Order for Enforcement of the Health Insurance Act

Expenses for high-cost medical treatment combined with long-term care are to be paid to the insured person on the reference date where the amount (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care" in this paragraph) obtained by deducting the total payment for combined long-term care for persons aged 70 or over (meaning the amount obtained by deducting the base amount for the combined long-term care calculation for persons aged 70 or over under the following paragraph from the household total of co-payments, etc. combined with long-term care for persons aged 70 or over prescribed in that paragraph (or zero, where that amount is equal to or less than the payment threshold specified by the Minister of Health, Labour and Welfare in consideration of the costs required for administering the payment of expenses for high-cost medical treatment combined with long-term care (hereinafter referred to as the "payment threshold" in this Article) or where the proviso to that paragraph applies to the calculation of that household total of co-payments, etc. combined with long-term care for persons aged 70 or over)) from the total sum of the following amounts exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation, and the amount of those expenses is to be the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation from the household total of co-payments, etc. combined with long-term care by the apportionment rate for the combined long-term care calculation (meaning the rate obtained by dividing the amount obtained by deducting the amount of expenses for high-cost medical treatment combined with long-term care to be paid under the provisions of the following paragraph from the amount listed in item (i), by the household total of co-payments, etc. combined with long-term care); provided, however, that this does not apply where the total sum of the amounts listed in that item through item (v) or the total sum of the amounts listed in items (vi) and (vii) is zero.

the total sum of the following amounts relating to medical treatment (including medical treatment under continued benefits) that the insured person on the reference date or a dependent thereof respectively received during the calculation period as an insured person of the relevant insurer or a dependent thereof (where high-cost medical expenses are paid pursuant to Article 41, paragraphs (1) through (5), Article 41-2 or Article 41-3, the amount after deducting the amount paid, and where money or goods to reduce the burden relating to the following amounts are provided as other benefits prescribed in Article 53 of the Act, the amount after deducting the amount equivalent to that money or those goods):

the total sum of the amounts listed in Article 41, paragraph (1), item (i), (a) through (f) relating to that medical treatment (excluding treatment subject to specified benefits) (for those relating to that medical treatment on or before the month that includes the day on which the person reaches the age of 70, limited to those of 21,000 yen or more for that medical treatment received from each single hospital, etc. in the same month (10,500 yen or more for those relating to medical treatment under the special rule on reaching age 75));

the total sum of the amounts that the person who received that medical treatment (limited to treatment subject to specified benefits) still has to bear for that treatment (for those relating to treatment subject to specified benefits on or before the month that includes the day on which the person reaches the age of 70, limited to those for which the amounts listed in Article 41, paragraph (1), item (i), (a) through (f) relating to that treatment subject to specified benefits are 21,000 yen or more for that treatment subject to specified benefits received from each single hospital, etc. in the same month (10,500 yen or more for those relating to medical treatment under the special rule on reaching age 75));

the total sum prescribed in item (i) for medical treatment that the insured person on the reference date received while that person was an insured person of the insurer of another health insurance in the calculation period, or medical treatment that a person who was a dependent of that person received while being a dependent of that person;

the total sum prescribed in item (i) for medical treatment (including medical treatment under continued benefits) that the dependent on the reference date received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person;

the total sum prescribed in item (i) for medical treatment that the dependent on the reference date received while that person was an insured person of the insurer of another health insurance in the calculation period, or medical treatment that a person who was a dependent of that person received while being a dependent of that person;

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 medical treatment (excluding the medical treatment prescribed in the preceding items) that the member, etc. received while the insured person on the reference date or the dependent on the reference date was a member, etc. (meaning a member, etc. prescribed in Article 41-2, paragraph (9); the same applies hereinafter in this item and paragraph (5)) in the calculation period, or medical treatment that a person who was a dependent, etc. (meaning a dependent, etc. prescribed in paragraph (10) of that Article; the same applies hereinafter in this item and paragraph (5)) of that member, etc. received while being a dependent, etc. thereof;

the total sum of the amounts listed in Article 22-2-2, paragraph (2), items (i) and (ii) of the Order for Enforcement of the Long-Term Care Insurance Act (Cabinet Order No. 412 of 1998) relating to in-home services, etc. (meaning in-home services, etc. prescribed in paragraph (1) of that Article; the same applies in the following paragraph) that the insured person on the reference date or the dependent on the reference date received during the calculation period (where expenses for high-cost long-term care service are paid pursuant to the provisions of paragraph (2) of that Article, the amount after deducting the amount paid);

the total sum of the amounts listed in Article 22-2-2, paragraph (2), items (iii) and (iv) of the Order for Enforcement of the Long-Term Care Insurance Act relating to preventive long-term care services, etc. (meaning preventive long-term care services, etc. prescribed in paragraph (2) of that Article; the same applies in the following paragraph) that the insured person on the reference date or the dependent on the reference date received during the calculation period (where expenses for high-cost preventive long-term care service are paid pursuant to the provisions of Article 29-2-2, paragraph (2) of that Order, the amount after deducting the amount paid).

