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Chapter IV Insurance Benefits (Articles 95 to 98-3)
The law as Act Partially Amending the Health Insurance Act, etc. (Act No. 31 of 2026) leaves it, with the words it changes marked.
The main text is read a page at a time: a chapter to a page, and a long chapter in runs of articles. The whole main text, and the supplementary provisions and appended tables this amendment changes. Those it leaves untouched are on the page for the text in force.
The Minister of Health, Labour and Welfare may rescind the designation referred to in Article 88, paragraph (1) pertaining to a designated home-nursing provider that falls under any of the following items:
厚生労働大臣は、次の各号のいずれかに該当する場合においては、当該指定訪問看護事業者に係る第八十八条第一項の指定を取り消すことができる。
the designated home-nursing provider has become unable to meet the standards and number of employees specified by Order of the Ministry of Health, Labour, and Welfare referred to in Article 92, paragraph (1) with regard to nurses and other employees at a home-nursing provider office to which the designation pertains;
指定訪問看護事業者が、当該指定に係る訪問看護事業所の看護師その他の従業者について、第九十二条第一項の厚生労働省令で定める基準又は同項の厚生労働省令で定める員数を満たすことができなくなったとき。
the designated home-nursing provider is no longer able to appropriately operate designated home-nursing services in accordance with standards for operations of designated home-nursing services prescribed in Article 92, paragraph (2) (including when applied mutatis mutandis to Article 111, paragraph (3) and Article 149);
指定訪問看護事業者が、第九十二条第二項（第百十一条第三項及び第百四十九条において準用する場合を含む。）に規定する指定訪問看護の事業の運営に関する基準に従って適正な指定訪問看護事業の運営をすることができなくなったとき。
there was a wrongful claim for payment pursuant to the provisions of Article 88, paragraph (6) (including when applied mutatis mutandis to Article 111, paragraph (3) and Article 149);
第八十八条第六項（第百十一条第三項及び第百四十九条において準用する場合を含む。）の規定による支払に関する請求について不正があったとき。
the designated home-nursing provider has been ordered to make a report, or submit or present record books or documents pursuant to the provisions of paragraph (1) of the preceding Article (including when applied mutatis mutandis to Article 111, paragraph (3) and Article 149; the same applies hereinafter in this Article), but fails to comply with the order or submits a false report;
指定訪問看護事業者が、前条第一項（第百十一条第三項及び第百四十九条において準用する場合を含む。以下この条において同じ。）の規定により報告若しくは帳簿書類の提出若しくは提示を命ぜられてこれに従わず、又は虚偽の報告をしたとき。
the designated home-nursing provider, or a nurse or employee at the home-nursing service office to which the designation pertains has been requested to appear pursuant to the provisions of paragraph (1) of the preceding Article but failed to respond or reply to questions pursuant to the provisions of the same paragraph, answered untruthfully, or refused, obstructed, or evaded an inspection pursuant to the provisions of the same paragraph (except when a nurse or employee at the home-nursing service office to which the designation pertains performed that conduct but the designated home-nursing provider had made efforts to provide reasonable care and supervision so as to prevent the conduct);
指定訪問看護事業者又は当該指定に係る訪問看護事業所の看護師その他の従業者が、前条第一項の規定により出頭を求められてこれに応ぜず、同項の規定による質問に対して答弁せず、若しくは虚偽の答弁をし、又は同項の規定による検査を拒み、妨げ、若しくは忌避したとき（当該指定に係る訪問看護事業所の看護師その他の従業者がその行為をした場合において、その行為を防止するため、当該指定訪問看護事業者が相当の注意及び監督を尽くしたときを除く。）。
there are grounds that correspond to any of item (ii) through the preceding item with respect to designated home-nursing for insured persons and their dependents pursuant to medical insurance laws other than this act or for insured persons pursuant to the Act on Assurance of Medical Care for Elderly People;
この法律以外の医療保険各法による被保険者若しくは被扶養者の指定訪問看護又は高齢者の医療の確保に関する法律による被保険者の指定訪問看護に関し、第二号から前号までのいずれかに相当する事由があったとき。
the designated home-nursing provider received its designation by wrongful means;
指定訪問看護事業者が、不正の手段により指定訪問看護事業者の指定を受けたとき。
the designated home-nursing provider has been sentenced to a fine pursuant to the provisions of this Act or other medical insurance laws which are specified by Cabinet Order and the payment of the fine has not yet been completed or the fine still applies;
指定訪問看護事業者が、この法律その他国民の保健医療に関する法律で政令で定めるものの規定により罰金の刑に処せられ、その執行を終わり、又は執行を受けることがなくなるまでの者に該当するに至ったとき。
the designated home-nursing provider has come to fall under the category of a person who 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
指定訪問看護事業者が、拘禁刑以上の刑に処せられ、その執行を終わり、又は執行を受けることがなくなるまでの者に該当するに至ったとき。
beyond what is provided for in the preceding items, the designated home nursing service provider violates this Act, other medical insurance laws which are specified by Cabinet Order, or an order or disposition based thereon.
