Act on Assurance of Medical Care for Elderly People

When an insured of National Health Insurance to whom Article 116-2, paragraphs (1) and (2) of the National Health Insurance Act apply, and who has an address within the area of an Association of Medical Care Systems for the Elderly Aged 75 and older other than the Association of Medical Care Systems for the Elderly Aged 75 and older to which the municipality in which the insured is deemed to have an address pursuant to those provisions (hereinafter in this paragraph referred to as the "municipality of the previous domicile") belongs (in the case of item (ii), limited to a person who is 65 years of age or older and less than 75 years of age), comes to fall under any of the following items, the person is, notwithstanding the provisions of Article 50, to be an insured for old-old medical care provided by the Association of Medical Care Systems for the Elderly Aged 75 and older to which the municipality of the previous domicile belongs (referred to as the "Association of Medical Care Systems for the Elderly Aged 75 and older of the previous domicile" in item (ii) and the following paragraph). In this case, notwithstanding the provisions of Article 52, the insured acquires the qualification from the day on which the insured comes to fall under any of those items.

when the person has reached 75 years of age;

if the person has been certified by the Association of Medical Care Systems for the Elderly Aged 75 and older of the previous domicile as having a disability of a degree of severity specified by Cabinet Order as referred to in Article 50, item (ii), pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare.

The provisions of the preceding Article apply mutatis mutandis to a person who is deemed to be an insured for Old-Old Healthcare provided by the Association of Medical Care Systems for the Elderly Aged 75 and older of the Previous Domicile pursuant to the provisions of the preceding paragraph. In this case, the necessary technical replacement of terms is specified by Cabinet Order.

The benefits under this Act pertaining to an insured (hereinafter referred to as an "old-old medical care benefit") are as follows:

benefits for medical treatment, and payment of dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, and transport expenses;

payment of high-cost medical expenses and Sizable medical and nursing expenses;

beyond what is set forth in the preceding two items, benefits provided pursuant to the provisions of Ordinance of the Association of Medical Care Systems for the Elderly Aged 75 and older.

The provision of benefits for medical treatment, or the payment of dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses or transport expenses, is not made in the case where the insured is able to receive, for the relevant illness or injury, benefits related to medical care based on laws and regulations such as medical compensation benefits, medical benefits for multiple-business workers or medical benefits under the provisions of the Industrial Accident Compensation Insurance Act (Act No. 50 of 1947), medical compensation under the provisions of the National Public Officers' Accident Compensation Act (Act No. 191 of 1951; including as applied mutatis mutandis pursuant to other Acts), medical compensation under the provisions of the Local Public Officers Accident Compensation Act (Act No. 121 of 1967) or a Prefectural or Municipal Ordinance based on that Act, or other laws and regulations specified by Cabinet Order, in the case where the insured is able to receive benefits equivalent to the respective benefits pursuant to the provisions of the Long-Term Care Insurance Act, or in the case where benefits related to medical care have been provided at the expense of the national government or a local government under laws and regulations other than these.

If benefits under a law or regulation as prescribed in the preceding paragraph are benefits in kind related to medical care, and co-payment or collection of actual costs has been made for the benefits and the amount of co-payment or collection of actual costs exceeds the amount of co-payment under this Act if the benefits are considered to have been provided as benefits for medical treatment under this Act, or if benefits under a law or regulation as prescribed in the same paragraph (excluding the Long-Term Care Insurance Act) are payment of medical expenses and the amount paid is less than the amount of dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, or transport expenses if dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, special medical expenses, or transport expenses are to be paid for the medical treatment under this Act, the Association of Medical Care Systems for the Elderly Aged 75 and older must pay the difference between those amounts to the insured.

In the case referred to in the preceding paragraph, when an insured receives the medical treatment at a medical institution providing services covered by health insurance, etc. (meaning a medical institution providing services covered by health insurance prescribed in Article 63, paragraph (3), item (i) of the Health Insurance Act (hereinafter referred to as a "medical institution providing services covered by health insurance") or pharmacies providing services covered by health insurance; the same applies hereinafter), 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. the expenses required for the medical 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 pursuant to the provisions of the preceding paragraph.

When expenses have been paid to a medical institution providing services covered by health insurance, etc. pursuant to the provisions of the preceding paragraph, the payment under paragraph (2) is deemed to have been made to insured to the extent of the payment.

When the Association of Medical Care Systems for the Elderly Aged 75 and older has provided an old-old medical care benefit (including payment of the difference under the provisions of paragraph (2) of the preceding Article; the same applies hereinafter) in the case where the grounds for the benefit arose from an act of a third party, it acquires the insured's right to claim damages against the third party to the extent of the value of that old-old medical care benefit (where that old-old medical care benefit is benefits for medical treatment, the amount obtained by deducting from the amount of expenses required for those benefits for medical treatment the amount equivalent to the co-payment that the insured must bear in relation to those benefits for medical treatment; the same applies in paragraph (1) of the following Article).

In the case referred to in the preceding paragraph, if a person who is to receive an old-old medical care benefit has received compensation for loss or damage from a third party for the same reason, the Association of Medical Care Systems for the Elderly Aged 75 and older is exempt from the responsibility to provide the old-old medical care benefit to the extent of the amount of the compensation.

A Association of Medical Care Systems for the Elderly Aged 75 and older may entrust its affairs concerning the collection or receipt of compensation for damage pertaining to the right to claim acquired pursuant to the provisions of paragraph (1) to a federation of national health insurance associations specified by Order of the Ministry of Health, Labour and Welfare.

If a person receives an old-old medical care benefit by deception or other wrongful acts, the Association of Medical Care Systems for the Elderly Aged 75 and older may collect all or part of the value of the old-old medical care benefit from that person.

In the case referred to in the preceding paragraph, when a physician providing health insurance treatment at a medical institution providing services covered by health insurance or an attending physician as prescribed in Article 78, paragraph (1) has made a false entry on a written diagnosis to be submitted to the Association of Medical Care Systems for the Elderly Aged 75 and older, and as a result, the late-stage elderly medical care benefit has been provided, the Association of Medical Care Systems for the Elderly Aged 75 and older may order the physician providing health insurance treatment or the attending physician to pay the money to be collected pursuant to the preceding paragraph jointly and severally with the person who has received the late-stage elderly medical care benefit.

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 (7), 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).

If a Association of Medical Care Systems for the Elderly Aged 75 and older finds it necessary in relation to an old-old medical care benefit, it may order the insured, the person who used to be the insured, or the person who receives an old-old medical care benefit to submit or present documents or other objects, or may have its personnel question or diagnose the person.

The Minister of Health, Labour and Welfare or the prefectural governor, when finding it necessary in relation to a medical care benefit for the old-old, may order physicians, dentists, pharmacists, or persons who provided medical care or those who employ them to make a report or present medical records, books and documents, and other objects, or may have their personnel question them, with regard to the medical care, provision of drugs, or medical treatment provided by them.

The Minister of Health, Labour and Welfare or the prefectural governor may, when finding it necessary, order an insured or a former insured that received payment of benefits for medical treatment, or expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses to make a report or have their official ask questions about the content of medical care, prescription or designated home-nursing pertaining to the payment of the benefits for medical treatment, or expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses.

The provisions of Article 16-10, paragraph (2) apply mutatis mutandis to questions pursuant to the provisions of the preceding two paragraphs, and the provisions of paragraph (3) of the same Article apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding two paragraphs.

The right to receive an old-old medical care benefit may not be transferred, pledged as collateral, or levied.

Taxes and other public charges may not be imposed on the basis of money and goods received as payment as a medical care benefit for Old-Old Age.