Supplementary Provisions, Article 19
第十九条
Where an insurer pays high-cost medical expenses to an insured person pursuant to the provisions of Article 41-3, paragraph (1) of the New Order for Enforcement of the Health Insurance Act, for a person who has received confirmation by the insurer that the person falls under an insured person whose standard monthly remuneration for the month that includes the reference date prescribed in the proviso to Article 41-2, paragraph (1) of the New Order for Enforcement of the Health Insurance Act (including the day deemed to be the reference date pursuant to Article 43, paragraph (12) of the New Order for Enforcement of the Health Insurance Act; hereinafter referred to as the "reference date" in the following paragraph) is less than 160,000 yen (excluding persons listed in Article 42, paragraph (11), item (iv) of the New Order for Enforcement of the Health Insurance Act), the insurer is to calculate those high-cost medical expenses using the base amount for calculating high-cost medical expenses in accordance with the provisions of Article 42, paragraph (11) (limited to the part relating to item (iv)) of the item (ii) New Order for Enforcement of the Health Insurance Act.
保険者は、新健康保険法施行令第四十一条の三第一項の規定により、被保険者に対し、高額療養費を支給する場合において、新健康保険法施行令第四十一条の二第一項ただし書に規定する基準日（新健康保険法施行令第四十三条第十二項の規定により基準日とみなされる日を含む。次項において「基準日」という。）の属する月の標準報酬月額が十六万円未満の被保険者である者（新健康保険法施行令第四十二条第十一項第四号に掲げる者を除く。）に該当していることにつき保険者の確認を受けている者については、第二号新健康保険法施行令第四十二条第十一項（第四号に係る部分に限る。）の規定の例による高額療養費算定基準額を用いて、当該高額療養費を算定するものとする。
Where an insurer pays high-cost medical expenses to an insured person pursuant to the provisions of Article 41-3, paragraph (2) of the New Order for Enforcement of the Health Insurance Act, for a person who has received confirmation by the insurer that the person falls under an insured person whose standard monthly remuneration for the month that includes the reference date is less than 160,000 yen (excluding persons listed in Article 42, paragraph (12), item (iv) or (v) of the New Order for Enforcement of the Health Insurance Act), the insurer is to calculate those high-cost medical expenses using the annual base amount for calculating high-cost medical expenses for persons aged 70 or over in accordance with the provisions of Article 42, paragraph (12) (limited to the part relating to item (iv)) of the item (ii) New Order for Enforcement of the Health Insurance Act.
保険者は、新健康保険法施行令第四十一条の三第二項の規定により、被保険者に対し、高額療養費を支給する場合において、基準日の属する月の標準報酬月額が十六万円未満の被保険者である者（新健康保険法施行令第四十二条第十二項第四号又は第五号に掲げる者を除く。）に該当していることにつき保険者の確認を受けている者については、第二号新健康保険法施行令第四十二条第十二項（第四号に係る部分に限る。）の規定の例による七十歳以上年間高額療養費算定基準額を用いて、当該高額療養費を算定するものとする。
The confirmation under the preceding two paragraphs is to be made by the insurer, as provided by Order of the Ministry of Health, Labour and Welfare, upon the application of the person who receives payment of high-cost medical expenses under the provisions of Article 41-3 of the New Order for Enforcement of the Health Insurance Act, or by its own authority.
前二項の確認は、厚生労働省令で定めるところにより、新健康保険法施行令第四十一条の三の規定による高額療養費の支給を受ける者の申請により、又は職権で保険者が行うものとする。
reference datemachine translation
「基準日」
The last day of the calculation period (計算期間), the period from 1 August each year to the following 31 July, on which high-cost medical expenses (高額療養費) and similar amounts for the whole period are worked out.
Defined inArticle 41-2, paragraph (1)
New Order for Enforcement of the Health Insurance Actmachine translation
「新健康保険法施行令」
In Articles 2, 17 and 19 of the supplementary provisions (附則) of Cabinet Order No. 240 of 2026, the Order for Enforcement of the Health Insurance Act as amended by Article 1 of that Cabinet Order.
Short name set inSupplementary Provisions, Article 2, paragraph (1)· applies only in this article and in Supplementary Provisions, Articles 17 and 19
item (ii) New Order for Enforcement of the Health Insurance Actmachine translation
「第二号新健康保険法施行令」
In Articles 3 and 19 of the supplementary provisions (附則) of Cabinet Order No. 240 of 2026, the Order for Enforcement of the Health Insurance Act as amended by Article 2 of that Cabinet Order, which comes into effect on 1 August 2027.
Short name set inSupplementary Provisions, Article 3, paragraph (1)· applies only in this article and in Supplementary Provisions, Article 19, paragraphs (1) and (2)
reference datemachine translation
「基準日」
In Article 19 of the supplementary provisions (附則) of Cabinet Order No. 240 of 2026, the reference date provided in the proviso to Article 41-2, paragraph (1) of the Order for Enforcement of the Health Insurance Act as that Cabinet Order amended it — the last day of the calculation period running from 1 August to the following 31 July — including a day deemed to be the reference date under Article 43, paragraph (12) of the amended Order.
Short name set inSupplementary Provisions, Article 19, paragraph (1)· applies only in this provision and in Supplementary Provisions, Article 19, paragraph (2)