won	About 890,000 won
3rd to 4th quartile	About 1.5 million won	About 1.5 million won
5th to 6th percentile	About 2.5 million won	About 2.5 to 2.6 million won
7th to 8th percentile	About 3.5 million won	About 3.47 to 3.96 million won
9th percentile	About 5.2 million won	About 5.21 million won
10th percentile	About 8.08 million won	About 8.26 million won
If the stay in a nursing hospital exceeds 120 days	No additional limit	Up to approximately 10.74 million won applied

 

Refund Methods: Prepayment vs. Postpayment

Advance pay:

Low-income class (1st to 5th quintile) If the upper limit is exceeded at the time of treatment, the patient does not have to pay directly.
This is how hospitals bill the National Health Insurance Corporation. This results in immediate savings.

 

Post-payment refund:

Middle and high-income class (6th to 10th percentile) After the deductible is accumulated at the end of the year,
The National Health Insurance Corporation will send a refund notice around August of the following year → Apply and receive a refund.
You may experience a high burden until the refund point, but you will ultimately be compensated.

 

Procedure and period for applying for a refund of the deductible limit

The National Health Insurance Corporation calculates whether there is an excess payment as of the end of August each year.

Sending a mail or app notification to those eligible for a refund

Apply online (health insurance app or website), by phone, by mail, by fax, etc.

 

Refunds will be processed within approximately 7 days of application.

 

Where can I apply for the co-payment limit?

🔗 Apply online

- National Health Insurance Service website: www.nhis.or.kr → Apply for a civil complaint → Apply for a refund of the maximum amount of your own share

- The Health Insurance App (available for download from the App Store)

 

☎️ Offline application

- Phone: National Health Insurance Customer Center 1577-1000

- Mail/Fax: Fill out the application form enclosed with the instructions and reply.

- Visit: Bring your ID to a nearby National Health Insurance Corporation branch and register.

 

※ Most eligible applicants will receive a mail notification from the Industrial Complex between August and September each year.
The fastest and most accurate way to apply is to refer to the instructions.

 

Key Summary

✅ The co-payment cap system is a system in which “if annual medical expenses exceed the income-based cap, the excess amount is refunded.”

👆 Starting in 2025, the refund criteria and upper limit will be adjusted, increasing the burden on high-income earners.

👇 Low-income earners will maintain their current level or be slightly more favorable.

🗓 Prepayment (low-income) vs. post-payment (middle- and high-income) structure

📌 The application process is not complicated, and most refunds are paid within a short period of time after August.

🌟 The 2025 self-payment ceiling standard and income bracket key points should be checked with a focus on the increased ceiling amount, application period, and refund method.

 

 

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