Health Insurance Act

The administrator of a medical institution providing services covered by health insurance must be a person who satisfies all of the following requirements.

the person is a physician providing health insurance treatment;

the person is equipped with the requirements specified by Order of the Ministry of Health, Labour and Welfare, such as the experience of having engaged in medical care as a physician providing health insurance treatment at a medical institution providing services covered by health insurance (limited to a hospital) for three years or more after completing clinical training under Article 16-2, paragraph (1) of the Medical Practitioners' Act (Act No. 201 of 1948), or the experience of having engaged in medical care as a physician providing health insurance treatment at a medical institution providing services covered by health insurance for three years or more after completing clinical training under Article 16-2, paragraph (1) of the Dental Practitioners Act (Act No. 202 of 1948).

In order to provide appropriate medical care efficiently, the administrator of a medical institution providing services covered by health insurance must, as specified by Order of the Ministry of Health, Labour and Welfare, supervise the physicians, dentists, pharmacists and other employees working at that medical institution providing services covered by health insurance, and exercise necessary care in the management and operation of that medical institution providing services covered by health insurance.

Registration under Article 64 is made upon an application by a physician, dentist or pharmacist.

If an application referred to in the preceding paragraph that corresponds to any of the following items is filed, the Minister of Health, Labour and Welfare may not make a registration under Article 64:

the applicant is a person whose registration under Article 64 pertaining to physicians providing health insurance treatment or pharmacists filling health insurance prescriptions pursuant to the provisions of this Act has been rescinded and five years have not elapsed from the date of rescission;

the applicant has been sentenced to a fine pursuant to the provisions of this Act or other laws pertaining to citizen's health and medical care which are specified by Cabinet Order, and the execution of the sentence has not yet been completed or the execution of the sentence still applies;

the applicant has been sentenced to imprisonment or a severer punishment and the execution of the sentence has not been completed or the execution of the sentence still applies; or

beyond what is provided in the preceding three items, the applicant is deemed extremely inappropriate as a physician providing health insurance treatment or a pharmacist filling health insurance prescriptions.

If the Minister of Health, Labour and Welfare determines not to make a registration referred to in Article 64 pertaining to a physician providing health insurance treatment or a pharmacist filling health insurance prescriptions, the Minister must undergo discussion at the relevant local social insurance medical council.

Beyond what is provided for in paragraphs (1) and (2), necessary matters concerning registration referred to in Article 64 pertaining to physicians providing insurance treatment and pharmacists filling insurance prescriptions are specified by Cabinet Order.

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 must provide medical care or prescription services covered by health insurance pursuant to Order of the Ministry of Health, Labour and Welfare.

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 (5), 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 medical institution providing services covered by health insurance or a pharmacy providing services covered by health insurance, and the physician providing health insurance treatment or the pharmacist filling health insurance prescriptions, must receive guidance from the Minister of Health, Labour and Welfare with respect to benefits for medical treatment and with respect to medical care or prescription services provided under a national health insurance program, respectively.

When the guidance referred to in the preceding paragraph is provided, and the Minister of Health, Labour and Welfare finds it necessary, the Minister is to have persons with knowledge and experience concerning medical care or prescription services attend during the guidance pursuant to designation by related organizations; provided, however, that this does not apply if related organizations make no designation or the designated persons do not attend.

A person who receives benefits for medical treatment from a medical institution providing services covered by health insurance or a pharmacy providing services covered by health insurance pursuant to the provisions of Article 63, paragraph (3) must pay, in accordance with the classifications listed in the following items, an amount obtained by multiplying the amount calculated pursuant to the provisions of Article 76, paragraph (2) or (3) with respect to the benefit by the ratio specified in the relevant item below, as the person's co-payment to the medical institution or the pharmacy when receiving the benefit:

if the month in which the person's 70th birthday falls has not yet begun:0.30;

if the month in which the person's 70th birthday falls has elapsed (excluding the case listed in the following item):0.20; and

if the month in which the person's 70th birthday falls has elapsed and the amount of remuneration calculated as specified by Cabinet Order is not less than the amount specified by Cabinet Order:0.30.

A medical institution providing services covered by health insurance or a pharmacy providing services covered by health insurance is to receive the co-payment referred to in the preceding paragraph (if the reduction referred to in Article 75-2, paragraph (1), item (i) is made, the co-payment after the reduction) and, when a person who received the relevant benefit for medical treatment fails to make all or part of the co-payment despite the efforts of the medical institution or pharmacy to receive the payment with the same level of care as the due care of a prudent manager, the insurer may impose a disposition on the person pursuant to the same rules as those for the money to be collected pursuant to the provisions of this Act, at the request of the medical institution or pharmacy.

When co-payment is made pursuant to the provisions of paragraph (1) of the preceding Article, if the amount of co-payment referred to in the same paragraph is a figure with less than five, it is to be rounded down to the nearest ten yen, whereas if it is a figure with at least five yen but less than ten yen, it is to be rounded up to the nearest ten yen.

