Order for Enforcement of the Health Insurance Act

The adjustment of finances for health insurance on the basis of a single branch-insured person that is carried out pursuant to the provisions of Article 160, paragraph (4) of the Act is to be age adjustment and financial capability adjustment.

The age adjustment referred to in the preceding paragraph is to be carried out, in accordance with the classification of cases listed in the following items, as specified respectively in those items.

in the case where the branch age-adjusted standard benefit cost is the branch average benefit cost or more: to deduct the amount obtained by deducting that branch average benefit cost from that branch age-adjusted standard benefit cost;

in the case where the branch age-adjusted standard benefit cost is less than the branch average benefit cost: to add the amount obtained by deducting that branch age-adjusted standard benefit cost from that branch average benefit cost.

The financial capability adjustment referred to in paragraph (1) is to be carried out, in accordance with the classification of cases listed in the following items, as specified respectively in those items.

in the case where the branch benefit cost apportioned by total remuneration is the branch average benefit cost or more: to add the amount obtained by deducting that branch average benefit cost from that branch benefit cost apportioned by total remuneration;

in the case where the branch benefit cost apportioned by total remuneration is less than the branch average benefit cost: to deduct the amount obtained by deducting that branch benefit cost apportioned by total remuneration from that branch average benefit cost.

In the preceding two paragraphs, the meanings of the terms listed in the following items are as prescribed respectively in those items.

"branch age-adjusted standard benefit cost" means the total sum of the amounts obtained, for each age group, as specified by Order of the Ministry of Health, Labour and Welfare, by multiplying the average benefit per person by age group relating to that age group (meaning the amount obtained, as specified by Order of the Ministry of Health, Labour and Welfare, by dividing the amount obtained by deducting, from the estimated amount of expenses required in the business year following the business year (meaning the business year following the business year prescribed in Article 45-2 and, where the premium rate for each prefecture is calculated pursuant to the preceding Article, the business year to which the month of application prescribed in that Article belongs; the same applies hereinafter in this paragraph) for the benefits for medical treatment, etc. relating to insured persons of health insurance administered by JHIA and their dependents belonging to that age group, the estimated total sum of the amount equivalent to the partial co-payment payable pursuant to the provisions of the Act out of that estimated amount and the amount of national subsidy pursuant to the provisions of Article 153 of the Act, by the estimated total number of insured persons of health insurance administered by JHIA and their dependents belonging to that age group in the business year following the business year) by the estimated total number of the branch-insured person concerned and the dependents of that person belonging to that age group in the business year following the business year;

"branch average benefit cost" means the amount obtained by multiplying, as specified by Order of the Ministry of Health, Labour and Welfare, the average benefit per person (meaning the amount obtained, as specified by Order of the Ministry of Health, Labour and Welfare, by dividing the amount obtained by deducting, from the estimated amount of expenses required in the business year following the business year for the benefits for medical treatment, etc. relating to insured persons of health insurance administered by JHIA and their dependents, the estimated total sum of the amount equivalent to the partial co-payment payable pursuant to the provisions of the Act out of that estimated amount and the amount of national subsidy pursuant to the provisions of Article 153 of the Act (referred to as the "estimated total benefit cost" in the following item), by the estimated total number of insured persons of health insurance administered by JHIA and their dependents in the business year following the business year) by the estimated total number of the branch-insured person concerned and the dependents of that person in the business year following the business year;

"branch benefit cost apportioned by total remuneration" means the amount obtained by multiplying, as specified by Order of the Ministry of Health, Labour and Welfare, the estimated total benefit cost by the estimated value of the total remuneration proportion ratio prescribed in Article 160, paragraph (3), item (ii) of the Act in the business year following the business year.

The rate specified by Cabinet Order as referred to in Article 160-2, paragraph (1) of the Act is 2.5/1,000.

JHIA must, at the end of each business year, accumulate the amount of surplus of that business year as a reserve until it reaches the sum of the amount equivalent to one-twelfth of the average per business year of the amount of expenses required for insurance benefits provided in that business year and the two business years immediately preceding it (including the amount of expenses required for payment of young-old payments, etc., aid for the old-old, etc., and day laborer contributions, long-term care payments, and contributions for securing medical care in the early phase of an epidemic, etc. (where there is a young-old subsidy, the amount after deducting it), and excluding the amount of childbirth and childcare grants and the amount of national subsidies pursuant to the provisions of Articles 153 and 154 of the Act), and the amount determined by the Minister of Health, Labour and Welfare in consultation with the Prime Minister, within a range not exceeding the amount equivalent to one-twelfth of the amount of expenses required for payment of the children and child-rearing support levy made in that business year, taking into account the expenses required for the payment of the children and child-rearing support levy by insurers in that year.

A health insurance society must, at the end of each business year, accumulate the amount of surplus of that business year as a reserve until it reaches the sum of the amount equivalent to three-twelfths of the average per business year of the amount of expenses required for insurance benefits provided in that business year and the two business years immediately preceding it (excluding the amount of expenses required for insurance benefits relating to medical treatment that an insured person or the dependent of that person received from a hospital, clinic, or pharmacy listed in Article 63, paragraph (3), item (iii) of the Act, and the amount of childbirth and childcare grants), the amount equivalent to one-twelfth of the average per business year of the amount of expenses required for payment of young-old payments, etc., aid for the old-old, etc., and day laborer contributions, long-term care payments, and contributions for securing medical care in the early phase of an epidemic, etc. provided in that business year and the two business years immediately preceding it (where there is a young-old subsidy, the amount after deducting it), and the amount determined by the Minister of Health, Labour and Welfare in consultation with the Prime Minister, within a range not exceeding the amount equivalent to one-twelfth of the amount of expenses required for payment of the children and child-rearing support levy made in that business year, taking into account the expenses required for the payment of the children and child-rearing support levy by insurers in that year.