Order for Enforcement of the Health Insurance Act

High-cost medical expenses are paid to the insured person on the reference date prescribed in item (i) if any of the total sum of the amounts listed in items (i) through (vi) (hereinafter in this paragraph referred to as the "total for the insured person on the reference date"), the total sum of the amounts listed in items (vii) through (xii) (hereinafter in this paragraph referred to as the "total for the dependent on the reference date"), or the total sum of the amounts listed in items (xiii) through (xviii) (hereinafter in this paragraph referred to as the "total for former dependents") exceeds the base amount for calculating high-cost medical expenses, and the amount paid is the total sum of the amount obtained by multiplying the amount obtained by deducting the base amount for calculating high-cost medical expenses from the total for the insured person on the reference date (if that amount is less than zero, zero) by the high-cost medical expenses apportionment rate (meaning the rate obtained by dividing the amount listed in item (i) by the total for the insured person on the reference date), the amount obtained by multiplying the amount obtained by deducting the base amount for calculating high-cost medical expenses from the total for the dependent on the reference date (if that amount is less than zero, zero) by the high-cost medical expenses apportionment rate (meaning the rate obtained by dividing the amount listed in item (vii) by the total for the dependent on the reference date), and the amount obtained by multiplying the amount obtained by deducting the base amount for calculating high-cost medical expenses from the total for former dependents (if that amount is less than zero, zero) by the high-cost medical expenses apportionment rate (meaning the rate obtained by dividing the amount listed in item (xiii) by the total for former dependents); provided, however, that this does not apply if the insured person on the reference date is, on the reference date (meaning the last day of the calculation period (meaning the period from August 1 each year to July 31 of the following year; the same applies hereinafter); the same applies hereinafter), a person to whom the provisions of Article 74, paragraph (1), item (iii) of the Act apply.

the total sum of the following amounts relating to outpatient treatment (limited to outpatient treatment on or after the month following the month that includes the day on which the person reaches the age of 70; the same applies hereinafter in this Article) (including outpatient treatment for insurance benefits under Article 98, paragraph (1) of the Act (including as applied mutatis mutandis pursuant to Article 110, paragraph (7) and Article 111, paragraph (3) of the Act) (hereinafter in this Article referred to as "outpatient treatment under continued benefits")) that the insured person on the reference date received, during the calculation period (limited to the period during which a person who is, on the reference date, an insured person of the relevant insurer (excluding specially-insured day laborers, members of mutual aid associations under the National Public Officers Mutual Aid Association Act and the Local Public Officers, etc. Mutual Aid Association Act, and subscribers to the Private School Personnel Mutual Aid System under the Private School Personnel Mutual Aid Association Act; the same applies hereinafter in this Article, Article 43, paragraph (11) and Articles 43-2 through 43-4) (hereinafter referred to as the "insured person on the reference date") was an insured person of the relevant insurer), as an insured person of the relevant insurer (excluding a case where the person is one to whom the provisions of Article 74, paragraph (1), item (iii) of the Act apply) (if high-cost medical expenses are paid pursuant to the provisions of paragraphs (1) through (5) of the preceding Article, the amount obtained by deducting the amount paid to the insured person on the reference date, and if money or goods for reducing the burden relating to the following amounts are provided as other benefits prescribed in Article 53 of the Act, the amount obtained by deducting the amount equivalent to that money or those goods relating to the insured person on the reference date):

the total sum of the amounts listed in paragraph (1), item (i), (a) through (f) of the preceding Article relating to the relevant outpatient treatment (excluding treatment subject to specified benefits);

the amount that that person still has to bear for the relevant outpatient treatment (limited to treatment subject to specified benefits);