Where the total sum (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care for persons aged 70 or over" in this paragraph) of the amounts calculated as provided by Order of the Ministry of Health, Labour and Welfare as amounts equivalent to those relating to medical treatment received on or after the month following the month that includes the day on which the person reaches the age of 70, or in-home services, etc. or preventive long-term care services, etc. (hereinafter referred to as "services subject to combination for persons aged 70 or over" in this paragraph and paragraph (6)), among the amounts listed in the items of the preceding paragraph, exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation for persons aged 70 or over, the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation for persons aged 70 or over from the household total of co-payments, etc. combined with long-term care for persons aged 70 or over by the apportionment rate for the combined long-term care calculation for persons aged 70 or over (meaning the rate obtained by dividing the amount calculated as provided by Order of the Ministry of Health, Labour and Welfare as an amount equivalent to the amount listed in item (i) of the preceding paragraph relating to services subject to combination for persons aged 70 or over, by the household total of co-payments, etc. combined with long-term care for persons aged 70 or over) is paid to the insured person on the reference date as expenses for high-cost medical treatment combined with long-term care; provided, however, that this does not apply where the total sum of the amounts calculated as provided by Order of the Ministry of Health, Labour and Welfare as amounts equivalent to the amounts listed in items (i) through (v) of the preceding paragraph relating to services subject to combination for persons aged 70 or over, or the total sum of the amounts calculated as provided by Order of the Ministry of Health, Labour and Welfare as amounts equivalent to the amounts listed in items (vi) and (vii) of that paragraph relating to services subject to combination for persons aged 70 or over, is zero.

The provisions of the preceding two paragraphs apply mutatis mutandis to the payment of expenses for high-cost medical treatment combined with long-term care 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 "listed in item (i)" in paragraph (1) is deemed to be replaced with "listed in item (iii)", the phrase "that item" in the proviso to that paragraph with "item (i)", and the phrase "item (i) of the preceding paragraph" in the preceding paragraph with "item (iii) of the preceding paragraph".

The provisions of paragraphs (1) and (2) apply mutatis mutandis to the payment of expenses for high-cost medical treatment combined with long-term care 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 an insured person of the insurer of another health insurance or a dependent thereof). In this case, the phrase "the amount listed in item (i)" in paragraph (1) is deemed to be replaced with "the total sum prescribed in item (i) for medical treatment (including medical treatment under continued benefits) that the person prescribed in paragraph (4) received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person", the phrase "the insured person on the reference date" in item (i) of that paragraph with "an insured person of the insurer of another health insurance (limited to a person who, on the reference date, is an insured person of the insurer of that other health insurance; hereinafter referred to as the "insured person on the reference date" in this paragraph and the following paragraph)", "of the relevant insurer" with "of the insurer of that other health insurance (hereinafter referred to as the "insurer on the reference date" in this paragraph)", the phrase "another health insurance" in item (ii) of that paragraph with "a health insurance other than that of the insurer on the reference date", the phrase "the dependent on the reference date" in item (iii) of that paragraph with "a dependent of the insured person on the reference date (limited to a person who, on the reference date, is a dependent of an insured person of the insurer on the reference date; hereinafter referred to as the "dependent on the reference date" in this paragraph)", "of the relevant insurer" with "of the insurer on the reference date", the phrase "another health insurance" in item (iv) of that paragraph with "a health insurance other than that of the insurer on the reference date", and the phrase "the amount listed in item (i) of the preceding paragraph relating to services subject to combination for persons aged 70 or over" in paragraph (2) with "the total sum prescribed in item (i) of the preceding paragraph for medical treatment (limited to medical treatment received on or after the month following the month that includes the day on which the person reaches the age of 70, and including medical treatment under continued benefits) that the person prescribed in paragraph (4) received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (limited to medical treatment received on or after the month following the month that includes the day on which the person reaches the age of 70, and including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person".

