Health Insurance Act

If a medical institution providing services covered by health insurance or a pharmacy providing services covered by health insurance as prescribed in Article 63, paragraph (3), item (i) or a designated home-nursing provider as prescribed in Article 88, paragraph (1) receives, by means of deception or other wrongful conduct, any payment of expenses relating to benefits for medical treatment or any payment pursuant to the provisions of Article 85, paragraph (5) (including when applied mutatis mutandis to Article 85-2, paragraph (5) or Article 86, paragraph (45)), Article 88, paragraph (6) (including when applied mutatis mutandis to Article 111, paragraph (3)) or Article 110, paragraph (4), the relevant insurer may cause the medical institution, pharmacy, or designated home-nursing provider to refund the amount so paid and to pay, in addition, an amount obtained by multiplying the amount to be refunded by four-tenths.

treatment that the Minister of Health, Labour and Welfare specifies as treatment, such as treatment using a drug that has particularly high substitutability for a pharmaceutical requiring guidance (meaning a pharmaceutical requiring guidance as prescribed in Article 4, paragraph (5), item (iii) of the Act on Securing Quality, Efficacy and Safety of Products Including Pharmaceuticals and Medical Devices (Act No. 145 of 1960)) or an over-the-counter pharmaceutical (meaning an over-the-counter pharmaceutical as prescribed in item (iv) of that paragraph), for which part of the cost is not covered by insurance benefits in view of the need to provide fair and efficient insurance benefits while ensuring the provision of appropriate medical care (hereinafter referred to as "partially uninsured treatment").

In specifying matters under paragraph (2), item (vi), the Minister of Health, Labour and Welfare is to give consideration so that the treatment takes into account income status, extent of symptoms, contents of medical treatment, and other circumstances of the person receiving the treatment.

the hospital, clinic or pharmacy pertaining to the relevant application has received repeated guidance due to a likelihood of inappropriate medical care or prescriptions with respect to insurance benefits pursuant to Article 73, paragraph (1) (including when applied mutatis mutandis to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149);

Beyond the provisions of the preceding paragraph (including when applied mutatis mutandis to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149), a medical institution providing services covered by health insurance or a pharmacy providing services covered by health insurance is responsible for benefits for medical treatment pursuant to the provisions of the Seamen'sMariners Insurance Act, National Health Insurance Act, National Public EmployeesOfficers Mutual Aid Association Act (Act No. 128 of 1958; including when this is applied mutatis mutandis to other laws and the same rule governs), or Local Public EmployeesOfficers, etc. Mutual Aid Association Act (hereinafter referred to as "medical insurance laws other than this act") as well as medical treatment for insured persons and dependents, benefits for medical treatment pursuant to the provisions of the Act on Assurance of Medical Care for Elderly People, and treatment pertaining to dietary treatment expenses for inpatients, living support expenses for inpatients, and medical expenses combined with treatment outside insurance coverage.

A physician providing health insurance treatment at a medical institution providing services covered by health insurance or a pharmacist filling health insurance prescriptions at a pharmacy providing services covered by health insurance is to be in charge of medical care or prescription pursuant to the provisions of the preceding paragraph (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149) and pursuant to medical insurance laws other than this act and the Act on Assurance of Medical Care for Elderly People.

a physician providing health insurance treatment at a medical institution providing services covered by health insurance or a pharmacist filling health insurance prescriptions at a pharmacy providing services covered by health insurance has violated the provisions of Article 72, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149; excluding when the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance had made efforts to provide reasonable care and supervision so as to prevent that violation);

beyond the preceding two items, a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance has violated the provisions of Article 70, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149);

wrongdoing is found with regard to a claim for expenses incurred in providing medical services, or a claim for payment pursuant to the provisions of Article 85, paragraph (5) (including when these provisions are applied mutatis mutandis to Article 85-2, paragraph (5), and Article 86, paragraph (45)) or Article 110, paragraph (4) (including when applied mutatis mutandis to Article 149);

the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance is requested to make a report, or to submit or present medical records, record books and other documents pursuant to the provisions of Article 78, paragraph (1) (including the cases where the same provision is applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149; the same applies in the following item) but fails to comply with the order or submits a false report;

the physician providing health insurance treatment or pharmacist filling health insurance prescriptions has violated the provisions of Article 72, paragraph (1) (including when applied mutatis mutandis to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149);

the physician providing health insurance treatment or pharmacist filling health insurance prescriptions had been requested to appear pursuant to the provisions of Article 78, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149; the same applies hereinafter in this item) but failed to respond or to reply to questions pursuant to the provisions of Article 78, paragraph (1), or answered untruthfully, or refused, obstructed, or evaded an inspection pursuant to the provisions of the same paragraph;

