Health Insurance Act

Dietary treatment expenses for inpatients are paid to an insured person (excluding insured persons undergoing special long-term hospitalization) who, pursuant to Order of the Ministry of Health, Labour and Welfare, has received from a hospital or clinic that the person selected from those listed in the items of Article 63, paragraph (3) confirmation of being an insured person by electronic eligibility confirmation, etc., for expenses required for dietary treatment that the person received along with benefits for medical treatment listed in Article 63, paragraph (1), item (v).

The amount of dietary treatment expenses for inpatients is the amount obtained by deducting the amount specified by the Minister of Health, Labor and Welfare taking into consideration the status of food expenses for an average household budget and the average amount of expenses required to provide meals at a specified facility for insured long-term care (meaning the specified facilities for insured long-term care prescribed in Article 51-3, paragraph (1) of the Long-Term Care Insurance Act) from the amount calculated based on standards specified by the Minister of Health, Labour and Welfare taking into account the average amount of expenses required for the dietary treatment (if the calculated amount exceeds the amount of expenses actually incurred in the dietary treatment, the amount of expenses actually incurred in the dietary treatment) (for a person specified by Order of Health, Labor and Welfare in consideration of income status and other circumstances, a separately determined amount; hereinafter referred to as "standard co-payment for dietary treatment").

When intending to specify the standards referred to in the preceding paragraph, the Minister of Health, Labour, and Welfare is to consult with the Central Social Insurance Medical Council.

If the circumstances to be taken into consideration have changed significantly since the Minister of Health, Labour, and Welfare determines the amount of standard co-payment for dietary treatment, the Minister must promptly revise the amount.

When an insured person (excluding insured persons undergoing special long-term hospitalization; the same applies hereinafter in this Article) has received dietary treatment at or from a hospital or clinic listed in Article 63, paragraph (3), item (i) or (ii), the insurer may, on behalf of the insured person, pay to the hospital or clinic the expenses incurred for the dietary treatment payable by the insured person to the hospital or clinic within the limit of the amount payable to the insured person as expenses for dietary treatment for inpatients.

When a payment pursuant to the provisions of the preceding paragraph is paid, it is deemed that the relevant dietary treatment expenses for inpatients are paid to the insured person.

When an insured person receives dietary treatment from a hospital or clinic listed in Article 63, paragraph (3), item (iii), if the insurer exempts the insured person from payment of an amount equivalent to the amount to be paid as dietary treatment expenses for inpatients among the expenses required for dietary treatment to be paid by the insured person, it is deemed that dietary treatment expenses for inpatients are paid to the insured person.

Upon acceptance of a payment of expenses incurred for dietary treatment, the hospital or clinic listed in the items of Article 63, paragraph (3) must issue a receipt therefor to the relevant insured person who makes the payment, pursuant to Ordinance of the Ministry of Health, Labour and Welfare.

The provisions of Article 64, Article 70, paragraph (1), Article 72, paragraph (1), Article 73, Article 76, paragraphs (3) through (6), Article 78, and paragraph (1) of the preceding Article apply mutatis mutandis to payment of dietary treatment received at or from a hospital or clinic listed in the items of Article 63, paragraph (3) and dietary treatment expenses for inpatients associated with that dietary treatment.

Living support expenses for inpatients are paid to an insured person undergoing special long-term hospitalization who, pursuant to Order of the Ministry of Health, Labour and Welfare, has received from a hospital or clinic that the person selected from those listed in the items of Article 63, paragraph (3) confirmation of being an insured person by electronic eligibility confirmation, etc., for expenses required for living support that the person received along with benefits for medical treatment listed in Article 63, paragraph (1), item (v).

The amount of living support expenses for inpatients is the amount obtained by deducting the amount specified by the Minister of Health, Labor and Welfare taking into consideration an amount equivalent to the amount of base cost for meal expenses prescribed in Article 51-3, paragraph (2), item (i) of the Long-Term Care Insurance Act and the amount of base cost for residence expenses prescribed in item (ii) of the same paragraph with regard to the status of food expenses for an average household budget and fuel, lighting and water charges as well as expenses required for living support at hospitals and clinics from the amount calculated based on standards specified by the Minister of Health, Labour and Welfare taking into account the average amount of expenses required for the living support (when the calculated amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses actually incurred in the living support) (for a person specified by Order of the Ministry of Health, Labor and Welfare in consideration of income status, extent of symptoms, contents of medical treatment, and other circumstances, a separately determined amount; hereinafter referred to as "standard co-payment for living support").

When intending to specify the standards referred to in the preceding paragraph, the Minister of Health, Labour, and Welfare is to consult with the Central Social Insurance Medical Council.

If the circumstances to be taken into consideration have changed significantly since the Minister of Health, Labour, and Welfare determined the amount of standard co-payment for living support, the minister must promptly revise the amount.

The provisions of Article 64, Article 70, paragraph (1), Article 72, paragraph (1), Article 73, Article 76, paragraphs (3) through (6), Article 78, Article 84, paragraph (1), and paragraphs (5) through (8) of the preceding Article apply mutatis mutandis to payment of living support received at or from a hospital or clinic listed in the items of Article 63, paragraph (3) and living support expenses for inpatients associated with the living support.

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 partially 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):

the amount calculated by deducting, from 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 obtained by multiplying that amount by the applicable ratio specified in the items of Article 74, paragraph (1) (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 the same paragraph for benefits for medical treatment, the amount calculated as if the relevant measures were taken), in accordance with the classifications listed in the in the same items;

the amount calculated by deducting the amount of standard co-payment for dietary treatment from the amount calculated for the dietary treatment pursuant to the standards set by the Minister of Health, Labour and Welfare prescribed in the provisions of Article 85, paragraph (2) (when the calculated amount exceeds the amount of expenses actually incurred for the dietary treatment, the amount of expenses actually incurred for the dietary treatment); and

the amount calculated by deducting the amount of standard co-payment for living support from the amount calculated for the living support pursuant to the standards set by the Minister of Health, Labour and Welfare prescribed in the provisions of paragraph (2) of the preceding Article (when the amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses actually incurred in the living support).

The amount of medical expenses combined with treatment outside insurance coverage 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) is the amount obtained by deducting the amount listed in item (ii) below from the amount listed in item (i) below (the aggregate of 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 the amount listed in item (iii) of that paragraph if the 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).

When intending to specify the matters as prescribed in paragraph (2), item (i) or in item (i), sub-item (a) or (b) of the preceding paragraph, the Minister of Health, Labour, and Welfare is to consult with the Central Social Insurance Medical Council.

The provisions of Article 64, 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 payment of evaluation 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 combined with treatment outside insurance coverage associated with the received 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).

When an insurer finds it difficult to pay benefits for medical treatment, expenses for dietary treatment for inpatients, living support expenses for inpatients, or medical expenses combined with treatment outside insurance coverage (hereinafter referred to as "benefits for medical treatment, etc." in this paragraph) or finds it unavoidable in cases where an insured person has received any medical care, medication or treatment at or from a hospital, clinic, pharmacy or any other person other than a medical institution providing services covered by health insurance, it may pay medical expenses in lieu of benefits for medical treatment, etc.

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.