the total sum prescribed in the preceding item for outpatient treatment (including outpatient treatment under continued benefits) that the insured person on the reference date received, during the calculation period (limited to the period during which the insured person on the reference date was an insured person of the insurer of another health insurance), as an insured person of the insurer of that other health insurance (excluding a case where the person is one to whom the provisions of Article 74, paragraph (1), item (iii) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that the insured person on the reference date received, during the calculation period (limited to the period during which the dependent of the insured person on the reference date (limited to a person who is, on the reference date, a dependent of an insured person of the relevant insurer; hereinafter in this Article, Article 43-2, paragraph (1) (including as applied mutatis mutandis pursuant to paragraph (3) of that Article), paragraph (3) and paragraph (5) referred to as the "dependent on the reference date") was an insured person of the relevant insurer and the insured person on the reference date was a dependent of that dependent on the reference date), as a dependent of an insured person of the relevant insurer (excluding a case where the person is one to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that the insured person on the reference date received, during the calculation period (limited to the period during which the dependent on the reference date was an insured person of the insurer of another health insurance and the insured person on the reference date was a dependent of that dependent on the reference date), as a dependent of an insured person of the insurer of that other health insurance (excluding a case where the person is one to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the amount calculated, as provided by Order of the Ministry of Health, Labour and Welfare, as an amount equivalent to the total sum prescribed in item (i) for outpatient treatment that the insured person on the reference date received, during the calculation period (limited to the period during which the insured person on the reference date was a member, etc. of an insurer body, etc.), as a member, etc. of that insurer body, etc. (excluding a case where the person is equivalent to a person to whom the provisions of Article 74, paragraph (1), item (iii) of the Act apply);

the amount calculated, as provided by Order of the Ministry of Health, Labour and Welfare, as an amount equivalent to the total sum prescribed in item (i) for outpatient treatment that the insured person on the reference date received, during the calculation period (limited to the period during which the dependent on the reference date was a member, etc. (excluding an insured person of the late-stage elderly medical care system) of an insurer body, etc. (excluding an Association of Medical Care Systems for the Elderly Aged 75 and older under the Act on Assurance of Medical Care for Elderly People) and the insured person on the reference date was a dependent, etc. of that dependent on the reference date), as a dependent, etc. of a member, etc. of that insurer body, etc. (excluding a case where the person is equivalent to a person to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that the dependent on the reference date received, during the calculation period (limited to the period during which the insured person on the reference date was an insured person of the relevant insurer and the dependent on the reference date was a dependent of that insured person on the reference date), as a dependent of an insured person of the relevant insurer (excluding a case where the person is one to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that the dependent on the reference date received, during the calculation period (limited to the period during which the insured person on the reference date was an insured person of the insurer of another health insurance and the dependent on the reference date was a dependent of that insured person on the reference date), as a dependent of an insured person of the insurer of that other health insurance (excluding a case where the person is one to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that the dependent on the reference date received, during the calculation period (limited to the period during which the dependent on the reference date was an insured person of the relevant insurer), as an insured person of the relevant insurer (excluding a case where the person is one to whom the provisions of Article 74, paragraph (1), item (iii) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that the dependent on the reference date received, during the calculation period (limited to the period during which the dependent on the reference date was an insured person of the insurer of another health insurance), as an insured person of the insurer of that other health insurance (excluding a case where the person is one to whom the provisions of Article 74, paragraph (1), item (iii) of the Act apply);

