Act on Assurance of Medical Care for Elderly People

A Association of Medical Care Systems for the Elderly Aged 75 and older provides the following benefits for medical treatment with respect to sickness and injury of an 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 insured:

medical examination;

provision of medicines or treatment materials;

treatment, surgery, or other medical treatment;

management of in-home medical treatment and care and other nursing involved in the medical treatment;

admission to a hospital or clinic, and care and other nursing incidental to medical treatment there.

Benefits for the following medical treatment are not to be included in the benefits referred to in the preceding paragraph:

medical treatment consisting of the provision of meals, which is provided in combination with the medical treatment listed in item (v) of the preceding paragraph (excluding hospitalization in a sanatorium ward provided for in Article 7, paragraph (2), item (iv) of the Medical Care Act and care and other nursing incidental to the medical treatment (hereinafter referred to as "long-term hospitalization and medical treatment")) (hereinafter referred to as "dietary treatment");

the following types of medical treatment given in combination with the type of medical treatment listed in item (v) of the preceding paragraph (limited to long-term inpatient treatment) (hereinafter referred to as "living support"):

medical treatment consisting of the provision of meals;

medical treatment consisting of the creation of an appropriate environment for medical treatment in terms of temperature, lighting and water supply;

medical treatment using advanced medical care techniques specified by the Minister of Health, Labour and Welfare and other medical treatment specified by the Minister of Health, Labour and Welfare as medical treatment for which it is necessary to evaluate whether or not it should be subject to the benefits referred to in the preceding paragraph from the viewpoint of efficiently providing appropriate medical care (excluding patient-requested treatment referred to in the following item) (hereinafter referred to as "evaluation treatment");

medical treatment using advanced medical technology, which is specified by the Minister of Health, Labour and Welfare as medical treatment for which it is necessary to evaluate, from the viewpoint of efficiently providing appropriate medical care, whether or not it should be subject to benefits as set forth in the preceding paragraph, based on a request from a person who intends to receive the medical treatment (hereinafter referred to as "patient-requested treatment");

the provision of a special sickroom pertaining to the selection of an insured and other medical treatment specified by the Minister of Health, Labour and Welfare (hereinafter referred to as "selective treatment").

treatment using a pharmaceutical that is particularly highly substitutable for a pharmaceutical requiring guidance (meaning a pharmaceutical requiring guidance prescribed in Article 4, paragraph (9), 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 an insured intends to receive the benefits under paragraph (1), the insured is to receive confirmation of being an insured and receive the benefits under paragraph (1) from a medical institution providing services covered by health insurance, etc. of the insured's own choosing, by electronic eligibility confirmation (meaning that a person who intends to receive medical treatment from a medical institution providing services covered by health insurance, etc. or to receive designated home-nursing prescribed in Article 78, paragraph (1) from a designated home-nursing provider makes an inquiry to the Association of Medical Care Systems for the Elderly Aged 75 and older about information pertaining to the status of the insured (including information necessary for claiming expenses related to insurance benefits), by a method of transmitting the electronic certificate for user certification (meaning the electronic certificate for user certification prescribed in Article 22, paragraph (1) of the Act on Certification Business of the Japan Agency for Local Authority Information Systems in Relation to Electronic Signatures, etc. (Act No. 153 of 2002)) recorded on the Individual Number Card (meaning the Individual Number Card prescribed in Article 2, paragraph (7) of the Act on the Use of Numbers to Identify a Specific Individual in Administrative Procedures (Act No. 27 of 2013)) or by any other method specified by Order of the Ministry of Health, Labour and Welfare, and, by a method using an electronic data processing system or any other method using information and communications technology, receives a reply from the Association of Medical Care Systems for the Elderly Aged 75 and older, provides that information to the medical institution providing services covered by health insurance, etc. or the designated home-nursing provider, and receives confirmation of being an insured from the medical institution providing services covered by health insurance, etc. or the designated home-nursing provider; the same applies hereinafter) or by any other method specified by Order of the Ministry of Health, Labour and Welfare (hereinafter referred to as "electronic eligibility confirmation, etc."); provided, however, that when the case falls under a case specified by Order of the Ministry of Health, Labour and Welfare, the insured need not receive that confirmation.

The request referred to in paragraph (2), item (iv) is to be made to the Minister of Health, Labour and Welfare, pursuant to the provisions of the Minister of Health, Labour and Welfare, by attaching a written opinion of the establisher of the core hospital for clinical research prescribed in Article 4-3 of the Medical Care Act (limited to medical institutions providing services covered by health insurance) which provides the medical treatment pertaining to the request and other necessary documents.

If the Minister of Health, Labour and Welfare receives a request referred to in paragraph (2), item (iv), the Minister is to promptly review the request, and if the medical treatment related to the request is found to be that which requires the evaluation referred to in the same item, the Minister is to specify the medical treatment as patient-requested treatment.

