Act on Assurance of Medical Care for Elderly People

An insured who has received deliveryA Order of the Ministry of the Health, Labour and Welfare that has been issued a document as referred to in the preceding paragraph pursuant to the provisions of that paragraph, or provision by electronic or magnetic means ofthat has been provided with the matters specified byinformation that Order of the Ministry of Health, Labour and Welfareinsured prescribes which is referred to in that paragraph, by electronic or magnetic means may receiveobtain the confirmation under referred to in the main clause of Article 64, paragraph (3), main clause (including as applied mutatis mutandis in pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (6)7), and Article 82, paragraph (67)) or Article 78, paragraph (3) (including as applied mutatis mutandis in pursuant to Article 82, paragraph (67)) by presenting that document or those matters displayed by a method specified by something that indicates the information in a way that Order of the Ministry of Health, Labour and Welfare prescribes.

When a medical institution providing services covered by health insurance, etc. or a designated home-nursing provider (meaning the designated home-nursing provider prescribed in Article 88, paragraph (1) of the Health Insurance Act; the same applies hereinafter) has received, by deception or other wrongful acts, any payment of expenses relating to benefits for medical treatment or any payment pursuant to the provisions of Article 74, paragraph (5) (including as applied mutatis mutandis pursuant to Article 75, paragraph (7), Article 76, paragraph (67), and Article 78, paragraph (8)), the Association of Medical Care Systems for the Elderly Aged 75 and older may have the medical institution providing services covered by health insurance, etc. or the designated home-nursing provider return the amount so paid and, in addition, pay the amount obtained by multiplying the amount to be returned by forty one hundredth (40 / 100).

treatment using a pharmaceutical that is particularly highly substitutable for a pharmaceutical requiring guidance (meaning a pharmaceutical requiring guidance prescribed in Article 4, paragraph (5), item (iii) of the Act on Securing Quality, Efficacy and Safety of Products Including Pharmaceuticals and Medical Devices (Act No. 145 of 1960)) or an over-the-counter pharmaceutical (meaning an over-the-counter pharmaceutical prescribed in item (iv) of that paragraph), and other treatment for which, in view of the necessity of providing fair and efficient old-old medical care benefit while ensuring the provision of appropriate medical care, a part of the expenses required is not to be made subject to old-old medical care benefit, as specified by the Minister of Health, Labour and Welfare (hereinafter referred to as "treatment partially outside insurance coverage");

When making the determination under paragraph (2), item (vi), the Minister of Health, Labour and Welfare is to give consideration so that the treatment reflects the status of income, the degree of pathological condition, the content of treatment and other circumstances of the person who receives the treatment.

When an insured receives evaluation treatment, patient-requested treatment, or selective treatment, or treatment partially outside insurance coverage at or from a medical institution providing services covered by health insurance, etc. that it has selected, the Association of Medical Care Systems for the Elderly Aged 75 and older pays medical expenses combined with treatment outside insurance coverage to the insured for the expenses required for the treatment; provided, however, that this does not apply during any period to which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) of the same Article apply to the insured.

TheIn the case where a person receives evaluation treatment, patient-requested treatment, or selective treatment (excluding the case where the person receives treatment partially outside insurance coverage together with that evaluation treatment, patient-requested treatment, or selective treatment), the amount of medical expenses combined with treatment outside insurance coverage is the amount listed in item (i) (if the medical treatment includes dietary treatment, the sum of the amount and the amount listed in item (ii), and if the medical treatment includes living support, the sum of the amount and the amount listed in item (iii)):

Medical institutions providing services covered by health In the case where a person receives treatment partially outside insurance, etc. and physicians providing services covered by health insurance, etc. must handle coverage (including the case where the person receives evaluation treatment, patient-requested treatment, or take charge of medical selective treatment together with that treatment covered by partially outside insurance coverage), the amount of medical expenses combined with treatment outside insurance coverage in accordance with is the amount obtained by deducting the standards for handling and taking charge of medical treatment covered by amount listed in item (ii) from the amount listed in item (i) (if the medical expenses combined withtreatment includes dietary treatment outside insurance coverage specified by , the sum of the amount so deducted and the Minister amount listed in item (ii) of Health, Labour the preceding paragraph, and if the medical treatment includes living support, the sum of the amount so deducted and Welfare.the amount listed in item (iii) of that paragraph):

the amount obtained by deducting the amount listed in (b) from the amount listed in (a);

the amount of expenses calculated for that treatment (excluding dietary treatment and living support) in accordance with the standards specified by the Minister of Health, Labour and Welfare in consideration of the standards for calculation of the amount of expenses required for benefits for medical treatment prescribed in Article 71, paragraph (1) (when that amount exceeds the amount of expenses actually incurred in that treatment, the amount of expenses actually incurred in that treatment);

the amount calculated in accordance with the standards specified by the Minister of Health, Labour and Welfare as expenses not to be made subject to old-old medical care benefit, in consideration of trends in medical expenses, the financial status of old-old medical care, the circumstances of the person who receives the treatment, and other matters.

