Act on Assurance of Medical Care for Elderly People

A Association of Medical Care Systems for the Elderly Aged 75 and older is to pay expenses related to benefits for medical treatment to medical institutions providing services covered by health insurance, etc., and the amount of expenses which a medical institution providing services covered by health insurance, etc. may claim from a Association of Medical Care Systems for the Elderly Aged 75 and older related to benefits for medical treatment is the amount calculated by deducting the amount of co-payment to be paid to the relevant medical institution providing services covered by health insurance, etc. with respect to the relevant benefits for medical treatment from the amount of expenses required for benefits for medical treatment calculated in accordance with the standards for calculation of the amount of expenses required for benefits for medical treatment set forth in paragraph (1) of the following Article.

A Association of Medical Care Systems for the Elderly Aged 75 and older may, with the authorization of the prefectural governor, specify otherwise in a contract with a medical institution providing services covered by health insurance, etc. with regard to the expenses required for the benefits for medical treatment set forth in the preceding paragraph pertaining to the benefits for medical treatment provided at the medical institution providing services covered by health insurance, etc., within the scope of the amount calculated pursuant to the provisions of the same paragraph.

When a medical institution providing services covered by health insurance, etc. requests payment of expenses related to benefits for medical treatment, the Association of Medical Care Systems for the Elderly Aged 75 and older is to make payment after conducting an examination in light of the standards for treatment and responsibility for benefits for medical treatment as set forth in paragraph (1) of the following Article, the standards for calculation of the amount of expenses required for benefits for medical treatment, and the provisions of the preceding paragraph.

The Association of Medical Care Systems for the Elderly Aged 75 and older may entrust affairs concerning the examination and payment under the provisions of the preceding paragraph to the Organization or the NHI federation.

A federation of national health insurance associations that is entrusted pursuant to the provisions of the preceding paragraph may entrust the affairs concerning the examination entrusted thereto, which pertain to the examination of medical bills specified by the Minister of Health, Labour and Welfare, to a corporation designated by the Minister of Health, Labour and Welfare as prescribed in Article 45, paragraph (6) of the National Health Insurance Act (hereinafter referred to as a "designated corporation").

A designated corporation that has been entrusted with the affairs concerning the review of medical bills specified by the Minister of Health, Labour and Welfare pursuant to the provisions of the preceding paragraph must have the review of the medical bills conducted by a person who satisfies the requirements specified by Order of the Ministry of Health, Labour and Welfare.

Beyond what is provided for in each of the preceding paragraphs, necessary matters concerning claims for expenses incurred in providing medical treatment at medical institutions providing services covered by health insurance, etc. are specified by Order of the Ministry of Health, Labour and Welfare.

The standards concerning the treatment and assignment of benefits for medical treatment and the standards concerning the calculation of the amount of expenses required for benefits for medical treatment are to be determined by the Minister of Health, Labour and Welfare after hearing the opinions of the Central Social Insurance Medical Council.

Notwithstanding the provisions of Article 2, paragraph (1) of the Social Insurance Medical Council Act (Act No. 47 of 1950), the Central Social Insurance Medical Council may deliberate on the particulars for which it has been asked for its opinion pursuant to the provisions of the preceding paragraph, and submit a report in writing, as well as make its own proposal in writing to the Minister of Health, Labour and Welfare with regard to the particulars prescribed in the same paragraph.

When the Minister of Health, Labour and Welfare or the prefectural governor finds it necessary in relation to benefits for medical treatment, the Minister or the governor may order a medical institution providing services covered by health insurance, etc., or a person who was an establisher or administrator of a medical institution providing services covered by health insurance, etc., a physician providing health insurance treatment, etc., or another employee (hereinafter referred to as a "former establisher, etc." in this paragraph) to make a report or to submit or present medical records and other books and documents, request the appearance of an establisher or administrator of a medical institution providing services covered by health insurance, etc., a physician providing health insurance treatment, etc., or another employee (including a former establisher, etc.), or have their official question the persons concerned or inspect the facilities, medical records, books and documents, and other articles of a medical institution providing services covered by health insurance, etc.

The provisions of Article 16-7, paragraph (2) and Article 66, paragraph (2) apply mutatis mutandis to questions and inspections pursuant to the provisions of the preceding paragraph, and the provisions of Article 16-7, paragraph (3) apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding paragraph.

When the prefectural governor finds that a disposition under the provisions of Article 80 of the Health Insurance Act needs to be made with respect to a medical institution providing services covered by health insurance, etc. in relation to benefits for medical treatment under the provisions of this Act, or that a disposition under the provisions of Article 81 of the Health Insurance Act needs to be made with respect to a physician providing health insurance treatment, etc. in relation to medical care or dispensing under the provisions of this Act, the prefectural governor must notify the Minister of Health, Labour and Welfare to that effect, stating the reasons.

The provisions of Article 64 of the Health Insurance Act apply mutatis mutandis to benefits for medical treatment under the provisions of this Act.

The Association of Medical Care Systems for the Elderly Aged 75 and older pays dietary treatment expenses for inpatients to an insured (excluding an insured who receives long-term hospitalization and medical treatment (referred to as a "long-term inpatient insured" in paragraph (1) of the following Article); the same applies hereinafter in this Article) for the expenses required for dietary treatment received together with the benefits for medical treatment listed in Article 64, paragraph (1), item (v) at a medical institution providing services covered by health insurance, etc. (excluding pharmacies providing services covered by health insurance; the same applies hereinafter in this Article and the following Article) of the insured's own choosing; provided, however, that this does not apply while the insured is subject to the provisions of Article 82, paragraph (1) or the main clause of paragraph (2).