An insurer may take any of the following measures with respect to an insured person who is in a disaster or other special circumstances specified by Order of the Ministry of Health, Labour and Welfare and regarding whom it is found difficult to make co-payment to a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance pursuant to the provisions of Article 74, paragraph (1):

to reduce the amount of co-payment;

to exempt the insured person from making co-payment; or

to decide to collect co-payment directly from the insured person in lieu of co-payment to the medical institution medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance or to postpone the collection.

Notwithstanding the provisions of Article 74, paragraph (1), if the measure referred to in item (i) of the preceding paragraph has been taken with respect to an insured person, it is sufficient for the person to pay the amount of co-payment so reduced to the relevant medical institution or pharmacy providing services covered by health insurance, and if the measure referred to in item (ii) or (iii) has been taken with respect to an insured person, the person is not required to make co-payment to the relevant medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance.

The provisions of the preceding Article apply mutatis mutandis to co-payment in the case referred to in the preceding paragraph.

Insurers is to pay expenses related to benefits for medical treatment to medical institutions providing services covered by health insurance and pharmacies providing services covered by health insurance. The amount of expenses which a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance may claim to an insurer in relation to benefits for medical treatment is calculated by deducting the amount of co-payment payable to the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance by the insured person in relation to the benefits for medical treatment from the amount of expenses incurred in providing the benefits for medical treatment.

The amount of expenses for benefits for medical treatment referred to in the preceding paragraph is to be calculated as specified by the Minister of Health, Labour and Welfare.

An insurer may, with the authorization of the Minister of Health, Labour and Welfare, specify otherwise in a contract with a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance with respect to the amount of expenses incurred in providing the benefits for medical treatment referred to in paragraph (1) to be provided at the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance within the range of the amount calculated pursuant to the provisions of the preceding paragraph.

When receiving a claim for expenses incurred in providing medical services from a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance, the insurer is to make payment after conducting an examination in light of the provisions of Order of the Ministry of Health, Labour and Welfare referred to in Article 70, paragraph (1) and Article 72, paragraph (1) and the provisions of the preceding two paragraphs.

An insurer may delegate affairs concerning the examination and payment pursuant to the provisions of the preceding paragraph to the Medical Information Infrastructure and Medical Fee Examination and Payment Organization (hereinafter referred to as the "Infrastructure Organization") under the Medical Information Infrastructure and Medical Fee Examination and Payment Organization Act (Act No. 129 of 1948) or a federation of National Health Insurance Associations prescribed in Article 45, paragraph (5) of the National Health Insurance Act (hereinafter referred to as the "NHI federation").

Beyond what is provided for in the preceding paragraphs, necessary matters concerning claims for expenses incurred in providing medical services at a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance are specified by Order of the Ministry of Health, Labour and Welfare.

The Minister of Health, Labour and Welfare may conduct a necessary survey to ensure the appropriateness of the provisions for chemicals among the provisions of paragraph (2) of the preceding Article and other provisions specified by the Minister of Health, Labour and Welfare.

The Minister of Health, Labour and Welfare is to conduct a necessary survey in order to ensure the appropriateness of the provisions of paragraph (2) of the preceding Article with regard to hospitals, among medical institutions providing services covered by health insurance, that are specified by Order of the Ministry of Health, Labour and Welfare.

A hospital prescribed in the preceding paragraph must, in order to contribute to the survey under that paragraph, report to the Minister of Health, Labour and Welfare information specified by the Minister of Health, Labour and Welfare, such as the content of medical care provided to patients admitted to that hospital (referred to as "medical care-related information" in Article 150-2, paragraph (1) and Article 150-3).

When the Minister of Health, Labour and Welfare finds it necessary in relation to benefits for medical treatment, the minister or governor may order a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance, or a person who was an establisher or manager, physician who provided health insurance treatment, pharmacist who filled health insurance prescriptions, or another employee of a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance (hereinafter referred to as "former establisher, etc." in this paragraph) to make a report or submit or present medical records or other books and other documents, may request an establisher, manager, physician providing health insurance treatment, pharmacist filling health insurance prescriptions or another employee of a medical institution or pharmacy providing services covered by health insurance (including former establishers, etc.) to appear, or may have an official question persons involved or inspect any equipment or medical records, record books and documents or other objects of the medical institution or pharmacy providing services covered by health insurance.

The provisions of Article 7-38, paragraph (2) and Article 73, paragraph (2) apply mutatis mutandis to questions or inspections pursuant to the provisions of the preceding paragraph, and the provisions of Article 7-38, paragraph (3) apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding paragraph.

A medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance may decline its designation by giving notice not less than one month in advance.

A physician providing health insurance treatment or pharmacist filling health insurance prescriptions may request deregistration by giving notice not less than one month in advance.