Medical Aid copays in South Korea
This calculator helps South Korean Medical Aid Type 1 and Type 2 recipients and their carers budget for one calendar month of covered care.
Medical Aid uses its own fixed copays, percentage shares, health-maintenance support and refund rules.
Applying ordinary National Health Insurance outpatient rates or income-decile annual ceilings can give a different answer.
This tool separates hospital and pharmacy copays, support deductions, monthly compensation and ceilings, and differential charges for outpatient visits above 365 per year.
Cash paid to a provider and refunds received later have different timing.
The results distinguish cash before refunds, the total calculated monthly refund and the cost after that total refund.
Use confirmed recipient status and billing records; the calculator does not decide benefit eligibility, diagnose a condition or recommend care.
It supports budgeting before admission, reviewing a month of receipts or preparing a discussion with NHIS and the local authority.
2026 jurisdiction and dates
These are South Korean rules for 2026, checked on 2026-10-04.
The Medical Aid Act Enforcement Decree version is effective 2026-01-01; the Enforcement Rule version is effective 2026-07-10.
Ordinary outpatient care follows current fixed-copay rules.
The earlier proposed 4% clinic, 6% hospital and 8% tertiary rates are not used.
Ordinary copays by recipient and provider
The table assumes ordinary covered care.
Percentage charges use covered gross costs before the patient share, rather than an already calculated patient payment.
Public health medical centers use the clinic group; public health centers, branches and posts use their separate exempt group.
Confirm the actual secondary or tertiary Medical Aid provider classification.
2026 South Korean Medical Aid ordinary copays| Care | Type 1 | Type 2 |
|---|
| Ordinary clinic outpatient | KRW 1,000 | KRW 1,000 |
| Hospital / general hospital outpatient | KRW 1,500 | 15% |
| Tertiary hospital outpatient | KRW 2,000 | 15% |
| Ordinary inpatient | KRW 0 | 10% |
| Pharmacy per prescription | KRW 500 | KRW 500 |
| Public health center / branch / post | KRW 0 | KRW 0 |
| Applicable CT / MRI / PET care | 5% | 15% |
A fixed copay cannot exceed the covered gross charges.
Applicable direct dispensing without a separate prescription uses Type 1 amounts of KRW 1,500 at a clinic, KRW 2,000 at a secondary provider and KRW 2,500 at a tertiary provider.
Type 2 clinic or qualifying chronic-condition secondary direct dispensing uses KRW 1,500; pharmacy direct dispensing uses KRW 900 per visit.
Pharmacy prescriptions issued by public health centers, branches or posts are exempt under ordinary rules.
Confirm mixed dispensing and prescription billing with the provider.
Enter gross charges and counts correctly
Outpatient and pharmacy
Group visits only when their conditions and covered gross amounts are the same.
Split differing charges into separate rows so fixed-charge caps and percentages remain meaningful.
Pharmacy count means prescriptions; use visits only for direct dispensing without a prescription.
A KRW 1,000 patient payment is not the covered gross amount.
Read the full covered-cost column of the itemized bill.
Admission and imaging
Enter the total gross charges for one admission with count 1.
For applicable CT/MRI/PET care, use the provider-confirmed percentage-based covered gross charges, excluding non-covered services.
Do not duplicate the same care as an ordinary fixed-copay row.
Separate drug purchase amounts or other billing conditions should be checked against the actual invoice.
Enter actual patient payments for non-covered care, meals, rooms, selective benefits and special fees as separate additional costs.
The calculator adds these amounts without multiplying them by the ordinary rate or including them automatically in monthly refund eligibility.
Enter other confirmed assistance for ordinary copays separately, including applicable disability or public-program support, to avoid counting the same cost twice.
Confirmed concessions and designated providers
Type 1 ordinary outpatient exemptions may apply to people under 18, pregnant recipients and eligible registered severe or rare/intractable conditions, among other statutory groups.
Select the exemption only after the provider confirms the status and the specific care it covers.
A diagnosis or age alone does not establish every billing exemption.
Dentures and implants have separate rules even when ordinary care is exempt.
Type 2 care-specific rules
- Use the confirmed exemption for care covered by the listed severe-disease rule.
- Eligible inpatient care under age 6 is exempt; eligible inpatient care at age 6–15 uses 3%.
- Eligible pregnancy percentage-based outpatient care and high-risk pregnancy inpatient care use 5%. The ordinary clinic fixed copay is not universally replaced by 5%.
- Only qualifying listed chronic-condition care at secondary providers uses the ordinary KRW 1,000 fixed copay. This does not apply to every chronic condition or tertiary hospital.
Type 1 direct outpatient care at the designated Medical Aid provider and pharmacy dispensing under that provider’s prescription can qualify for exemption.
Registration with a designated provider does not exempt all referral hospitals.
Enforcement Rule Article 19-4 effective 2026-07-10 distinguishes referred care, so mark direct care only on the relevant rows.
