Act on Assurance of Medical Care for Elderly People

When an insured or a person who used to be an insured has suffered illness or injury intentionally or due to an intentional criminal act, benefits for medical treatment, or 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 pertaining to the illness or injury (hereinafter referred to as "benefits for medical treatment, etc." in this Subsection) are not paid.

When an insured suffers illness or injury due to a conflict, state of drunkenness or extreme misconduct, benefits for medical treatment, etc. for such illness or injury may not be paid in whole or in part.

If a person who is or was an insured is confined in a penal institution, workhouse, or any other facility equivalent thereto, no benefits for medical treatment, etc. are paid for the period during which the person is confined.

The Association of Medical Care Systems for the Elderly Aged 75 and older may refrain from providing part of the benefits for medical treatment, etc. when an insured or a person who used to be an insured fails, without justifiable grounds, to follow instructions concerning medical treatment.

When a person who is or was an insured or a person who receives an old-old medical care benefit fails to comply with an order pursuant to the provisions of Article 60 or refuses to answer questions or undergo a medical examination without justifiable grounds, the Association of Medical Care Systems for the Elderly Aged 75 and older may refrain from providing benefits for medical treatment, etc., in whole or in part.

When an insured who is eligible to receive an old-old medical care benefit is delinquent in payment of insurance premiums and, during the period from the due date for payment of those insurance premiums until the period specified by Order of the Ministry of Health, Labour and Welfare has elapsed, still does not pay those insurance premiums even though a municipality has carried out encouragement of insurance premium payment, etc., the Association of Medical Care Systems for the Elderly Aged 75 and older is to temporarily suspend payment of all or part of the old-old medical care benefit, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, except where it is found that there are special circumstances specified by Cabinet Order, such as a disaster, regarding the delinquency in payment of those insurance premiums.

Even if the period specified by Order of the Ministry of Health, Labour and Welfare as prescribed in the preceding paragraph has not elapsed, if an insured who is eligible to receive an old-old medical care benefit is still in arrears on insurance premiums even though a municipality has carried out encouragement of insurance premium payment, etc., the Association of Medical Care Systems for the Elderly Aged 75 and older may, as specified by Order of the Ministry of Health, Labour and Welfare, temporarily suspend payment of all or part of the old-old medical care benefit, except where it is found that there are special circumstances specified by Cabinet Order, such as a disaster, in respect of the arrears of those insurance premiums.

If an insured to which the provisions of Article 82, paragraph (1) or the main clause of paragraph (2) are applied and for which the payment of the old-old medical care benefit has been temporarily suspended in whole or in part pursuant to the provisions of the preceding two paragraphs still does not pay the delinquent insurance premiums, the Association of Medical Care Systems for the Elderly Aged 75 and older may, pursuant to the provisions of the Order of the Ministry of Health, Labour and Welfare, deduct the amount of the insurance premiums that the insured is delinquent from the amount of the old-old medical care benefit pertaining to the temporary suspension, by giving notice to the insured in advance.

The national government, pursuant to the provisions of Cabinet Order, bears for an Association of Medical Care Systems for the Elderly Aged 75 and older an amount equivalent to 3/12 of the sum total of the following amounts (hereinafter referred to as the "total amount subject to sharing"):

the amount (referred to as the "Amount Subject to Sharing" in item (i) of the following paragraph and Article 100, paragraph (1), item (i)) obtained by deducting, from the sum total of the amount obtained by deducting the amount equivalent to the co-payment pertaining to benefits for medical treatment from the amount of expenses required for benefits for medical treatment pertaining to the insured, and the amount of expenses required for 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, transport expenses, high-cost medical expenses, and sizable medical and nursing expenses (hereinafter referred to as the "amount of expenses incurred in providing benefits for medical treatment, etc."), the amount of expenses incurred in providing benefits for medical treatment, etc. pertaining to persons who fall under the cases set forth in Article 67, paragraph (1), item (iii) (hereinafter referred to in this paragraph, Article 100, paragraph (1), item (i), and paragraph (2), item (i) as the "amount of specified expenses");

the amount (referred to as the "physician allowance contribution amount subject to sharing" in Article 100, paragraph (1), item (ii) and Article 120, paragraph (1), item (i), (b)) obtained by deducting, from the amount of expenses required for payment of physician allowance contribution, the amount (referred to as the "amount of specified physician allowance contribution" in Article 100, paragraph (1), item (ii) and Article 120, paragraph (1), item (i), (b)) obtained by multiplying the amount of expenses required for payment of that physician allowance contribution by the ratio of the amount of specified expenses to the amount of expenses incurred in providing benefits for medical treatment, etc.;

the amount (referred to as the "contribution amount subject to sharing" in Article 100, paragraph (1), item (iii)) obtained by deducting, from the amount of expenses required for payment of contribution for securing medical care in the early phase of an epidemic, the amount (referred to as the "amount of specified contribution for securing medical care in the early phase of an epidemic" in that item) obtained by multiplying the amount of expenses required for payment of that contribution for securing medical care in the early phase of an epidemic by the ratio of the amount of specified expenses to the amount of expenses incurred in providing benefits for medical treatment, etc.