the amount calculated, as provided by Order of the Ministry of Health, Labour and Welfare, as an amount equivalent to the total sum prescribed in item (i) for outpatient treatment that the dependent on the reference date received, during the calculation period (limited to the period during which the insured person on the reference date was a member, etc. (excluding an insured person of the late-stage elderly medical care system) of an insurer body, etc. (excluding an Association of Medical Care Systems for the Elderly Aged 75 and older under the Act on Assurance of Medical Care for Elderly People) and the dependent on the reference date was a dependent, etc. of that insured person on the reference date), as a dependent, etc. of a member, etc. of that insurer body, etc. (excluding a case where the person is equivalent to a person to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the amount calculated, as provided by Order of the Ministry of Health, Labour and Welfare, as an amount equivalent to the total sum prescribed in item (i) for outpatient treatment that the dependent on the reference date received, during the calculation period (limited to the period during which the dependent on the reference date was a member, etc. of an insurer body, etc.), as a member, etc. of that insurer body, etc. (excluding a case where the person is equivalent to a person to whom the provisions of Article 74, paragraph (1), item (iii) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that a person who was a dependent of the insured person on the reference date (excluding the dependent on the reference date) received, during the calculation period (limited to the period during which the insured person on the reference date was an insured person of the relevant insurer and the person who was a dependent of that insured person on the reference date (excluding the dependent on the reference date) was a dependent of that insured person on the reference date), as a dependent of an insured person of the relevant insurer (excluding a case where the person is one to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that a person who was a dependent of the insured person on the reference date (excluding the dependent on the reference date) received, during the calculation period (limited to the period during which the insured person on the reference date was an insured person of the insurer of another health insurance and the person who was a dependent of that insured person on the reference date (excluding the dependent on the reference date) was a dependent of that insured person on the reference date), as a dependent of an insured person of the insurer of that other health insurance (excluding a case where the person is one to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that a person who was a dependent of the dependent on the reference date (excluding the insured person on the reference date) received, during the calculation period (limited to the period during which the dependent on the reference date was an insured person of the relevant insurer and the person who was a dependent of that dependent on the reference date (excluding the insured person on the reference date) was a dependent of that dependent on the reference date), as a dependent of an insured person of the relevant insurer (excluding a case where the person is one to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the total sum prescribed in item (i) for outpatient treatment (including outpatient treatment under continued benefits) that a person who was a dependent of the dependent on the reference date (excluding the insured person on the reference date) received, during the calculation period (limited to the period during which the dependent on the reference date was an insured person of the insurer of another health insurance and the person who was a dependent of that dependent on the reference date (excluding the insured person on the reference date) was a dependent of that dependent on the reference date), as a dependent of an insured person of the insurer of that other health insurance (excluding a case where the person is one to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the amount calculated, as provided by Order of the Ministry of Health, Labour and Welfare, as an amount equivalent to the total sum prescribed in item (i) for outpatient treatment that a person who was a dependent, etc. of the insured person on the reference date (excluding the dependent on the reference date) received, during the calculation period (limited to the period during which the insured person on the reference date was a member, etc. (excluding an insured person of the late-stage elderly medical care system) of an insurer body, etc. (excluding an Association of Medical Care Systems for the Elderly Aged 75 and older under the Act on Assurance of Medical Care for Elderly People) and the person who was a dependent, etc. of that insured person on the reference date (excluding the dependent on the reference date) was a dependent, etc. of that insured person on the reference date), as a dependent, etc. of a member, etc. of that insurer body, etc. (excluding a case where the person is equivalent to a person to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply);

the amount calculated, as provided by Order of the Ministry of Health, Labour and Welfare, as an amount equivalent to the total sum prescribed in item (i) for outpatient treatment that a person who was a dependent, etc. of the dependent on the reference date (excluding the insured person on the reference date) received, during the calculation period (limited to the period during which the dependent on the reference date was a member, etc. (excluding an insured person of the late-stage elderly medical care system) of an insurer body, etc. (excluding an Association of Medical Care Systems for the Elderly Aged 75 and older under the Act on Assurance of Medical Care for Elderly People) and the person who was a dependent, etc. of that dependent on the reference date (excluding the insured person on the reference date) was a dependent, etc. of that dependent on the reference date), as a dependent, etc. of a member, etc. of that insurer body, etc. (excluding a case where the person is equivalent to a person to whom the provisions of Article 110, paragraph (2), item (i), (d) of the Act apply).

The provisions of the preceding paragraph apply mutatis mutandis to the payment of high-cost medical expenses to a person who was an insured person of the relevant insurer during the calculation period (limited to a dependent on the reference date). In this case, the phrase "(meaning the rate obtained by dividing the amount listed in item (i)" in that paragraph is deemed to be replaced with "(meaning the rate obtained by dividing the amount listed in item (iii)", "(meaning the rate obtained by dividing the amount listed in item (vii)" with "(meaning the rate obtained by dividing the amount listed in item (ix)", and "(meaning the rate obtained by dividing the amount listed in item (xiii)" with "(meaning the rate obtained by dividing the amount listed in item (xv)", and the term "Article 74, paragraph (1), item (iii)" in the proviso to that paragraph is deemed to be replaced with "Article 110, paragraph (2), item (i), (d)".