前各号に掲げる場合のほか、指定訪問看護事業者が、この法律その他国民の保健医療に関する法律で政令で定めるもの又はこれらの法律に基づく命令若しくは処分に違反したとき。
The Minister of Health, Labour and Welfare must make public notice of the cases listed below in those cases:
厚生労働大臣は、次に掲げる場合には、その旨を公示しなければならない。
a home-nursing provider is designated;
指定訪問看護事業者の指定をしたとき。
there is a notification pursuant to the provisions of Article 93 (except for a change of matters specified by Order of the Ministry of Health, Labour, and Welfare referred to in the same Article and matters pertaining to suspension or recommencement of business provided by the same Article); or
第九十三条の規定による届出（同条の厚生労働省令で定める事項の変更並びに同条に規定する事業の休止及び再開に係るものを除く。）があったとき。
the designation of a designated home-nursing provider is rescinded pursuant to the provisions of the preceding Article.
前条の規定により指定訪問看護事業者の指定を取り消したとき。
When an insured person has been transported to a hospital or clinic in order to receive medical treatment (including medical treatment covered by medical expenses combined with treatment outside insurance coverage), the insurer pays, as transport expenses, an amount calculated pursuant to Order of the Ministry of Health, Labour and Welfare to the insured person.
被保険者が療養の給付（保険外併用療養費に係る療養を含む。）を受けるため、病院又は診療所に移送されたときは、移送費として、厚生労働省令で定めるところにより算定した金額を支給する。
The transport expenses referred to in the preceding paragraph are to be paid only if the insurer finds it necessary pursuant to Order of Ministry of Health, Labour and Welfare.
前項の移送費は、厚生労働省令で定めるところにより、保険者が必要であると認める場合に限り、支給するものとする。
If an insured person has lost eligibility and become a specially-insured day laborer or a dependent thereof, and, at the time of loss of the eligibility, the person is receiving, from among benefits for medical treatment, medical treatment covered by expenses for dietary treatment for inpatients, medical treatment covered by expenses for living support for inpatients, medical treatment covered by expenses for medical treatment combined with treatment outside insurance coverage, medical treatment covered by medical expenses, medical treatment covered by medical expenses for home-nursing, a designated in-home service covered by expenses for in-home long-term care service pursuant to the provisions of the Long-Term Care Insurance Act (meaning designated in-home service prescribed in Article 41, paragraph (1) of the same Act; the same applies in Article 129, paragraph (2), item (ii)), an in-home service covered by an exceptional allowance for in-home long-term care service (meaning in-home service prescribed in Article 8, paragraph (1) of the same Act; the same applies in Article 129, paragraph (2), item (ii) and Article 135, paragraph (1)), a service equivalent thereto, a designated community-based service covered by expenses for community-based long-term care service (meaning designated community-based service prescribed in Article 42-2, paragraph (1) of the same Act; the same applies in Article 129, paragraph (2), item (ii)), a community-based service covered by an exceptional allowance for community-based long-term care service (meaning community-based service prescribed in Article 8, paragraph (14) of the same Act; the same applies in Article 129, paragraph (2), item (ii) and Article 135, paragraph (1)), a service equivalent thereto, a designated facility service, etc. covered by expenses for long-term care facility service (meaning designated facility service, etc. prescribed in Article 48, paragraph (1) of the same Act; the same applies in Article 129, paragraph (2), item (ii)), a facility service covered by an exceptional allowance for long-term care facility service (meaning facility service prescribed in Article 8, paragraph (25) of the same Act; the same applies in Article 129, paragraph (2), item (ii) and Article 135, paragraph (1)), a designated service to prevent long-term care covered by expenses for service to prevent long-term care (meaning designated service to prevent long-term care prescribed in Article 53, paragraph (1) of the same Act; the same applies in Article 129, paragraph (2), item (ii)), a service to prevent long-term care covered by exceptional allowance for service to prevent long-term care (meaning service to prevent long-term care prescribed in Article 8-2, paragraph (1) of the same Act; the same applies in Article 129, paragraph (2), item (ii) and Article 135, paragraph (1)), or a service equivalent thereto, those equivalent to medical treatment, then the person may receive from the relevant insurer benefits for medical treatment, expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or transport expenses with respect to the relevant illness or injury, and any illness arising therefrom.