When intending to issue the Order of the Ministry of Health, Labour and Welfare referred to in Article 70, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149) or Article 70, paragraph (3), Article 70-2, or Article 72, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149), or intending to make a determination under Article 63, paragraph (2), item (iii) , (v) or (vvi), or Article 76, paragraph (2) (including when these provisions are applied mutatis mutandis pursuant to Article 149), the Minister of Health, Labour and Welfare is to consult with the Central Social Insurance Medical Council; provided, however, that this does not apply to a determination under Article 63, paragraph (2), item (iii) pertaining to advanced medical care techniques.

When an insured person, pursuant to Order of the Ministry of Health, Labour and Welfare, receives confirmation of being an insured person by electronic eligibility confirmation, etc. from a medical institution providing services covered by health insurance, etc. that the person selected, and receives evaluation treatment, patient-requested treatment , selective treatment or selectivepartially uninsured treatment, medical expenses combined with treatment outside insurance coverage are paid for expenses required for that treatment.

The amount of medical expenses combined with treatment outside insurance coverage in the case where evaluation treatment, patient-requested treatment or selective treatment is received (excluding the case where partially uninsured treatment is received together with that evaluation treatment, patient-requested treatment or selective treatment) is the amount listed in item (i) below (the aggregate of that amount and the amount listed in item (ii) if the medical treatment includes dietary treatment, or the aggregate of that amount and the amount listed in item (iii) if the medical treatment includes living support):

When intending to specify The amount of medical expenses combined with treatment outside insurance coverage in the matters as prescribed case where partially uninsured treatment is received (including the case where evaluation treatment, patient-requested treatment or selective treatment is received together with that partially uninsured treatment) is the amount obtained by deducting the amount listed in item (i), ii) below from the amount listed in item (i) below (the Ministeraggregate of Health, Labour, that deducted amount and the amount listed in item (ii) of the preceding paragraph if the medical treatment includes dietary treatment, or the aggregate of that deducted amount and Welfare is to consult with the amount listed in item (iii) of that paragraph if the Central Social Insurance Medical Council.medical treatment includes living support):

the amount obtained by deducting the amount listed in (b) from the amount listed in (a);

the amount of expenses calculated for the medical treatment (excluding dietary treatment and living support) pursuant to the rules prescribed by the Minister of Health, Labour and Welfare taking into account the provisions of Article 76, paragraph (2) (when the calculated amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred in the medical treatment);

the amount calculated, as costs not covered by insurance benefits, pursuant to the rules prescribed by the Minister of Health, Labour and Welfare taking into consideration trends in medical expenses, the financial condition of medical insurance, the circumstances of the person receiving the treatment, and other matters;

the amount obtained by multiplying the amount listed in the preceding item by the applicable ratio specified in the items of Article 74, paragraph (1) in accordance with the classifications listed in those items (if any of the measures listed in the items of Article 75-2, paragraph (1) need to be taken with respect to the co-payment referred to in Article 74, paragraph (1) for benefits for medical treatment, the amount calculated as if the relevant measures were taken).

The provisions of Article 64, Article 70, paragraph (1), Article 72,When intending to specify the matters as prescribed in paragraph (12), Article 73, Article 76, paragraphs (3) through (6), Article 77, Article 78, Article 84, paragraph (1item (i) or in item (i), Article 85, paragraphs (5) through (8) apply mutatis mutandis tosub-item (a) or (b) of the preceding paragraph, the paymentMinister of evaluation treatment, patient-requested treatmentHealth, Labour, and selective treatment received at or from a medical institution providing services covered by health insurance, as well as medical expenses combinedWelfare is to consult with treatment outside insurance coverage associated with the received treatmentthe Central Social Insurance Medical Council.

The provisions of Article 75 apply mutatis mutandis to payment of the amount calculated by deducting the amount payable as medical expenses combined with treatment outside insurance coverage with respect to expenses incurred in the relevant medical treatment from the amount of expenses calculated pursuant64, Article 70, paragraph (1), Article 72, paragraph (1), Article 73, Article 76, paragraphs (3) through (6), Article 77, Article 78, Article 84, paragraph (1), Article 85, paragraphs (5) through (8) apply mutatis mutandis to the provisionspayment of paragraph (2) in the case referred to in Article 85, paragraph (5) as applied mutatis mutandis pursuant to the preceding paragraph (when the amount exceeds the amount ofevaluation treatment, patient-requested treatment, selective treatment, and partially uninsured treatment received at or from a medical institution providing services covered by health insurance, etc., as well as medical expenses actually incurred in the medicalcombined with treatment, the amount of expenses actually incurred in outside insurance coverage associated with the medicalreceived treatment).

