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 or selective 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 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).
When intending to specify the matters as prescribed in item (i), the Minister of Health, Labour, and Welfare is to consult with the Central Social Insurance Medical Council.
厚生労働大臣は、前項第一号の定めをしようとするときは、中央社会保険医療協議会に諮問するものとする。
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, and selective treatment received at or from a medical institution providing services covered by health insurance, 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) 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).