被保険者が資格を喪失し、かつ、日雇特例被保険者又はその被扶養者となった場合において、その資格を喪失した際に療養の給付、入院時食事療養費に係る療養、入院時生活療養費に係る療養、保険外併用療養費に係る療養、療養費に係る療養若しくは訪問看護療養費に係る療養又は介護保険法の規定による居宅介護サービス費に係る指定居宅サービス（同法第四十一条第一項に規定する指定居宅サービスをいう。第百二十九条第二項第二号において同じ。）、特例居宅介護サービス費に係る居宅サービス（同法第八条第一項に規定する居宅サービスをいう。同号及び第百三十五条第一項において同じ。）若しくはこれに相当するサービス、地域密着型介護サービス費に係る指定地域密着型サービス（同法第四十二条の二第一項に規定する指定地域密着型サービスをいう。同号において同じ。）、特例地域密着型介護サービス費に係る地域密着型サービス（同法第八条第十四項に規定する地域密着型サービスをいう。同号及び第百三十五条第一項において同じ。）若しくはこれに相当するサービス、施設介護サービス費に係る指定施設サービス等（同法第四十八条第一項に規定する指定施設サービス等をいう。同号において同じ。）、特例施設介護サービス費に係る施設サービス（同法第八条第二十五項に規定する施設サービスをいう。同号及び第百三十五条第一項において同じ。）、介護予防サービス費に係る指定介護予防サービス（同法第五十三条第一項に規定する指定介護予防サービスをいう。同号において同じ。）若しくは特例介護予防サービス費に係る介護予防サービス（同法第八条の二第一項に規定する介護予防サービスをいう。同号及び第百三十五条第一項において同じ。）若しくはこれに相当するサービスのうち、療養に相当するものを受けているときは、当該疾病又は負傷及びこれにより発した疾病につき、当該保険者から療養の給付又は入院時食事療養費、入院時生活療養費、保険外併用療養費、療養費、訪問看護療養費若しくは移送費の支給を受けることができる。
Benefits for medical treatment, or expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or transportation expenses pursuant to the provisions of the preceding paragraph are not paid when any of the events listed in the following items has occurred:
前項の規定による療養の給付又は入院時食事療養費、入院時生活療養費、保険外併用療養費、療養費、訪問看護療養費若しくは移送費の支給は、次の各号のいずれかに該当するに至ったときは、行わない。
the relevant person has become eligible for payment of benefits for medical treatment, expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, transport expenses, dependent's medical expenses, dependent's medical expenses for home-nursing, or dependent's transport expenses pursuant to the provisions of the next chapter with respect to the relevant illness or injury;
当該疾病又は負傷について、次章の規定により療養の給付又は入院時食事療養費、入院時生活療養費、保険外併用療養費、療養費、訪問看護療養費、移送費、家族療養費、家族訪問看護療養費若しくは家族移送費の支給を受けることができるに至ったとき。
the person has become an insured person, insured person covered by Seamen's Insurance, a dependent thereof, an insured person covered by National Health Insurance, or a person with late-stage elderly medical care insurance; or
その者が、被保険者若しくは船員保険の被保険者若しくはこれらの者の被扶養者、国民健康保険の被保険者又は後期高齢者医療の被保険者等となったとき。
six months have elapsed since the day on which the relevant person lost eligibility as an insured person.
被保険者の資格を喪失した日から起算して六月を経過したとき。
Benefits for medical treatment, or expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, or transport expenses pursuant to the provisions of paragraph (1) are not paid during the period in which the relevant person is eligible for payment of special medical expenses (including medical expenses paid pursuant to the provisions of Article 132 as applied mutatis mutandis to Article 145, paragraph (6)), transport expenses, or dependent's transport expenses pursuant to the provisions of the next chapter with respect to the relevant illness or injury.
