Health Insurance Act

When an insured person receives, from a person designated by the Minister of Health, Labour and Welfare (hereinafter referred to as a "designated home-nursing provider"), care for medical treatment or necessary assistance with medical treatment provided at the home of a person who is in a condition of continuing to receive medical treatment at home due to sickness or injury (limited to a person whom the attending physician finds to conform to the standards specified by Order of the Ministry of Health, Labour and Welfare as to the degree of necessity for treatment) by a nurse or other person specified by Order of the Ministry of Health, Labour and Welfare (excluding that provided by a medical institution providing services covered by health insurance, etc., or a long-term care health facility prescribed in Article 8, paragraph (27) of the Long-Term Care Insurance Act or a long-term care medical institution prescribed in paragraph (28) of that Article; hereinafter referred to as "home-nursing") that is provided by an office operating the home-nursing business pertaining to that designation (meaning the business of providing home-nursing) (hereinafter referred to as "designated home nursing"), medical expenses for home-nursing are paid to the insured person for the expenses required for that designated home nursing.

The medical expenses for home-nursing referred to in the preceding paragraph are paid only if the insurer finds it necessary pursuant to Order of the Ministry of Health, Labour and Welfare.

A person who intends to receive designated home nursing is to, as specified by Order of the Ministry of Health, Labour and Welfare, receive confirmation of being an insured person by electronic eligibility confirmation, etc. from the designated home-nursing provider that the person selects, and receive that designated home nursing.

The amount of expenses for home nursing is calculated by deducting, from the amount specified by the Minister of Health, Labour and Welfare for the home nursing taking into account the average expenses required for home-nursing, the amount obtained by multiplying the specified amount by the applicable ratio specified in an item 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 items of the same paragraph.

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

When an insured person has received designated home-nursing from a designated home-nursing provider, the insurer may, on behalf of the relevant insured person, pay to the designated home-nursing provider expenses incurred in the designated home-nursing payable by the insured person to the designated home-nursing provider, within the limit of the amount payable to the insured person as medical expenses for home-nursing.

When a payment pursuant to the provisions of the preceding paragraph is made, it is deemed that medical expenses for home-nursing are paid to the insured person.

The provisions of Article 75 apply mutatis mutandis to the payment of the amount calculated by deducting, from the amount of expenses calculated pursuant to the provisions of paragraph (4) in the case referred to in paragraph (6), the amount payable as medical expenses for home-nursing with respect to expenses incurred in the relevant designated home-nursing.

Upon acceptance of the payment of expenses incurred in designated home-nursing, the designated home-nursing provider must issue a receipt therefor to the insured person who made the payment, pursuant to Order of the Ministry of Health, Labour and Welfare.

When requested to pay medical expenses for home-nursing expenses by a designated home-nursing provider, an insurer is to conduct an examination in light of the matters prescribed in paragraph (4) and standards for operations in home-nursing prescribed in Article 92, paragraph (2) (limited to the part regarding the handling of designated home-nursing).

An insurer may delegate affairs concerning the examination and payment pursuant to the provisions of the preceding paragraph to the Infrastructure Organization or an NHI federation.

No designated home-nursing is to be included in any of the types of medical treatment listed in the items of Article 63, paragraph (1).

Beyond what is provided for in the provisions of the preceding paragraphs, necessary matters concerning requests for medical expenses for home-nursing by a designated home-nursing provider are specified by Order of the Ministry of Health, Labour and Welfare.

The designation referred to in paragraph (1) of the preceding Article is determined pursuant to Order of the Ministry of Health, Labour, and Welfare, upon application by a person that operates a home-nursing business, for each place of business that operates home-nursing business (hereinafter referred to as "home-nursing provider office").

With respect to a provider of home-nursing services other than a designated home-nursing provider, when a designation of an in-home service provider pursuant to the main clause of Article 41, paragraph (1) of the Long-Term Care Insurance Act (limited to a provider of home-nursing services which meets the standards specified by Order of the Ministry of Health, Labor and Welfare; the same applies in the following paragraph), a designation of a community-based service provider pursuant to the provisions of the main clause of Article 42-2, paragraph (1) of the same Act (limited to a provider of home-nursing services which satisfies the standards specified by Order of the Ministry of Health, Labor and Welfare; the same applies in the following paragraph), or a designation of a provider of services to prevent long-term care pursuant to the provisions of the main clause of Article 53, paragraph (1) of the same Act (limited to a provider of home-nursing services which meets the standards specified by Order of the Ministry of Health, Labor and Welfare; the same applies in the following paragraph) has been made, the designation referred to in paragraph (1) of the preceding Article is deemed to have been made for the relevant provider of home-nursing services; provided, however, that this does not apply if the provider of home-nursing services gives a different notification pursuant to Order of the Ministry of Health, Labour, and Welfare.