The provisions of Article 75 apply mutatis mutandis to payment of the amount calculated by deducting the amount payable as medical expenses combined with treatment outside insurance coverage with respect to expenses incurred in the relevant medical treatment from the amount of expenses calculated pursuant to the provisions of paragraph (2) or (3) in the case referred to in Article 85, paragraph (5) as applied mutatis mutandis pursuant to the preceding paragraph (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 of medical expenses is determined by the insurer based on: (a) the amount calculated by deducting, from the amount calculated for the medical treatment (excluding dietary treatment and living support) (in the case where partially uninsured treatment is received (including the case where evaluation treatment, patient-requested treatment or selective treatment is received together with that partially uninsured treatment), the amount obtained by deducting from that amount the amount calculated in accordance with the example of the determination by the Minister of Health, Labour and Welfare pursuant to the provisions of paragraph (3), item (i), (b) of the preceding Article), the amount calculated by multiplying the amount by the applicable ratio specified in the items of Article 74, paragraph (1) in accordance with the classifications listed in the items of the same paragraph; and (b) the amount calculated by deducting, from the amount of expenses calculated for the dietary treatment or living support, the amount of standard co-payment for dietary treatment or standard co-payment for living support, respectively.

The amount of expenses referred to in the preceding paragraph is calculated as the amount referred to in Article 76, paragraph (2) when a benefit for medical treatment is to be received, the amount referred to in Article 85, paragraph (2) when expenses for dietary treatment for inpatients are to be received, the amount referred to in Article 85-2, paragraph (2) when expenses for living support for inpatients are to be received, and the amount referred to in paragraph (2) or (3) of the preceding Article when medical expenses combined with treatment outside insurance coverage are to be received; however, the amount must not exceed the amount of expenses actually required for medical treatment.

the amount obtained by multiplying the amount of expenses calculated for the medical treatment (excluding dietary treatment and living support) (if the amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred; the same applies hereinafter in this item) (in the case where partially uninsured treatment is received from a medical institution providing services covered by health insurance, etc. (including the case where evaluation treatment, patient-requested treatment or selective treatment is received together with that partially uninsured treatment), the amount obtained by deducting from that amount of expenses the amount calculated in accordance with the example of the determination by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 86, paragraph (3), item (i), (b)) by the ratio prescribed in (a) through (d) listed below in accordance with the classifications in (a) through (d):

The amount of expenses for medical treatment referred to in item (i) of the preceding paragraph is calculated pursuant to the provisions of Article 76, paragraph (2) when medical treatment (excluding evaluation treatment, patient-requested treatment, selective treatment, and selective partially uninsured treatment) is received from a medical institution providing services covered by health insurance, andetc., the provisions of Article 86, paragraph (2), item (i) when evaluation treatment, patient-requested treatment or selective treatment is received from a medical institution providing services covered by health insurance, etc. (excluding when partially uninsured treatment is received together with that evaluation treatment, patient-requested treatment or selective treatment), and the provisions of paragraph (3), item (i) of the same Article when partially uninsured treatment is received from a medical institution providing services covered by health insurance, etc. (including when evaluation treatment, patient-requested treatment or selective treatment is received together with that partially uninsured treatment), the amount of expenses for dietary treatment for inpatients referred to in item (ii) of the preceding paragraph is calculated pursuant to the provisions of Article 85, paragraph (2), and the amount of expenses for living support for inpatients referred to in item (iii) of the preceding paragraph is calculated pursuant to the provisions of Article 85-2, paragraph (2).

When a specially insuredspecially-insured day laborer submits the laborer's qualified recipient card and receives evaluation treatment, patient-requested treatment, selective treatment, or selectivepartially uninsured treatment from a hospital, clinic, or pharmacy that the laborer selected from those listed in Article 63, paragraph (3), item (i) or (ii), medical expenses combined with treatment outside insurance coverage are paid for expenses required for that treatment.

Beyond the affairs prescribed in Article 76, paragraph (5) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (45), Article 110, paragraph (7), and Article 149; the same applies in item (i)) and in Article 88, paragraph (11) (including when applied mutatis mutandis pursuant to Article 111, paragraph (3) and Article 149; the same applies hereinafter in the same item), an insurer may delegate the following affairs to the Infrastructure Organization or an NHI federation: