Act on Assurance of Medical Care for Elderly People

When an insured receives evaluation treatment, patient-requested treatment, 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.

In 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)):

the amount calculated by deducting, from the amount of expenses calculated for the medical 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 the amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred in the medical treatment), the amount obtained by multiplying the amount of expenses 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 the same 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 the same paragraph for benefits for medical treatment, the amount calculated as if the measures were taken);

the amount calculated by deducting the amount of standard co-payment for dietary treatment from the amount of expenses calculated for the dietary treatment in accordance with the standards specified by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 74, paragraph (2) (when the calculated amount exceeds the amount of expenses actually incurred in the dietary treatment, the amount of expenses actually incurred);

the amount calculated by deducting the amount of standard co-payment for living support from the amount of expenses calculated for the living support in accordance with the standards specified by the Minister of Health, Labour and Welfare pursuant to the provisions of paragraph (2) of the preceding Article (when the calculated amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses actually incurred).

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 of medical expenses combined with treatment outside insurance coverage is the amount obtained by deducting the amount listed in item (ii) from the amount listed in item (i) (if the medical treatment includes dietary treatment, the sum of the amount so deducted and the amount listed in item (ii) of the preceding paragraph, and if the medical treatment includes living support, the sum of the amount so deducted and 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).

Medical institutions providing services covered by health insurance, etc. and physicians providing health insurance treatment, etc. must handle or take charge of medical treatment covered by medical expenses combined with treatment outside insurance coverage in accordance with the standards for handling and taking charge of medical treatment covered by medical expenses combined with treatment outside insurance coverage 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 for evaluation treatment (excluding those pertaining to advanced medical care techniques prescribed in Article 64, paragraph (2), item (iii)), selective treatment, treatment partially outside insurance coverage, standards pursuant to the provisions of paragraph (2), item (i) and paragraph (3), item (i), (a) and (b), and standards concerning treatment 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 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, paragraph (3), Article 66, Article 70, paragraphs (2) through (7), Article 72, and Article 74, paragraphs (5) through (7), and Article 64 of the Health Insurance Act apply mutatis mutandis to payment of evaluation 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 the relevant treatment. In this case, the necessary technical replacement of terms in these 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.

When a Association of Medical Care Systems for the Elderly Aged 75 and older finds it difficult to pay benefits for medical treatment, or expenses for dietary treatment for inpatients, living support expenses for inpatients, or medical expenses combined with treatment outside insurance coverage (hereinafter referred to as "benefits for medical treatment, etc." in this paragraph and the following paragraph), or when an insured has received any medical care, medication or treatment at or from hospitals, clinics, pharmacies or any other persons other than medical institutions providing services covered by health insurance, etc. and the Association of Medical Care Systems for the Elderly Aged 75 and older finds it unavoidable, it may pay medical expenses in lieu of benefits for medical treatment, etc.;provided, however, that this does not apply during any period for which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) of the same Article are applied to the insured.

When an insured 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 the Association of Medical Care Systems for the Elderly Aged 75 and older finds that the failure to receive that confirmation was due to an emergency or other unavoidable reason, it is to pay medical expenses in lieu of benefits for medical treatment, etc.; 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 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.

When an insured has received home-nursing (meaning care for medical treatment or necessary assistance with medical examination and treatment provided at the residence of an insured who is in a condition of continuously receiving medical treatment at home due to illness or injury (limited to an insured whom the attending physician has found to conform, as to the degree of necessity of the treatment, to the standards specified by Order of the Ministry of Health, Labour and Welfare) by a nurse or other person specified by Order of the Ministry of Health, Labour and Welfare; hereinafter referred to as "designated home-nursing") provided, by an office conducting the home-nursing business pertaining to the designation (meaning the home-nursing business prescribed in Article 88, paragraph (1) of the Health Insurance Act), from a designated home-nursing provider, the Association of Medical Care Systems for the Elderly Aged 75 and older pays the insured medical expenses for home-nursing for the expenses required for the designated home-nursing. However, this does not apply while the insured is subject to the application of Article 82, paragraph (1) or the main clause of paragraph (2).

The medical expenses for home-nursing referred to in the preceding paragraph are to be paid only if the Association of Medical Care Systems for the Elderly Aged 75 and older finds it necessary pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare.

When an insured intends to receive designated home-nursing, the insured is to, as provided by Order of the Ministry of Health, Labour and Welfare, receive confirmation of being an insured from the designated home-nursing provider of the insured's choice by electronic eligibility confirmation, etc., and receive that designated home-nursing.

The amount of medical expenses for home-nursing is the amount calculated by deducting, from the amount calculated in accordance with the standards specified by the Minister of Health, Labour and Welfare in consideration of the average home-nursing expenses (meaning the average expenses required for designated home-nursing) for the relevant designated home-nursing, the amount obtained by multiplying the relevant amount 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 the same paragraph (or, if any of the measures listed in the items of Article 69, paragraph (1) should be taken with respect to benefits for medical treatment, the amount calculated as if the relevant measures were taken).

When the Minister of Health, Labour and Welfare intends to specify the standards set forth in the preceding paragraph, the Minister must hear the opinions of the Central Social Insurance Medical Council in advance.

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.

If a designated home-nursing provider requests payment of medical expenses for home-nursing, the Association of Medical Care Systems for the Elderly Aged 75 and older is to pay the expenses after conducting an examination in light of the standards specified by the Minister of Health, Labour and Welfare as set forth in paragraph (4) and the standards for business management of designated home-nursing as prescribed in paragraph (1) of the following Article (limited to the part regarding the treatment of designated home-nursing).

The provisions of Article 70, paragraphs (4) through (7) and Article 74, paragraphs (5) through (7) apply mutatis mutandis to designated home-nursing received at or from a designated home-nursing provider and to the payment of medical expenses for home-nursing associated with the relevant service. In such a case, Cabinet Order provides for the necessary technical replacement of terms in connection with these provisions.

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 (4) in the case referred to in Article 74, paragraph (5) as applied mutatis mutandis pursuant to the preceding paragraph, the amount payable as medical expenses for home-nursing with respect to expenses incurred in the relevant designated home-nursing.

Designated home-nursing is not to be included in any of the types of medical treatment listed in the items of Article 64, paragraph (1).

Beyond what is provided for in the preceding paragraphs, necessary matters concerning the application of the calculation method specified by the Minister of Health, Labour and Welfare as set forth in paragraph (4) and a claim for medical expenses for home-nursing by a designated home-nursing provider are specified by Cabinet Order.