An expiration of the designation of a designated in-home service provider pursuant to the provisions of Article 70-2, paragraph (1) of the Long-Term Care Insurance Act or a rescission or suspension of validity of the designation of a designated in-home service provider pursuant to Article 77, paragraph (1) or Article 115-35, paragraph (6) of the same Act, a rescission or suspension of validity of the designation of a designated community-based service provider referred to in Article 78-10 of the same Act (including when applied by replacing terms pursuant to the provisions of Article 78-17 of the same Act), expiration of the designation of a designated community-based service provider referred to in Article 70-2, paragraph (1) of the same Act as applied mutatis mutandis pursuant to Article 78-12 of the same Act, or Article 78-15, paragraph (1) or (3) of the same Act (including when applied mutatis mutandis pursuant to paragraph (5) of that Article), rescission or expiration of the designation of a designated provider of services to prevent long-term care pursuant to Article 115-9, paragraph (1) of the same Act or Article 115-35, paragraph (6), or expiration of the designation of a designated provider of services to prevent long-term care service pursuant to Article 70-2, paragraph (1) of the same Act as applied mutatis mutandis to Article 115-11 of the same Act does not have any effect on the validity of a designation referred to in paragraph (1) of the preceding Article which is deemed to have been made pursuant to the provision of the main clause of the preceding paragraph.

When an application referred to in paragraph (1) corresponds to any of the following items, the Minister of Health, Labour and Welfare must not make a designation referred to in the main clause of paragraph (1) of the preceding Article:

the applicant is not a local government, a medical corporation, a social welfare corporation, or other person specified by the Minister of Health, Labour, and Welfare;

the knowledge and skills of the nurses and other employees at the home-nursing provider office to which the application pertains, and the number thereof, do not meet standards and number specified by Order of the Ministry of Health, Labour, and Welfare referred to in Article 92, paragraph (1);

it is determined that the applicant is unable to provide designated home-nursing services appropriately in accordance with standards for operations in home-nursing prescribed in Article 92, paragraph (2) (including when applied mutatis mutandis to Article 111, paragraph (3) and Article 149);

the applicant is a person whose designation referred to in paragraph (1) of the preceding Article pertaining to a designated home-nursing provider has been rescinded pursuant to the provisions of this Act and five years have not elapsed from the date of the rescission;

the applicant has been sentenced to a fine pursuant to the provisions of this Act or medical insurance laws other than this act which are specified by Cabinet Order, and the payment of the fine has not been completed or the fine still applies;

the applicant has been sentenced to imprisonment or a more severe penalty and the sentence has not been completed or has not yet expired;

with respect to social insurance premiums, the applicant has received a disposition of delinquency based on the provisions of social insurance laws or the Local Tax Act by the day preceding the day on which the application was filed, and has continued to be delinquent, without justifiable grounds, for three months or more from the date on which the applicant received the disposition with respect to all social insurance premiums the due dates of which came after the date on which the applicant received the disposition; or

beyond what is provided for in the preceding items, the applicant is deemed significantly inappropriate as a designated home-nursing provider.

A home-nursing provider is to provide appropriate designated home-nursing itself according to the physical and mental conditions of the person receiving home-nursing, in accordance with the standards for operations in home-nursing prescribed in Article 92, paragraph (2).

Beyond what is provided for in the provisions of the preceding paragraph (including when applied mutatis mutandis to Article 111, paragraph (3) and Article 149), a home-nursing provider is to provide insured persons and their dependents with designated home-nursing under medical insurance laws other than this act as well as the Act on Assurance of Medical Care for Elderly People.

A designated home-nursing provider, and the nurses and other employees at the home-nursing provider's office to which the designation pertains must receive guidance from the Minister of Health, Labour and Welfare concerning designated home-nursing.

A designated home-nursing provider must employ the number of employees, including nurses, specified by Order of the Ministry of Health, Labour, and Welfare in accordance with standards specified by Order of the Ministry of Health, Labour, and Welfare, at each home-nursing provider office to which the designation pertains.

Beyond what is provided for in the preceding paragraph, standards for operations of a designated home-nursing business are provided for by the Minister of Health, Labour, and Welfare.

When specifying matters concerning the standards for operations of a designated home-nursing business prescribed in the preceding paragraph (limited to the part concerning the handling of designated home-nursing), the Minister of Health, Labour, and Welfare is to hear the opinions of the Central Social Insurance Medical Council.

When the name or location of a home-nursing provider office to which the designation of a designated home-nursing provider pertains or other matters specified by Order of the Ministry of Health, Labour and Welfare are changed, or when the home-nursing business is abolished, suspended, or recommenced, the designated home-nursing provider must provide notification of the change to the Minister of Health, Labour and Welfare within ten days pursuant to Order of the Ministry of Health, Labour and Welfare.

If the Minister of Health, Labour and Welfare finds it necessary in relation to the payment of medical expenses for home-nursing, the Minister may order a designated home-nursing provider or an entity which was a designated home-nursing provider, or a person who was a nurse or other employee at the home-nursing provider office to which the designation pertains (hereinafter referred to as a "former designated home-nursing business, etc." in this paragraph) to make a report, or submit or present the books and other documents, may request a designated home-nursing provider, or a nurse or other employee at the home-nursing provider office to which the designation pertains (including a former designated home-nursing businesses, etc.) to appear, or may have the ministry's official question the persons involved, or inspect the books and other documents or other articles of the designated home-nursing provider at the home-nursing provider office to which the designation pertains.

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