The 30% differential can apply even at the designated provider; exclusion from that differential needs its own confirmation.
The 30% share above 365 annual outpatient visits
From 2026, applicable outpatient visits above 365 per year have a 30% patient share of covered gross charges.
Use NHIS counts for January 1 through December 31.
Pharmacy prescriptions and inpatient episodes are excluded from the outpatient count in this screen.
Enforcement Rule Article 8-6 describes notices above 180, 240 and 300 visits and the procedure after exceeding 365.
Ordinary exemption and differential exclusion are separate
Check differential exclusion for children, pregnancy, listed severe disabilities, registered severe/rare/intractable/tuberculosis cases and unavoidable visits approved by the review committee.
Confirmed exclusion restores the applicable ordinary rules.
If excess visits are expected but the status remains uncertain, the final refund and net cost are withheld.
Do not use a budgeting result to stop necessary care; ask the Medical Aid case manager and treating provider about the required process.
Provider totals alone do not establish the chronology of excess visits.
Enter the confirmed 30% count for each row from NHIS and receipts, then reconcile it with the annual starting count.
Starting at 364 visits and adding 2 outpatient visits gives 1 expected excess visit.
If their charges differ, enter the dated, confirmed billing groups separately.
Differential-care charges are excluded from the ordinary monthly compensation and ceiling calculation.
Health-maintenance support and deduction allocation
Eligible Type 1 recipients receive monthly health-maintenance support of KRW 6,000 for outpatient copays.
The monthly allowance may differ from the amount available today because of previous deductions and carried balances.
Enter the actual balance from the virtual account or provider eligibility check.
The calculator does not apply this support to Type 2; support eligibility for exempt recipients must be checked separately.
Support can also pay differential-care copays
The 2026 Medical Aid Guide, pages 272–273, preserves support generation/payment for eligible recipients after differential treatment begins.
A designated-provider recipient subject to the differential may receive support from that month through year end.
The differential care still remains outside monthly compensation and ceilings.
Allocate the actual support deducted for 30% care first, then apply the remaining available balance to ordinary outpatient/pharmacy copays.
For ordinary copays of KRW 10,000, differential copays of KRW 30,000 and balance KRW 6,000, allocating KRW 2,000 to differential care leaves KRW 4,000 for ordinary care.
Eligible ordinary copays become KRW 6,000; differential cash becomes KRW 28,000, giving total cash KRW 34,000.
Care chronology can change the allocation and therefore the refund basis.
The tool does not calculate carried-balance refunds or retroactive deductions for past care.
Monthly refund formulas and the KRW 2,000 boundary
Eligible copay X equals ordinary outpatient/pharmacy and inpatient copays, less ordinary-care health support and other confirmed assistance.
Do not include separate non-covered/meals costs or 30% differential-care charges in X.
For 2026, the period is a calendar month from day 1 through month end, rather than a rolling 30-day period.
Type 1 monthly calculation
- X ≤ KRW 20,000: zero
- KRW 20,000 < X ≤ KRW 50,000: (X − KRW 20,000) × 50%
- X > KRW 50,000: X − KRW 50,000
These bands are alternatives rather than cumulative marginal refunds.
X = KRW 70,000 gives a KRW 20,000 refund, not KRW 35,000.
Type 2 monthly calculation
Monthly refund = max(X − KRW 200,000, 0) × 50%.
The annual KRW 800,000 ceiling requires annual records after monthly compensation.
Nursing-hospital admission above 240 days per year can use a KRW 1,200,000 ceiling; this monthly screen does not perform that annual settlement.
A calculated statutory refund below KRW 2,000 is not paid.
For Type 1, X = KRW 23,999 gives a whole-won estimate of KRW 1,999 and no payment; X = KRW 24,000 gives KRW 2,000.
X = KRW 50,000 gives KRW 15,000, while X = KRW 50,001 enters the upper alternative with a KRW 1 estimate and no payment.
The calculator does not smooth this legal boundary; compare actual payment treatment with the local authority.
Previously paid refunds are deducted once to show additional expected payment; when they exceed the estimate, additional payment is zero.
How to use and interpret the result
- Select recipient type and the provider-confirmed concession. Recheck special conditions and support when changing type.
- Verify earlier annual outpatient visits, differential/exclusion status and actual support balance.
- Enter provider rows, counts and covered gross amounts. Mark applicable imaging, chronic-condition fixed rules, direct dispensing and designated direct care only on their actual rows.
- Enter other support, refunds already paid for the care month and separate patient costs.
- Compare cash before refunds with cost after the total refund. Additional refund is the future amount excluding previous payments; do not add it to the total refund again.
- Save or print the review and reconcile it with provider, NHIS and local authority records. Saving a review does not submit or complete a claim.
‘Needs review’ does not mean zero cost.