Expenses for high-cost medical treatment combined with long-term care for 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 member, etc. (excluding a householder, etc. under National Health Insurance who is an insured person or a dependent thereof, and an insured person of the late-stage elderly medical care system) or a dependent, etc.) are to be paid where the amount (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care" in this paragraph) obtained by deducting the total payment for combined long-term care for persons aged 70 or over (meaning the amount obtained by deducting the base amount for the combined long-term care calculation for persons aged 70 or over under the following paragraph from the household total of co-payments, etc. combined with long-term care for persons aged 70 or over prescribed in that paragraph (or zero, where that amount is equal to or less than the payment threshold or where the proviso to that paragraph applies to the calculation of that household total of co-payments, etc. combined with long-term care for persons aged 70 or over)) from the total sum of the amounts equivalent to the amounts listed in the items of paragraph (1) (hereinafter referred to as the "aggregated burden amount" in this paragraph and the following paragraph), calculated as provided by Order of the Ministry of Health, Labour and Welfare by deeming that member, etc. to be the insured person on the reference date and that dependent, etc. to be the dependent on the reference date, exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation, and the amount of those expenses is to be the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation from the household total of co-payments, etc. combined with long-term care by the apportionment rate for the combined long-term care calculation (meaning the rate obtained by dividing the amount obtained by deducting the amount of expenses for high-cost medical treatment combined with long-term care to be paid under the provisions of the following paragraph from the aggregated burden amount relating to medical treatment (including medical treatment under continued benefits) that the person prescribed in this paragraph received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person, by the household total of co-payments, etc. combined with long-term care); provided, however, that this does not apply where the total sum of the aggregated burden amounts relating to paragraph (1), items (i) through (v), or the total sum of the aggregated burden amounts relating to items (vi) and (vii) of that paragraph, is zero.

Where the total sum (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care for persons aged 70 or over" in this paragraph) of the amounts calculated as provided by Order of the Ministry of Health, Labour and Welfare (hereinafter referred to as the "aggregated burden amount for persons aged 70 or over" in this paragraph) as amounts equivalent to those relating to services subject to combination for persons aged 70 or over, among the aggregated burden amounts, exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation for persons aged 70 or over, the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation for persons aged 70 or over from the household total of co-payments, etc. combined with long-term care for persons aged 70 or over by the apportionment rate for the combined long-term care calculation for persons aged 70 or over (meaning the rate obtained by dividing the aggregated burden amount for persons aged 70 or over relating to medical treatment (including medical treatment under continued benefits) that the person prescribed in the preceding paragraph received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person, by the household total of co-payments, etc. combined with long-term care for persons aged 70 or over) is to be paid as expenses for high-cost medical treatment combined with long-term care to the person prescribed in that paragraph; provided, however, that this does not apply where the total sum of the aggregated burden amounts for persons aged 70 or over relating to paragraph (1), items (i) through (v), or the total sum of the aggregated burden amounts for persons aged 70 or over relating to items (vi) and (vii) of that paragraph, is zero.

Expenses for high-cost medical treatment combined with long-term care for 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 an insured person of the late-stage elderly medical care system) are to be paid where the total sum (hereinafter referred to as the "household total of co-payments, etc. combined with long-term care" in this paragraph) of the amounts equivalent to the amounts listed in the items of paragraph (1), calculated as provided by Order of the Ministry of Health, Labour and Welfare by deeming that insured person of the late-stage elderly medical care system to be the insured person on the reference date (hereinafter referred to as the "aggregated burden amount" in this paragraph) exceeds the amount obtained by adding the payment threshold to the base amount for the combined long-term care calculation, and the amount of those expenses is to be the amount obtained by multiplying the amount obtained by deducting the base amount for the combined long-term care calculation from the household total of co-payments, etc. combined with long-term care by the apportionment rate for the combined long-term care calculation (meaning the rate obtained by dividing the aggregated burden amount relating to medical treatment (including medical treatment under continued benefits) that the person prescribed in this paragraph received while that person was an insured person of the relevant insurer in the calculation period, or medical treatment (including medical treatment under continued benefits) that a person who was a dependent of that person received while being a dependent of that person, by the household total of co-payments, etc. combined with long-term care); provided, however, that this does not apply where the total sum of the aggregated burden amounts relating to paragraph (1), items (i) through (v), or the total sum of the aggregated burden amounts relating to items (vi) and (vii) of that paragraph, is zero.