第一項の規定による療養の給付又は入院時食事療養費、入院時生活療養費、保険外併用療養費、療養費、訪問看護療養費若しくは移送費の支給は、当該疾病又は負傷について、次章の規定により特別療養費（第百四十五条第六項において準用する第百三十二条の規定により支給される療養費を含む。）又は移送費若しくは家族移送費の支給を受けることができる間は、行わない。
Benefits for medical treatment, or expenses for dietary treatment for inpatients, expenses for living support for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, or medical expenses for home-nursing pursuant to the provisions of paragraph (1) are not paid if the relevant person is eligible for any benefit corresponding to one of the above benefits pursuant to the provisions of the Long-Term Care Insurance Act with respect to the relevant illness or injury.
第一項の規定による療養の給付又は入院時食事療養費、入院時生活療養費、保険外併用療養費、療養費若しくは訪問看護療養費の支給は、当該疾病又は負傷について、介護保険法の規定によりそれぞれの給付に相当する給付を受けることができる場合には、行わない。
When an insured person, pursuant to Order of the Ministry of Health, Labour and Welfare, receives confirmation that the person is an insured person by electronic eligibility confirmation, etc., and receives delivery care, from a delivery-handling medical institution providing services covered by health insurance, etc. or a birthing center listed in the following items (hereinafter referred to as "designated birthing centers, etc.") that the insured person selects, delivery expenses are paid for the expenses required for the delivery care.
被保険者が、厚生労働省令で定めるところにより、分娩取扱保険医療機関等又は次に掲げる助産所（以下「指定助産所等」という。）のうち、自己の選定するものから、電子資格確認等により、被保険者であることの確認を受け、分娩の手当を受けたときは、その分娩の手当に要した費用について、分娩費を支給する。
a birthing center designated by the Minister of Health, Labour and Welfare (hereinafter referred to as "designated birthing center");
厚生労働大臣の指定を受けた助産所（以下「指定助産所」という。）
a birthing center which provides delivery care to an insured person administered by a specific insurer and which is specified by the insurer; and
特定の保険者が管掌する被保険者に対して分娩の手当を行う助産所であって、当該保険者が指定したもの
a birthing center established by an insurer which is a health insurance society.
健康保険組合である保険者が開設する助産所
The amount of delivery expenses is the amount of expenses calculated for the relevant delivery care as specified by the Minister of Health, Labour and Welfare in consideration of the standard amount of expenses required for delivery care.
分娩費の額は、当該分娩の手当につき分娩の手当に要する標準的な費用の額を勘案して厚生労働大臣が定めるところにより算定した費用の額とする。
When an insured person receives delivery care from a hospital or clinic listed in Article 63, paragraph (3), item (i) or (ii) (limited to one that handles deliveries) or a birthing center listed in paragraph (1), item (i) or (ii), the insurer may, on behalf of the insured person, pay to the hospital or clinic or the birthing center the expenses required for the delivery care payable by the insured person to the hospital or clinic or the birthing center within the limit of the amount payable to the insured person as delivery expenses.
被保険者が第六十三条第三項第一号若しくは第二号に掲げる病院若しくは診療所（分娩を取り扱うものに限る。）又は第一項第一号若しくは第二号に掲げる助産所から分娩の手当を受けたときは、保険者は、その被保険者が当該病院若しくは診療所又は当該助産所に支払うべき分娩の手当に要した費用について、分娩費として被保険者に対し支給すべき額の限度において、被保険者に代わり、当該病院若しくは診療所又は当該助産所に支払うことができる。
When a payment pursuant to the provisions of the preceding paragraph is made, it is deemed that delivery expenses are paid to the insured person.
前項の規定による支払があったときは、被保険者に対し分娩費の支給があったものとみなす。
When an insured person receives delivery care from a hospital or clinic listed in Article 63, paragraph (3), item (iii) (limited to one that handles deliveries) or a birthing center listed in paragraph (1), item (iii), if the insurer exempts the insured person from payment of an amount equivalent to the amount to be paid to the insured person as delivery expenses among the expenses required for the delivery care to be paid by the insured person, it is deemed that delivery expenses are paid.