The amount of dietary treatment expenses for inpatients is the amount calculated by deducting the amount specified by the Minister of Health, Labour and Welfare in consideration of the status of food expenses for an average household budget and the average amount of expenses required to provide meals at a specified nursing care insurance facilities, etc. (meaning a specified facility, etc. for insured long-term care prescribed in Article 51-3, paragraph (1) of Long-Term Care Insurance Act) (for a person specified by Order of the Ministry of Health, Labour and Welfare in consideration of income status and other circumstances, a separately determined amount; hereinafter referred to as the "standard co-payment for dietary treatment") from the amount of expenses calculated based on the standards specified by the Minister of Health, Labour and Welfare in consideration of the average amount of expenses required for the dietary treatment (when the calculated amount exceeds the amount of expenses actually incurred in the dietary treatment, the amount of expenses actually incurred).

If the circumstances pertaining to the matters to be taken into consideration have significantly changed after the Minister of Health, Labour and Welfare has determined the standard co-payment amount for dietary treatment, the Minister must promptly revise the amount.

A medical institution providing services covered by health insurance, etc. and a physician providing health insurance treatment, etc. (excluding pharmacists filling health insurance prescriptions; the same applies in paragraph (4) of the following Article) must handle or take charge of medical treatment pertaining to dietary treatment expenses for inpatients in accordance with the standards for the handling and taking charge of medical treatment pertaining to dietary treatment expenses for inpatients specified by the Minister of Health, Labour and Welfare.

When an insured has received dietary treatment at or from a medical institution providing services covered by health insurance, etc., the Association of Medical Care Systems for the Elderly Aged 75 and older may, on behalf of the insured, pay to the medical institution providing services covered by health insurance, etc. expenses incurred for the dietary treatment payable by the insured to the medical institution providing services covered by health insurance, etc., within the limit of the amount payable to the insured as expenses for dietary treatment for inpatients.

If a payment under the provisions of the preceding paragraph is made, it is deemed that dietary treatment expenses for inpatients are paid to the insured.

A medical institution providing services covered by health insurance, etc. must, when receiving payment of the expenses required for dietary treatment, issue a receipt to the insured who made the payment, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare.

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 under the provisions of paragraph (2) and standards concerning the treatment and taking charge of medical treatment pertaining to dietary treatment expenses for inpatients prescribed in paragraph (4).

The provisions of Article 71, paragraph (2) apply mutatis mutandis to the authority of the Central Social Insurance Medical Council concerning the particulars prescribed in the preceding paragraph.

The provisions of Article 64 of the Health Insurance Act and Article 64, paragraph (3), Article 66, Article 70, paragraphs (2) through (7), and Article 72 of this Act apply mutatis mutandis to dietary treatment received at or from a medical institution providing services covered by health insurance and to the payment of dietary treatment expenses for inpatients associated with that treatment. In such a case, Cabinet Order provides for the necessary technical replacement of terms in connection with these provisions.

With respect to expenses required for living support received by a long-term inpatient insured in combination with benefits for medical treatment listed in Article 64, paragraph (1), item (v) at or from a medical institution providing services covered by health insurance, etc. selected by the long-term inpatient insured, the Association of Medical Care Systems for the Elderly Aged 75 and older pays living support expenses for inpatients to the long-term inpatient insured; 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 long-term inpatient insured.

The amount of living support expenses for inpatients is the amount calculated by deducting the amount specified by the Minister of Health, Labour and Welfare in consideration of the amount equivalent to the base cost for food expenses prescribed in Article 51-3, paragraph (2), item (i) of the Long-Term Care Insurance Act and the base cost for residence expenses prescribed in item (ii) of the same paragraph with regard to the status of food expenses and light, heating and water utility costs for an average household budget and the expenses required for living support at hospitals and clinics (for a person specified by the Order of the Ministry of Health, Labour and Welfare in consideration of the status of income, the degree of pathological condition, the content of treatment and other circumstances, a separately specified amount; hereinafter referred to as the "standard co-payment for living support") from the amount calculated based on the standards specified by the Minister of Health, Labour and Welfare in consideration of the average expenses required for the living support (when the calculated amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses actually incurred in the living support).

When the circumstances pertaining to the matters to be taken into consideration have significantly changed after the Minister of Health, Labour and Welfare has determined the standard co-payment amount for living support, the Minister must promptly revise the amount.

Medical institutions providing services covered by health insurance, etc. and physicians providing services covered by health insurance, etc. must handle or take charge of medical treatment pertaining to living support expenses for inpatients in accordance with the standards for handling and taking charge of medical treatment pertaining to living support expenses for inpatients specified by the Minister of Health, Labour and Welfare.

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 under the provisions of paragraph (2) and standards concerning the treatment and assignment of medical treatment pertaining to living support expenses for inpatients prescribed in the preceding paragraph.

The provisions of Article 71, paragraph (2) apply mutatis mutandis to the authority of the Central Social Insurance Medical Council concerning the particulars prescribed in the preceding paragraph.

The provisions of Article 64 of the Health Insurance Act and Article 64, paragraph (3), Article 66, Article 70, paragraphs (2) through (7), Article 72, and paragraphs (5) through (7) of the preceding Article of this Act apply mutatis mutandis to living support received at or from a medical institution providing services covered by health insurance and to the payment of living support expenses for inpatients associated with the living support. In such a case, Cabinet Order provides for the necessary technical replacement of terms in connection with these provisions.