When an insured receives evaluation treatment, patient-requested treatment, or selective treatment 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.
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).
Medical institutions providing services covered by health insurance, etc. and physicians providing services covered by health insurance, 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, standards pursuant to the provisions of paragraph (2), item (i), 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.
厚生労働大臣は、評価療養（第六十四条第二項第三号に規定する高度の医療技術に係るものを除く。）、選定療養、第二項第一号の規定による基準並びに前項に規定する保険外併用療養費に係る療養の取扱い及び担当に関する基準を定めようとするときは、あらかじめ中央社会保険医療協議会の意見を聴かなければならない。
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 of the Health Insurance Act and Article 64, paragraph (3), Article 66, Article 70, paragraphs (2) through (7), Article 72, and Article 74, paragraphs (5) through (7) of this Act apply mutatis mutandis to payment of evaluation treatment, patient-requested treatment, and selective treatment 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.
健康保険法第六十四条並びに本法第六十四条第三項、第六十六条、第七十条第二項から第七項まで、第七十二条及び第七十四条第五項から第七項までの規定は、保険医療機関等について受けた評価療養、患者申出療養及び選定療養並びにこれらに伴う保険外併用療養費の支給について準用する。この場合において、これらの規定に関し必要な技術的読替えは、政令で定める。
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) 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.
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