If the Minister of Health, Labour and Welfare has determined that the medical treatment pertaining to the application prescribed in paragraph (2), item (iv) pursuant to the provisions of the preceding paragraph is patient-requested treatment, the Minister is to promptly notify the person who has made the application to that effect.

If the Minister of Health, Labour and Welfare has reviewed the request referred to in paragraph (2), item (iv) pursuant to the provisions of paragraph (5) and has determined that the medical treatment pertaining to the request is not to be specified as patient-requested treatment, the Minister is to promptly notify the person who has made the request to that effect by giving the reason.

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.

A medical institution providing services covered by health insurance, etc. or a physician providing health insurance treatment, etc. (meaning a physician providing health insurance treatment or pharmacist filling health insurance prescriptions as prescribed in Article 64 of the Health Insurance Act; the same applies hereinafter) must handle or take charge of medical treatment benefits for medical care for elderly people in accordance with the standards for handling and taking charge of medical treatment benefits as set forth in Article 71, paragraph (1).

Guidance by the Minister of Health, Labour and Welfare or the prefectural governor must be received by Health Insurance-Covered Medical Institutions, etc. with regard to benefits for medical treatment, and by Health Insurance-Covered Physicians, etc. with regard to medical care or prescription of Old-Old Healthcare.

The Minister of Health, Labour and Welfare or the prefectural governor, when providing the guidance prescribed in the preceding paragraph and finding it necessary, is to have a person with relevant expertise related to medical care or prescription services attend in accordance with the designation by the relevant organization; provided, however, that this does not apply when the relevant organization makes no designation or when the designated person does not attend.

A person who receives benefits for medical treatment from a medical institution providing services covered by health insurance, etc. pursuant to the provisions of Article 64, paragraph (3) must, when receiving those benefits, pay to that medical institution providing services covered by health insurance, etc., as a co-payment, the amount obtained by multiplying the amount calculated for those benefits in accordance with the standards for calculating the amount of expenses required for benefits for medical treatment under Article 70, paragraph (2) or Article 71, paragraph (1) by the ratio specified in the relevant item, in accordance with the category of cases listed in the following items.

in cases other than the cases set forth in the following item and item (iii):ten percent;

if the amount of income calculated pursuant to Cabinet Order for a person receiving benefits for medical treatment or for an insured or other person specified by Cabinet Order who is another Household Member of the household to which the person belongs is not less than the amount specified by Cabinet Order (other than in the case set forth in the following item):20 percent;

in the case where the amount of income calculated as specified by Cabinet Order for a person receiving the relevant benefits for medical treatment, or for an insured or other person specified by Cabinet Order who is another Household Member of the household to which that person belongs, is not less than the amount specified by Cabinet Order that exceeds the amount specified by Cabinet Order in the preceding item: 30 percent.

A medical institution providing services covered by health insurance, etc. is to receive payment of the co-payment under the preceding paragraph (where a measure under Article 69, paragraph (1), item (i) has been taken, the reduced co-payment), and if, despite the medical institution providing services covered by health insurance, etc. having endeavored to receive that payment with the same care as a good administrator, the insured still fails to pay all or part of the co-payment, the Association of Medical Care Systems for the Elderly Aged 75 and older may, upon the request of that medical institution providing services covered by health insurance, etc., dispose of it in the same manner as money to be collected pursuant to the provisions of this Act.

In the case of making co-payment pursuant to the provisions of paragraph (1) of the preceding Article, if the amount of co-payment includes a fraction less than five yen, the fraction is to be rounded down, and if the amount includes a fraction not less than five yen but less than ten yen, the fraction is to be rounded up to the nearest ten yen.

The Association of Medical Care Systems for the Elderly Aged 75 and older may take the following measures with respect to an insured who has special circumstances, such as a disaster, specified by Order of the Ministry of Health, Labour and Welfare and who is found to have difficulty paying the co-payment under Article 67, paragraph (1) to a medical institution providing services covered by health insurance, etc.:

to reduce the amount of co-payment;

exemption from co-payment;

to decide to collect co-payment directly from the insured person in lieu of co-payment to the medical institution providing services covered by health insurance, etc., and to suspend such collection.

Notwithstanding the provisions of Article 67, paragraph (1), in the case of an insured that has received the measures set forth in item (i) of the preceding paragraph, it is sufficient for the insured to pay the reduced amount of co-payment to the medical institution providing services covered by health insurance, etc., and in the case of an insured that has received the measures set forth in item (ii) or item (iii) of the preceding paragraph, it is not required to pay the co-payment to the medical institution providing services covered by health insurance, etc.

The provisions of the preceding Article apply mutatis mutandis to the payment of co-payment in the case referred to in the preceding paragraph.

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.