Before you start

Address registration completed
Residence card
Employment details, if enrolling through an employer scheme
My Number

Step-by-step

1
Establish which scheme you are in
Full-time employees are usually enrolled in shakai hoken by their employer, which splits contributions and includes pension. Everyone else — freelancers, part-timers, students, people between jobs — must enrol in National Health Insurance with the city themselves. There is no third option of being uninsured.
Via employerWho: YouWeek 1–2
2
Enrol with the city if your employer does not
Do it in the same visit as your address registration, at the city hall. National Health Insurance premiums are income-based and calculated on last year's income, so a first year in Japan is usually very cheap and the second is not.
In personWho: YouWithin 14 days
3
Understand the 30% co-payment and the monthly ceiling
You pay 30% of most treatment costs at the counter. Above a monthly threshold that scales with income, the high-cost medical expense benefit caps what you pay. Apply for a limit certificate in advance if you know a major treatment is coming.
In personWho: You
4
Work out how an ambulance would reach you
This is a genuinely Nagasaki question. If your home is up a stairway with no vehicular access, emergency services reach you on foot with a stretcher, and the time that adds is real. It is worth knowing the nearest point a vehicle can stop, and worth weighing if you have a chronic condition, are pregnant, or are considering a slope property for an older relative.
In personWho: You
5
Enrol in the pension and keep every record
Pension enrolment is compulsory alongside health insurance. Keep your pension book and all contribution records — they are what you need to claim the lump-sum withdrawal if you leave Japan.
In personWho: You
6
Claim the pension lump-sum withdrawal when you leave
If you leave Japan having contributed for at least six months, you can claim a lump-sum refund of part of your pension contributions, applied for within two years of departure. It is very commonly forgotten.
OnlineWho: YouWithin 2 years of leaving Japan

Documents you’ll need

Residence card
My Number
Health insurance card or registered My Number card
Pension handbook
Jūminhyō residence certificate

Things most newcomers don’t know

The high-cost medical expense benefit is what makes the 30% co-payment survivable.

Paying 30% of everything sounds alarming until you learn that monthly out-of-pocket costs are capped at a threshold scaling with income. A major operation or a long hospital stay costs a manageable amount rather than a catastrophic one. Applying for the limit certificate before a planned treatment means the cap is applied at the counter.

Source: Ministry of Health, Labour and Welfare

Access, not availability, is the local health question.

Nagasaki has a university hospital and a full set of prefectural facilities for a city its size, so specialist care is not the issue. Terrain is. A stairway-access house means an ambulance crew carries you down on foot, and a household weighing a cheap slope property should treat that as part of the price rather than an abstraction — it is one of the reasons those houses are cheap and one of the reasons so many stand empty.

Source: community-reported

The pension lump-sum withdrawal is real money and departing residents routinely forget it.

Anyone who contributed for at least six months can claim back part of their pension contributions after leaving Japan, applied for within two years of departure. It requires paperwork sent from abroad plus a Japanese bank account or a tax representative, so the groundwork has to be done before you go.

Source: Japan Pension Service

The city still administers survivor healthcare, and the associated research is world-class.

Nagasaki City issues and administers the Atomic Bomb Survivor's Health Handbook, which entitles holders to defined medical support — eighty years on, this remains a working municipal function rather than a historical one. Nagasaki University's Atomic Bomb Disease Institute and its Institute of Tropical Medicine, the only one of its kind in Japan, sit alongside the university hospital. None of this changes an ordinary newcomer's care, but it explains why a city of 390,000 has the research medicine it does.

Source: Nagasaki City; Nagasaki University