The provisions of the preceding paragraph apply mutatis mutandis to the payment of high-cost medical expenses to a person who was an insured person of the relevant insurer during the calculation period (limited to a person who, on the reference date, is a dependent, etc. of a member, etc. (excluding an insured person of the late-stage elderly medical care system) of an insurer body, etc. (excluding an Association of Medical Care Systems for the Elderly Aged 75 and older under the Act on Assurance of Medical Care for Elderly People)). In this case, the term "Article 74, paragraph (1), item (iii)" in the proviso to that paragraph is deemed to be replaced with "Article 110, paragraph (2), item (i), (d)", the term "to be the insured person on the reference date, and the dependent, etc. on the reference date (" in the table of that paragraph with "(meaning a person who, on the reference date, is a member, etc. (excluding an insured person of the late-stage elderly medical care system) of an insurer body, etc. (excluding an Association of Medical Care Systems for the Elderly Aged 75 and older under the Act on Assurance of Medical Care for Elderly People); the same applies hereinafter in this table) to be the insured person on the reference date, and the dependent, etc. on the reference date (", "paragraph (1), item (i)" with "paragraph (1), item (iii)", "paragraph (1), item (vii)" with "paragraph (1), item (ix)", and "paragraph (1), item (xiii)" with "paragraph (1), item (xv)".

In paragraph (1) (including where applied mutatis mutandis in paragraphs (2) through (4)), paragraph (5) (including where applied mutatis mutandis in paragraph (6)) and paragraph (6), "insurer body, etc." means the Japan Health Insurance Association as an insurer under Article 123, paragraph (1) of the Act, the Japan Health Insurance Association that provides benefits relating to medical care under the provisions of the Mariners Insurance Act, a municipality (including a special ward; the same applies hereinafter), a National Health Insurance Society, a mutual aid association under the National Public Officers Mutual Aid Association Act or the Local Public Officers, etc. Mutual Aid Association Act, the Promotion and Mutual Aid Corporation for Private Schools of Japan, or an Association of Medical Care Systems for the Elderly Aged 75 and older under the Act on Assurance of Medical Care for Elderly People.

In paragraph (1) (including where applied mutatis mutandis in paragraphs (2) through (4)), paragraph (5) (including where applied mutatis mutandis in paragraph (6)) and paragraph (6), "member, etc." means a specially-insured day laborer (including a person who was a specially-insured day laborer (limited to a person who is within the period until there is no blank space left on the specially-insured day laborer's insurance book issued pursuant to Article 126 of the Act on which to affix a health insurance stamp, and excluding a person who is within a period in which the person does not become a specially-insured day laborer under Article 3, paragraph (2) of the Act owing to approval under the proviso to that paragraph, or a person who has returned that specially-insured day laborer's insurance book pursuant to Article 126, paragraph (3) of the Act); the same applies in the following paragraph, Article 43-3, paragraph (5) and Article 44, paragraphs (2) through (8)), an insured person of Mariners Insurance, a member of a mutual aid association under the National Public Officers Mutual Aid Association Act or the Local Public Officers, etc. Mutual Aid Association Act, a subscriber to the Private School Personnel Mutual Aid System under the provisions of the Private School Personnel Mutual Aid Association Act, the head of a household to which an insured person of National Health Insurance belongs or a member of a National Health Insurance Society (hereinafter referred to as a "householder, etc. under National Health Insurance"), or an insured person of the late-stage elderly medical care system.

In paragraph (1) (including where applied mutatis mutandis in paragraphs (2) through (4)), paragraph (5) (including where applied mutatis mutandis in paragraph (6)) and paragraph (6), "dependent, etc." means a dependent of a specially-insured day laborer, a dependent under the provisions of 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, or an insured person of National Health Insurance who belongs to the same household as a householder, etc. under National Health Insurance, other than that householder, etc. under National Health Insurance.