the amount obtained by multiplying the amount listed in the preceding item by the applicable ratio specified in the items of Article 67, paragraph (1) in accordance with the categories of the cases listed in the items of that paragraph (when the measures listed in the items of Article 69, paragraph (1) should be taken with respect to the co-payment set forth in Article 67, paragraph (1) for benefits for medical treatment, the amount calculated as if the measures were taken).

The Minister of Health, Labour and Welfare must hear the opinions of the Central Social Insurance Medical Council in advance, when the Minister intends to establish standards for evaluationMedical institutions providing services covered by health insurance, etc. and physicians providing health insurance treatment, etc. must handle or take charge of medical treatment (excluding those pertaining to advancedcovered by medical care techniques prescribed in Article 64, paragraph (2), item (iii)), selectiveexpenses combined with treatment, standards pursuant to the provisions of paragraph (2), item (i), and outside insurance coverage in accordance with the standards concerning treatmentfor handling and taking charge of medical treatment pertaining tocovered by medical expenses combined with treatment outside insurance coverage prescribed inspecified by the preceding paragraphMinister of Health, Labour and Welfare.

The provisionsMinister of Health, Labour and Welfare must hear the opinions of the Central Social Insurance Medical Council in advance, when the Minister intends to establish standards for evaluation treatment (excluding those pertaining to advanced medical care techniques prescribed in Article 7164, paragraph (2) apply mutatis mutandis , item (iii)), selective treatment, treatment partially outside insurance coverage, standards pursuant to the authorityprovisions of the Central Social Insurance Medical Council paragraph (2), item (i) and paragraph (3), item (i), (a) and (b), and standards concerning the particularstreatment and taking charge of medical treatment pertaining to medical expenses combined with treatment outside insurance coverage prescribed in the preceding paragraph.

The provisions of Article 64 of the Health Insurance Act and Article 6471, paragraph (3), Article 66, Article 70, paragraphs (2) through (7), Article 72, and Article 74, paragraphs (5) through (7) of this Act apply mutatis mutandis to payment of evaluation treatment, patient-requested treatment, and selective treatment received at or from a medical institution providing services covered by health insurance, and medical expenses combined with treatment outside insurance coverage associated with the relevant treatment. In this case,authority of the necessary technical replacement of terms in these provisions is specified by Cabinet OrderCentral Social Insurance Medical Council concerning the particulars prescribed in the preceding paragraph.

The provisions of Article 68 apply mutatis mutandis to the payment of the amount calculated by deducting, from the amount of expenses calculated pursuant to the provisions of paragraph (2) for the medical treatment in64, paragraph (3), Article 66, Article 70, paragraphs (2) through (7), Article 72, and Article 74, paragraphs (5) through (7), and Article 64 of the case set forth in Article 74, paragraph (5) as appliedHealth Insurance Act apply mutatis mutandis pursuant to the provisionspayment of the preceding paragraph (when the amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred), the amount payable asevaluation treatment, patient-requested treatment, selective treatment, and treatment partially outside insurance coverage received at or from a medical institution providing services covered by health insurance, and medical expenses combined with treatment outside insurance coverage associated with respect to the relevant treatment. In this case, the expenses incurred necessary technical replacement of terms in the medical treatmentthese provisions is specified by Cabinet Order.

The provisions of Article 68 apply mutatis mutandis to the payment of the amount calculated by deducting, from the amount of expenses calculated pursuant to the provisions of paragraph (2) or (3) for the medical treatment in the case set forth in Article 74, paragraph (5) as applied mutatis mutandis pursuant to the provisions of the preceding paragraph (when the amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred), the amount payable as medical expenses combined with treatment outside insurance coverage with respect to the expenses incurred in the medical treatment.

