Act on Assurance of Medical Care for Elderly People

A designated home-nursing provider and nurses and other employees at the office to which the designation pertains must receive guidance from the Minister of Health, Labour and Welfare or the prefectural governor with regard to designated home-nursing.

When the Minister of Health, Labour and Welfare or the prefectural governor finds it necessary in relation to the payment of medical expenses for home-nursing, the Minister or the governor may order a designated home-nursing provider, a person that was a designated home-nursing provider, or a person that was a nurse or other employee at the office relevant to the designation (hereinafter referred to as a "person that was a designated home-nursing provider, etc." in this paragraph) to make a report, submit or present books and documents, request the appearance of a designated home-nursing provider, a nurse or other employee at the office relevant to the designation, or a person that was a designated home-nursing provider, etc., or have their official question the persons concerned or inspect the books, documents, and other articles of the designated home-nursing provider at the office relevant to the designation.

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

If a prefectural governor finds it necessary for a designated home-nursing provider to be subject to a disposition under the provisions of Article 95 of the Health Insurance Act with regard to designated home-nursing under the provisions of this Act, the governor must notify the Minister of Health, Labour and Welfare to that effect by giving the reason therefor.

If a insured that is delinquent in the payment of insurance premiums (excluding a insured that is eligible to receive payment of general medical expenses for illness under the Atomic Bomb 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 of general medical expenses for atomic bomb survivors, etc." in paragraph (5)); 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 of insurance 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 (5), and paragraph (6)), 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.

Even before the period specified by Order of the Ministry of Health, Labour and Welfare as prescribed in the preceding paragraph has elapsed, if a person delinquent in payment of insurance premiums still does not pay the insurance premiums even though a municipality has carried out encouragement of insurance premium payment, etc., and 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 may pay the person delinquent in payment of insurance premiums special medical expenses for the expenses required for the medical treatment or designated home-nursing, in lieu of benefits for medical treatment, etc. However, this does not apply if it is found that there are special circumstances specified by the Cabinet Order referred to in that paragraph.

When paying special medical expenses pursuant to the provisions of paragraph (1) or the main clause of the preceding paragraph, the Association of Medical Care Systems for the Elderly Aged 75 and older is to notify a person delinquent in insurance premiums to the effect that special medical expenses will be paid if the person delinquent in insurance premiums receives medical treatment at or from a medical institution providing services covered by health insurance, or receives designated home-nursing at or from a designated home-nursing provider, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare.

The amount of special medical expenses is the amount listed in item (i) (or, if the medical treatment includes dietary treatment, the sum total of that amount and the amount listed in item (ii); if the medical treatment includes living support, the sum total of that amount and the 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).

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 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 if the relevant insured has become eligible for the payment of general medical expenses for atomic bomb survivors, etc., and the insured 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. to the relevant insured.

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 of the preceding paragraph, it is to notify in advance, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, an insured who falls under the case prescribed in that paragraph that, when the insured receives medical treatment from a medical institution providing services covered by health insurance, etc. or designated home-nursing from a designated home-nursing provider, benefits for medical treatment, etc. will be provided.

The provisions of Article 64, paragraph (3), Article 65, Article 66, Article 70, paragraph (2), Article 72, Article 74, paragraph (7) (including as applied mutatis mutandis pursuant to Article 78, paragraph (8)), Article 78, paragraph (3), Article 79, paragraph (2), Article 80, and the preceding Article, and Article 64 of the Health 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 payment of special medical expenses incidental thereto. In this case, any necessary technical replacement of terms is specified by Cabinet Order.

If a person delinquent in payment of insurance premiums to whom the provisions of paragraph (1) or the main clause of paragraph (2) 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 may pay medical expenses to the person.

When a person delinquent in payment of 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 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, the Association is to 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".

When an insured has been transferred to a hospital or clinic in order to receive medical treatment (including medical treatment covered by medical expenses combined with treatment outside insurance coverage and medical treatment covered by special medical expenses), the Association of Medical Care Systems for the Elderly Aged 75 and older pays, as transport expenses, an amount calculated pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare to the insured.

The transport expenses 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 the amount of co-payment prescribed in Article 67 with respect to benefits for medical treatment or the amount calculated by deducting, from the amount of expenses incurred in medical treatment (excluding dietary treatment and living support; hereinafter the same applies in this Article), the amount paid as medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses with respect to the expenses incurred in the medical treatment, or the amount equivalent to the difference paid pursuant to the provisions of Article 57, paragraph (2) (referred to as the "amount of co-payment, etc." in paragraph (1) of the following Article) is extremely large, the Association of Medical Care Systems for the Elderly Aged 75 and older pays high-cost medical expenses to the insured that received the benefits for medical treatment, or the payment of the medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses.

The requirements for payment and the amount of high-cost medical expenses and other necessary matters concerning the payment of high-cost medical expenses shall be prescribed by Cabinet Order by taking into consideration the impact of the burden of the expenses incurred in the relevant medical treatment on household finances, in particular the household finances of persons who continuously receive medical treatment over a long period, and the amount of expenses incurred in the medical treatment.

When the sum of the amount of co-payment, etc. (when high-cost medical expenses set forth in paragraph (1) of the preceding Article are paid, the amount obtained by deducting the amount so paid) and the amount to be borne by a user of long-term care service as prescribed in Article 51, paragraph (1) of the Long-Term Care Insurance Act (when allowance for high-cost long-term care service set forth in the same paragraph is paid, the amount obtained by deducting the amount so paid) and the amount to be borne by a user of preventive long-term care service as prescribed in Article 61, paragraph (1) of the same Act (when High-Cost Long-Term Prevention Care Service Allowance set forth in the same paragraph is paid, the amount obtained by deducting the amount so paid) is extremely large, the Association of Medical Care Systems for the Elderly Aged 75 and older pays Sizable medical and nursing expenses to the insured that received benefits for medical treatment, or payment of medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or special medical expenses pertaining to the amount of co-payment, etc.

The provisions of paragraph (2) of the preceding Article apply mutatis mutandis to the payment of a Sizable medical and nursing expenses.

A Association of Medical Care Systems for the Elderly Aged 75 and older is to, pursuant to the provisions of its Ordinances, pay funeral expenses or provide funeral rites benefits with regard to the death of an insured; provided, however, that if there are special reasons, the payment or benefits may not be made in whole or in part.

In addition to the benefits set forth in the preceding paragraph, the Association of Medical Care Systems for the Elderly Aged 75 and older may pay injury and sickness allowance and provide other medical care benefit for the old-old pursuant to the provisions of the ordinances of the Association of Medical Care Systems for the Elderly Aged 75 and older.