被保険者が第六十三条第三項第三号に掲げる病院若しくは診療所（分娩を取り扱うものに限る。）又は第一項第三号に掲げる助産所から分娩の手当を受けた場合において、保険者がその被保険者の支払うべき分娩の手当に要した費用のうち分娩費として被保険者に支給すべき額に相当する額の支払を免除したときは、分娩費の支給があったものとみなす。
Upon acceptance of the payment of expenses required for delivery care, a delivery-handling medical institution providing services covered by health insurance, etc. or designated birthing center, etc. must issue a receipt therefor to the insured person who made the payment, pursuant to Order of the Ministry of Health, Labour and Welfare.
分娩取扱保険医療機関等又は指定助産所等は、分娩の手当に要した費用につき、その支払を受ける際、当該支払をした被保険者に対し、厚生労働省令で定めるところにより、領収証を交付しなければならない。
When an insurer receives a claim from a delivery-handling medical institution providing services covered by health insurance or a designated birthing center for the expenses required for delivery care (limited to the amount payable to the insured person as delivery expenses; the same applies in paragraph (9)), the insurer is to make payment after examination in light of the provisions of paragraph (2), the Order of the Ministry of Health, Labour and Welfare referred to in Article 70, paragraph (1) and Article 72, paragraph (1) as applied mutatis mutandis pursuant to Article 98-5, and the Order of the Ministry of Health, Labour and Welfare referred to in Article 98-10, paragraph (1) and Article 98-13, paragraph (1).
保険者は、分娩取扱保険医療機関又は指定助産所から分娩の手当に要した費用（分娩費として被保険者に対し支給すべき額を限度とする。第九項において同じ。）の請求があったときは、第二項の定め並びに第九十八条の五において準用する第七十条第一項及び第七十二条第一項の厚生労働省令並びに第九十八条の十第一項及び第九十八条の十三第一項の厚生労働省令に照らして審査の上、支払うものとする。
An insurer may delegate the affairs concerning examination and payment pursuant to the provisions of the preceding paragraph to the Infrastructure Organization or an NHI federation.
保険者は、前項の規定による審査及び支払に関する事務を基盤機構又は国保連合会に委託することができる。
Beyond what is provided for in the preceding paragraphs, necessary matters concerning claims for expenses incurred in providing delivery care at a delivery-handling medical institution providing services covered by health insurance or designated birthing center are specified by Order of the Ministry of Health, Labour and Welfare.
前各項に定めるもののほか、分娩取扱保険医療機関又は指定助産所の分娩の手当に要した費用の請求に関して必要な事項は、厚生労働省令で定める。
When an insurer finds it difficult to pay delivery expenses pursuant to the provisions of paragraph (1) in cases where an insured person receives delivery care, or finds it unavoidable in cases where an insured person has received delivery care from a person other than a delivery-handling medical institution providing services covered by health insurance, etc. or designated birthing center, etc., the insurer may pay, pursuant to Order of the Ministry of Health, Labour and Welfare, an amount equivalent to the cost required for that delivery care, determined by the insurer based on the amount of expenses calculated in accordance with the example of the determination under paragraph (2); however, that amount must not exceed the amount of expenses actually required for that delivery care.
保険者は、被保険者が分娩の手当を受ける場合において第一項の規定による分娩費の支給を行うことが困難であると認めるとき、又は被保険者が分娩取扱保険医療機関等若しくは指定助産所等以外の者から分娩の手当を受けた場合において保険者がやむを得ないものと認めるときは、厚生労働省令で定めるところにより、第二項の定めの例により算定した費用の額を基準として保険者が定める当該分娩の手当に要した費用に相当する金額を支給することができる。ただし、その額は、現に当該分娩の手当に要した費用の額を超えることができない。
Survey by the Minister of Health, Labour and Welfare Regarding Determination of the Amount of Delivery Expenses
分娩費の額の定めに関する厚生労働大臣の調査
The Minister of Health, Labour and Welfare is to conduct necessary surveys in order to ensure the appropriateness of the determination under paragraph (2) of the preceding Article.
厚生労働大臣は、前条第二項の定めを適正なものとするため、必要な調査を行うものとする。
A delivery-handling medical institution providing services covered by health insurance or designated birthing center must report to the Minister of Health, Labour and Welfare, in order to contribute to the survey referred to in the preceding paragraph, the details of the delivery care provided at that delivery-handling medical institution providing services covered by health insurance or designated birthing center and other information specified by the Minister.
分娩取扱保険医療機関又は指定助産所は、前項の調査に資するため、当該分娩取扱保険医療機関又は指定助産所において提供する分娩の手当の内容その他の厚生労働大臣が定める情報を厚生労働大臣に報告しなければならない。