The amount of medical expenses is determined by the Association of Medical Care Systems for the Elderly Aged 75 and older based on: (a) the amount calculated by deducting, from the amount calculated for the medical treatment (excluding dietary treatment and living support) (in the case where a person receives treatment partially outside insurance coverage (including the case where the person receives evaluation treatment, patient-requested treatment, or selective treatment together with that treatment partially outside insurance coverage), the amount obtained by deducting, from that amount, the amount calculated in accordance with the standards under the provisions of Article 76, paragraph (3), item (i), (b)), the amount obtained by multiplying that amount by the applicable ratio specified in the items of Article 67, paragraph (1) in accordance with the categories of cases listed in the items of the same paragraph; and (b) the amount calculated by deducting, from the amount calculated for the dietary treatment or living support, the amount of standard co-payment for dietary treatment or standard co-payment for living support.

With regard to the calculation of the amount of expenses referred to in the preceding paragraph, the provisions of Article 71, paragraph (1) apply mutatis mutandis if benefits for medical treatment are to be received, the provisions of Article 74, paragraph (2) apply mutatis mutandis if dietary treatment expenses for inpatients are to be received, the provisions of Article 75, paragraph (2) apply mutatis mutandis if living support expenses for inpatients are to be received, and the provisions of paragraph (2) or (3) of the preceding Article apply mutatis mutandis if medical expenses combined with treatment outside insurance coverage are to be received; provided, however, that the amount may not exceed the amount of expenses actually incurred in the medical treatment.

If ana insured that is delinquent in the payment of insurance premiums (excluding ana insured that is eligible to receive payment of general medical expenses for illness under the Act on Assistance for Atomic Bomb Victims Survivors' Assistance Act (Act No. 117 of 1994) and other medical care benefits specified by Order of the Ministry of Health, Labour and Welfare (referred to as "payment, etc. of general medical expenses for illness caused by atomic bombsatomic bomb survivors, etc." in paragraph (45)); hereinafter referred to as a "person delinquent in payment of insurance premiums" in this Article) does not pay the insurance premiums during the period from the due date for payment of the insurance premiums until the expiration of the period specified by Order of the Ministry of Health, Labour and Welfare, even though a municipality has made efforts to encourage payment of the insurance premiums, to secure opportunities for consultation pertaining to the payment of the insurance premiums, and to contribute to the payment of the insurance premiums specified by Order of the Ministry of Health, Labour and Welfare (referred to as "encouragement, etc. of payment of insurance premiumsinsurance premium payment, etc." in the following paragraph and Article 92, paragraphs (1) and (2)), and when the person delinquent in payment of insurance premiums has received medical treatment from a medical institution providing services covered by health insurance, etc. or designated home-nursing from a designated home-nursing provider, the Association of Medical Care Systems for the Elderly Aged 75 and older pays to the person delinquent in payment of insurance premiums special medical expenses in lieu of benefits for medical treatment, or payment of dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, or medical expenses for home-nursing (referred to as "benefits for medical treatment, etc." in the following paragraph, paragraph (45), and paragraph (56)), with regard to expenses required for the medical treatment or designated home-nursing, except when it is found that there are special circumstances specified by Cabinet Order.

If a person delinquent in paymentThe amount of insurance premiums whospecial medical expenses is subject to the provisions of paragraph (1) or the main clause of paragraph (2) completes payment of the delinquent insurance premiums, or it is found that the amount of delinquent payment pertaining to the person has significantly decreased, or there are special circumstances specified by Cabinet Order, such as disasters, or amount listed in item (i) (or, if the relevant insured has become eligible formedical treatment includes dietary treatment, the payment, etc.sum total of medical expenses for atomic bomb-related general diseases,that amount and the insured that falls under these cases has receivedamount listed in item (ii); if the medical treatment from a medical institution providing services covered by health insurance, etc. or designated home-nursing from a designated home-nursing providerincludes living support, the Association of Medical Care Systems for the Elderly Aged 75sum total of that amount and older provides benefits for medical treatment, etc. to the relevant insuredthe amount listed in item (iii)).

the amount obtained by deducting, from the amount specified in each of (a) through (d) for the relevant case listed in (a) through (d) with regard to the medical treatment in question (excluding dietary treatment and living support), the amount obtained by multiplying that amount by the ratio specified in each item of Article 67, paragraph (1) according to the category of cases listed in the items of that paragraph (or, if the measures under each item of Article 69, paragraph (1) are to be taken with regard to the co-payment under Article 67, paragraph (1) pertaining to benefits for medical treatment, the amount on the assumption that those measures have been taken);