The national government, in addition to what is provided for in the preceding paragraph, pursuant to the provisions of Cabinet Order, in order to achieve the financial stability of old-old medical care, bears, with respect to the Association of Medical Care Systems for the Elderly Aged 75 and older, an amount equivalent to 1/4 of the amount obtained by multiplying the sum total of the expenses required for benefits related to extremely expensive medical care that are not less than the amount calculated as specified by Cabinet Order as having a significant impact on the finances of old-old medical care due to the occurrence of benefits related to extremely expensive medical care, taking into consideration the ratio of benefits related to extremely expensive medical care to the amount of expenses required for all benefits related to medical care pertaining to insured and other factors, by the sum of the following rates (referred to as the "amount of high-cost medical expenses subject to sharing" in Article 96, paragraph (2)).

the rate obtained by dividing the amount equivalent to one twelfth of the Amount Subject to Sharing by the amount of expenses required for Benefits for Medical Treatment, etc.;

the contribution rate for the old-old in Article 100, paragraph (2).

Beyond what is provided for in the preceding two paragraphs, pursuant to the provisions of Cabinet Order, the national government is to grant two-thirds of the estimated total amount of special burden adjustment, etc. for the relevant fiscal year to the Organization each fiscal year; provided, however, that if the estimated total amount of special burden adjustment, etc. for the fiscal year before the previous fiscal year exceeds the total amount of special burden adjustment, etc. for the same fiscal year, the national government is to grant two-thirds of the amount obtained by subtracting the excess amount from the estimated total amount of special burden adjustment, etc. for the relevant fiscal year, and if the estimated total amount of special burden adjustment, etc. for the fiscal year before the previous fiscal year is less than the total amount of special burden adjustment, etc. for the same fiscal year, the national government is to grant two-thirds of the amount obtained by adding the less amount to the estimated total amount of special burden adjustment, etc. for the relevant fiscal year.

If a Association of Medical Care Systems for the Elderly Aged 75 and older unjustly fails to secure the revenue that it should have secured, the national government may reduce the amount to be borne by the Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of the preceding Article, pursuant to the provisions of Cabinet Order.

The amount to be reduced pursuant to the provisions of the preceding paragraph may not exceed the amount which was unjustly not secured.

The national government provides adjustment grants to a Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of a Cabinet Order in order to adjust the finances of medical care for the elderly.

The total amount of adjustment grants under the provisions of the preceding paragraph is the sum total of the amount equivalent to 1/12 of the total of the estimated amounts of the total amount subject to sharing and the amount equivalent to 1/120 of the estimated amount of the children and child-rearing support levy under the Act on Support for Children and Child-rearing (Act No. 65 of 2012) (hereinafter referred to as the "children and child-rearing support levy").

A prefecture, pursuant to the provisions of Cabinet Order, bears an amount equivalent to one twelfth of the total amount subject to sharing by a Association of Medical Care Systems for the Elderly Aged 75 and older.

Beyond what is set forth in the preceding paragraph, a prefecture is to bear an amount equivalent to one fourth of the amount subject to high medical care cost contribution to the Association of Medical Care Systems for the Elderly Aged 75 and older, pursuant to the provisions of Cabinet Order.

If a Association of Medical Care Systems for the Elderly Aged 75 and older unjustly fails to secure the revenue it should have secured and the national government reduces the amount to be borne pursuant to the provisions of Article 94, the prefecture may reduce the amount to be borne by the Association of Medical Care Systems for the Elderly Aged 75 and older pursuant to the provisions of the preceding Article, pursuant to the provisions of Cabinet Order.

The amount to be reduced pursuant to the provisions of the preceding paragraph may not exceed the amount which was unjustly not secured.

A Municipality, pursuant to the provisions of a Cabinet Order, is to bear an amount equivalent to one twelfth of the Total Amount Subject to Sharing with a Association of Medical Care Systems for the Elderly Aged 75 and older in its general account.

A Municipality, pursuant to the provisions of a Cabinet Order, must transfer from the general account to the special account for medical care for the elderly of the Municipality the amount calculated, pursuant to the provisions of a Cabinet Order, based on the total amount of insurance premiums pertaining to the insured reduced based on the reduced assessment of insurance premiums for persons with small income pursuant to the provisions of the Ordinances of the Association of Medical Care Systems for the Elderly Aged 75 and older, by taking into consideration the financial status of medical care for the elderly and other circumstances.

A municipality must, pursuant to the provisions of Cabinet Order, transfer from the general account to the special account of the municipality for old-old medical care, with respect to an insured who was a dependent under the provisions of the Health Insurance Act, the Mariners Insurance Act, the National Public Officers Mutual Aid Association Act (including as applied mutatis mutandis pursuant to other Acts) or the Local Public Officers, etc. Mutual Aid Association Act on the day before the day on which the insured came to fall under any of the items of Article 52, the amount calculated as specified by Cabinet Order, taking into consideration the financial status of old-old medical care and other circumstances, on the basis of the total amount of reduction where, limited to the period from the month containing the day on which the insured came to fall under any of the cases listed in the items of that Article until the month in which two years have elapsed, insurance premiums are reduced pursuant to a reduced assessment of insurance premiums made as provided by Ordinance of the Association.

A prefecture, pursuant to the provisions of Cabinet Order, bears an amount equivalent to three quarters of the amount to be transferred pursuant to the provisions of the preceding two paragraphs.