Health Insurance Act

With regard to sickness and injury of insured persons, benefits for medical treatment are paid as listed below:

medical examinations;

provision of medication or materials for medical treatment;

treatment, operations or any other medical treatment;

in-home medical care management as well as care and any other nursing involved in in-home medical care; and

hospitalization or visiting a clinic, and care and other nursing involved in medical treatment provided there.

Benefits for the following types of medical treatment are not included in the benefits referred to in the preceding paragraph:

medical treatment consisting of the provision of meals and given in combination with the type of medical treatment listed in item (v) of the preceding paragraph (excluding hospitalization in a sanatorium ward (hereinafter referred to as "sanatorium ward") as prescribed in Article 7, paragraph (2), item (iv) of the Medical Care Act (Act No. 205 of 1948), and care and other nursing involved in the medical treatment there which is provided to an insured person whose 65th birthday is in any month before the month in which the person receives the relevant medical treatment (hereinafter referred to as "insured person undergoing special long-term hospitalization"); hereinafter referred to as "dietary treatment");

the following types of medical treatment given in combination with the type of medical treatment listed in item (v) of the preceding paragraph (limited to medical treatment provided to an insured person undergoing special long-term hospitalization; hereinafter referred to as "living support"):

medical treatment consisting of the provision of meals;

medical treatment consisting of the creation of an appropriate environment for medical treatment in terms of temperature, lighting and water supply;

medical treatment using advanced medical care techniques specified by the Minister of Health, Labour and Welfare and other medical treatment which are specified by the Minister of Health, Labour and Welfare as treatment that requires evaluation to determine whether it should be subject to benefits referred to in the preceding paragraph from the viewpoint of efficiently providing appropriate medical care (excluding patient-requested treatment in the following item; hereinafter referred to as "evaluation treatment");

medical treatment using advanced medical care techniques and specified by the Minister of Health, Labour and Welfare as treatment that requires evaluation to determine whether it should be subject to benefits referred to in the preceding paragraph, based on a request by the person who intends to receive the medical treatment, from the viewpoint of efficiently providing appropriate medical care (hereinafter referred to as "patient-requested treatment"); and

the provision of a special ward pertaining to the selection of insured persons and other medical treatment prescribed by the Minister of Health, Labour and Welfare (hereinafter referred to as "selective treatment").

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 (9), 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").

A person who intends to receive benefits under paragraph (1) is, pursuant to Order of the Ministry of Health, Labour and Welfare, to receive confirmation that the person is an insured person from a hospital, clinic, or pharmacy that the person selects from those listed below, by electronic eligibility confirmation or another method specified by Order of the Ministry of Health, Labour and Welfare (hereinafter referred to as "electronic eligibility confirmation, etc."), and to receive the benefits under that paragraph:

a hospital or clinic designated by the Minister of Health, Labour and Welfare (if the hospital or clinic has received a designation excluding all or some of its beds pursuant to the provisions of Article 65, excluding those beds; hereinafter referred to as "medical institution providing services covered by health insurance") or a pharmacy designated by the Minister of Health, Labour and Welfare (hereinafter referred to as "pharmacy providing services covered by health insurance");

a hospital, clinic, or pharmacy which provides medical care or prescriptions to an insured person administered by a specific insurer and which is specified by the insurer; and

a hospital, clinic, or pharmacy established by an insurer which is a health insurance society.

A request referred to in paragraph (2), item (iv), as prescribed by the Minister of Health, Labour and Welfare, is to be made to the Minister of Health, Labour and Welfare and accompanied by statements by the establisher of the core clinical research hospital provided for by Article 4-3 of the Medical Care Act (limited to a medical institution providing services covered by health insurance) which provides the medical treatment to which the request pertains and other necessary documents.

When the Minister of Health, Labour and Welfare receives a request under paragraph (2), item (iv), the Minister of Health, Labour and Welfare is to promptly examine the request and specify the medical treatment pertaining to the request as patient-requested treatment if it is found to require the evaluation provided for in that item.

If Minister of Health, Labour and Welfare determines that the medical treatment to which the application referred to in paragraph (2), item (iv) pertains pursuant to the provisions of the preceding paragraph is patient-requested treatment, the Minister is to promptly notify the applicant to that effect.

If the Minister of Health, Labour and Welfare examines the application referred to in paragraph (2), item (iv) pursuant to the provisions of paragraph (5) and determines that the medical treatment pertaining to the application is not to be specified as patient-requested treatment, the Minister is to promptly notify the applicant to that effect and the reason therefor.

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.

A physician or dentist engaged in medical treatment covered by health insurance at a medical institution providing services covered by health insurance or a pharmacist engaged in prescription covered by health insurance at a pharmacy providing services covered by health insurance must be a physician or dentist registered by the Minister of Health, Labour and Welfare (hereinafter collectively referred to as a "physician providing health insurance treatment") or a pharmacist registered by the Minister (hereinafter referred to as a "pharmacist filling health insurance prescriptions").