(a) in the case where benefits for medical treatment can be received: the amount of expenses calculated according to the standard for calculating the amount of expenses required for benefits for medical treatment prescribed in Article 71, paragraph (1) (or, if that amount exceeds the amount of expenses actually required for the medical treatment in question, the amount of expenses actually required for the medical treatment);

(b) in the case prescribed in Article 76, paragraph (2) where medical expenses combined with treatment outside insurance coverage can be received: the amount of expenses calculated according to the standard under the provisions of item (i) of that paragraph (or, if that amount exceeds the amount of expenses actually required for the medical treatment in question, the amount of expenses actually required for the medical treatment);

(c) in the case prescribed in Article 76, paragraph (3) where medical expenses combined with treatment outside insurance coverage can be received: the amount obtained by deducting the amount calculated according to the standard under the provisions of item (i), (b) of that paragraph from the amount of expenses calculated according to the standard under the provisions of item (i), (a) of that paragraph (or, if that amount exceeds the amount of expenses actually required for the medical treatment in question, the amount of expenses actually required for the medical treatment);

(d) in the case where medical expenses for home-nursing can be received: the amount of expenses calculated according to the standard specified by the Minister of Health, Labour and Welfare under Article 78, paragraph (4) (or, if that amount exceeds the amount of expenses actually required for the medical treatment in question, the amount of expenses actually required for the medical treatment);

the amount obtained by deducting the standard co-payment for dietary treatment from the amount of expenses calculated, with regard to the dietary treatment in question, according to the standard under the provisions of Article 74, paragraph (2) (or, if that amount exceeds the amount of expenses actually required for the dietary treatment in question, the amount of expenses actually required for the dietary treatment);

the amount obtained by deducting the standard co-payment for living support from the amount of expenses calculated, with regard to the living support in question, according to the standard under the provisions of Article 75, paragraph (2) (or, if that amount exceeds the amount of expenses actually required for the living support in question, the amount of expenses actually required for the living support).

When the Association of Medical Care Systems for the Elderly Aged 75 and older is to provide benefits for medical treatment, etc. pursuant to the provisions If a person delinquent in payment of insurance premiums who is subject to the provisions of paragraph (1) or the main clause of paragraph (2) completes payment of the preceding paragraph, delinquent insurance premiums, or it is to notify in advance, pursuant found that the amount of delinquent payment pertaining to the provisions of Order of the Ministry of Health, Labour and Welfare, an person has significantly decreased, or there are special circumstances specified by Cabinet Order, such as disasters, or if the relevant insured who falls under has become eligible for the case prescribed in that paragraph that, when payment of general medical expenses for atomic bomb survivors, etc., and the insured receives that falls under these cases has received medical treatment from a medical institution providing services covered by health insurance, etc. or designated home-nursing from a designated home-nursing provider, the Association of Medical Care Systems for the Elderly Aged 75 and older provides benefits for medical treatment, etc. will be providedto the relevant insured.

The provisions When the Association of Article 64 of Medical Care Systems for the Health Insurance ActElderly Aged 75 and Article 64, paragraph (3), Article 65, Article 66, Article 70, paragraph (2), Article 72, Article 74,older is to provide benefits for medical treatment, etc. pursuant to the provisions of the preceding paragraph (7) (including as applied mutatis mutandis, it is to notify in advance, pursuant to Article 78, paragraph (8)), Article 76, paragraph (2), Article 78, paragraph (3), Article 79, paragraph (2), Article 80, andthe provisions of Order of the Ministry of Health, Labour and Welfare, an insured who falls under the preceding Article of this Act apply mutatis mutandis to medical treatment or designated home-nursing pertaining to specialcase prescribed in that paragraph that, when the insured receives medical expenses received at ortreatment from a medical institution providing services covered by health insurance, etc. or a designated home-nursing provider, and to the payment of specialfrom a designated home-nursing provider, benefits for medical expenses incidental thereto. In this case, any necessary technical replacement of terms is specified by Cabinet Ordertreatment, etc. will be provided.

If a person delinquent in insurance premiums to whom the provisions of The provisions of Article 64, paragraph (3), Article 65, Article 66, Article 70, paragraph (1) or the main clause of2), Article 72, Article 74, paragraph (2) are 7) (including as applied would be subjectmutatis mutandis pursuant to the provisions of Article 78, paragraph (8)), Article 7778, paragraph (1) if those provisions were not applied, 3), Article 79, paragraph (2), Article 80, and the Association of Medical Care Systems forpreceding Article, and Article 64 of the Elderly Aged 75 and older may payHealth Insurance Act apply mutatis mutandis to medical treatment or designated home-nursing pertaining to special medical expenses received at or from a medical institution providing services covered by health insurance, etc. or a designated home-nursing provider, and to the personpayment of special medical expenses incidental thereto. In this case, any necessary technical replacement of terms is specified by Cabinet Order.

WhenIf a person delinquent in payment of insurance premiums who is subject to whom the provisions of paragraph (1) or the main clause of paragraph (2) has received medical care or medication from a medical institution providing services covered by health insurance, etc. without receiving confirmation of being an insured by electronic eligibility confirmation, etc., and are applied would be subject to the provisions of Article 77, paragraph (1) if those provisions were not applied, the Association of Medical Care Systems for the Elderly Aged 75 and older finds that the failure to receive that confirmation was duemay pay medical expenses to an emergency or other unavoidable reason, the Association is to pay medical expensesperson.

The provisions When a person delinquent in payment of Article 77, paragraphs (3) and (4) apply mutatis mutandis to the insurance premiums who is subject to the provisions of paragraph (1) or the main clause of paragraph (2) has received medical care or medication from a medical expenses pursuant to the provisions institution providing services covered by health insurance, etc. without receiving confirmation of the preceding two paragraphs. In this case, being an insured by electronic eligibility confirmation, etc., and the term "if the person is to receive" in paragraph (4) of Association of Medical Care Systems for the Elderly Aged 75 and older finds that the same Article is deemed failure to receive that confirmation was due to be replaced with "if an emergency or other unavoidable reason, the personAssociation is eligible to receive"pay medical expenses.

The provisions of Article 77, paragraphs (3) and (4) apply mutatis mutandis to the medical expenses pursuant to the provisions of the preceding two paragraphs. In this case, the term "if the person is to receive" in paragraph (4) of the same Article is deemed to be replaced with "if the person is eligible to receive".

In addition to the operations under the provisions of the National Health Insurance Act, a Federation of National Health Insurance Associationsan NHI federation performs the operations of examination and payment of claims for expenses required for benefits for medical treatment provided based on entrustment from an Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of Article 70, paragraph (4) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (67), and Article 78, paragraph (8)), as well as dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, and medical expenses for home-nursing.

Affairs that are to be administered by a prefecture pursuant to the provisions of Article 44, paragraph (4) (including as applied mutatis mutandis pursuant to Article 124, Article 124-8 and Article 10 of the Supplementary Provisions), Article 61, paragraphs (1) and (2), Article 66, paragraph (1) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (67), and Article 82, paragraph (67)) and paragraph (2) (including as applied mutatis mutandis pursuant to Article 72, paragraph (2), Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (67), and Article 82, paragraph (67)), Article 70, paragraph (2), and Article 72, paragraphs (1) and (3) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (67), and Article 82, paragraph (67)), Article 80, and Article 81, paragraphs (1) and (3) (including as applied mutatis mutandis pursuant to Article 82, paragraph (67)), Article 133, paragraph (2), Article 134, paragraph (2) (including as applied mutatis mutandis pursuant to Article 10 of the Supplementary Provisions), Article 152, paragraphs (1) and (3) (including as applied mutatis mutandis pursuant to Article 11, paragraph (2) of the Supplementary Provisions), and Article 88 and Article 89, paragraph (1) of the National Health Insurance Act as applied mutatis mutandis pursuant to Article 127 are deemed to be item (i) statutory entrusted function prescribed in Article 2, paragraph (9), item (i) of the Local Autonomy Act.

In addition to the affairs prescribed in Article 70, paragraph (4) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (67) and Article 78, paragraph (8)), the Association of Medical Care Systems for the Elderly Aged 75 and older may entrust the following affairs to the Organization or the NHI federation:

a person who is or was an officer or employee of a designated corporation that conducts a review of medical bills specified by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 70, paragraph (5) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (67), and Article 78, paragraph (8));

a person who conducts or used to conduct a review of medical bills specified by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 70, paragraph (6) (including as applied mutatis mutandis pursuant to Article 74, paragraph (10), Article 75, paragraph (7), Article 76, paragraph (67), and Article 78, paragraph (8)).