Unconfirmed differential status, inconsistent counts, excessive support inputs or a concession incompatible with recipient type withhold the final result.
Correct the provider rows and confirmed status before relying on the displayed plan.
Worked fictional examples
Type 1 outpatient and pharmacy
4 clinic visits × KRW 1,000 = KRW 4,000; 2 general-hospital visits × KRW 1,500 = KRW 3,000; 6 prescriptions × KRW 500 = KRW 3,000.
Ordinary copays total KRW 10,000.
Deducting an actual support balance of KRW 6,000 leaves cash KRW 4,000.
Eligible copays remain below KRW 20,000, so compensation is zero.
This checks ordinary rules with sufficient covered gross charges and is not an average provider price.
Type 2 outpatient and admission
General-hospital outpatient gross charges KRW 100,000 × 15% give KRW 15,000.
Admission gross charges KRW 3,000,000 × 10% give KRW 300,000.
Eligible monthly copays total KRW 315,000; half of the KRW 115,000 excess above KRW 200,000 gives refund KRW 57,500.
Cost after the total refund is KRW 257,500.
If KRW 20,000 was already paid, additional refund is KRW 37,500 and cash after only that future refund is KRW 277,500.
Annual ceiling settlement is excluded.
Practical uses and excluded billing rules
A carer can reconcile clinic, hospital and pharmacy receipts with support deductions and monthly payments.
A Type 2 recipient planning admission can request an itemized estimate separating covered gross costs from meals and rooms.
Frequent outpatient users can check NHIS notices and exclusion registration with a Medical Aid case manager.
Outside this screen
- Income/assets and family-support eligibility decisions; full annual ceiling settlement
- Dentures, implants, Chuna therapy, special psychiatric fees and the large-hospital minor-condition pharmacy 3% rule
- Infant/premature-infant outpatient concessions not offered here, selective benefits and detailed meals/room rates
- Missing referrals, benefit restrictions and unapproved extension-related full or special patient payment
- Private insurance, tax credits, advance-payment recovery, improper benefit recovery and final claims review
Provider-confirmed patient amounts for excluded items can be added as separate costs for budgeting only.
Applying one ordinary rate to a mixed invoice may overstate support, so use itemized billing categories.
Percentage estimates floor each visit to whole won; actual billing rounding and later review adjustments can differ.
Inputs and medical details are not sent as custom analytics events or submitted to a server by this calculator.
Frequently asked questions
Is every Type 1 hospital bill free?
Ordinary inpatient covered care can be exempt.
Ordinary outpatient/pharmacy copays, meals, rooms, non-covered care and special services may still require payment.
Does a Type 1 clinic use 4%?
The current 2026 decree uses the ordinary KRW 1,000 fixed clinic copay.
The earlier proposed percentage reform is not treated as current law.
Does designated-provider status exempt a referral hospital?
Registration alone does not exempt every provider.
Distinguish designated direct care and its prescription pharmacy from care at another referred institution.
Does every Type 2 chronic condition use KRW 1,000?
The fixed rule is limited to listed chronic-condition care at secondary providers.
Tertiary care or care for a different condition needs its applicable ordinary rate.
Can health support pay copays above 365 visits?
The 2026 guide describes continued support for eligible differential-care recipients.
Enter actual deductions for that care, while excluding its 30% charges from monthly refunds.
Does Type 1 eligible cost KRW 70,000 refund KRW 35,000?
The calculator uses Article 13’s alternative upper band: KRW 20,000 over the KRW 50,000 ceiling.
It does not add KRW 15,000 from the lower band; confirm final payment with the local authority.
Does it calculate the Type 2 annual KRW 800,000 ceiling?
One month cannot establish annual records and nursing-hospital stay days.
After monthly compensation, ask NHIS and the local authority about annual settlement.
What if the cost is unknown or genuinely zero?
Initial zero costs represent an empty plan, not a free-care decision.
Add receipts or quotes; Needs review means final amounts are withheld pending confirmation.
Official evidence and next steps
The National Law Information OPEN API confirmed the current Medical Aid Act MST252715, Enforcement Decree MST280521 and Enforcement Rule MST288079 and their effective dates.
Evidence includes Decree Article 13 and Annex 1 (annex ID17832921), Rule Articles 8-6, 19-4 and 19-5 and Annex 1-2 (annex ID18284265).
Differential Notice No. 2025-248 has serial 2100000271124 and is effective 2026-01-01.
The 2026 Medical Aid Guide pages 272–275, 279 and 289–290 cross-check differential support, refund bands and maintenance support.
Recheck fixed copays, support amounts, designated-provider referrals and differential exclusions after the verification date if rules change.
Take the saved review and itemized receipts to the provider for covered scope, NHIS for visit counts/support deductions and the local authority for monthly payment history.
For ordinary National Health Insurance annual ceilings, use the separate calculator below; do not combine that result with Medical Aid.
Open the National Health Insurance ceiling calculator