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Article 88Medical Expenses for Home-Nursing

第八十八条(訪問看護療養費)

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 or a long-term care medical institution prescribed in ; 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.

被保険者が、厚生労働大臣が指定する者(以下「指定訪問看護事業者」という。)から当該指定に係る訪問看護事業(疾病又は負傷により、居宅において継続して療養を受ける状態にある者(主治の医師がその治療の必要の程度につき厚生労働省令で定める基準に適合していると認めたものに限る。)に対し、その者の居宅において看護師その他厚生労働省令で定める者が行う療養上の世話又は必要な診療の補助(保険医療機関等又はに規定する介護老人保健施設若しくはに規定する介護医療院によるものを除く。以下「訪問看護」という。)を行う事業をいう。)を行う事業所により行われる訪問看護(以下「指定訪問看護」という。)を受けたときは、その指定訪問看護に要した費用について、訪問看護療養費を支給する。

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.

前項の訪問看護療養費は、厚生労働省令で定めるところにより、保険者が必要と認める場合に限り、支給するものとする。

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.

指定訪問看護を受けようとする者は、厚生労働省令で定めるところにより、自己の選定する指定訪問看護事業者から、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、当該指定訪問看護を受けるものとする。

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.

訪問看護療養費の額は、当該指定訪問看護につき指定訪問看護に要する平均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から、その額に第七十四条第一項各号に掲げる場合の区分に応じ、同項各号に定める割合を乗じて得た額(療養の給付に係る同項の一部負担金について第七十五条の二第一項各号の措置が採られるべきときは、当該措置が採られたものとした場合の額)を控除した額とする。

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.

厚生労働大臣は、前項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。

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.

被保険者が指定訪問看護事業者から指定訪問看護を受けたときは、保険者は、その被保険者が当該指定訪問看護事業者に支払うべき当該指定訪問看護に要した費用について、訪問看護療養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、当該指定訪問看護事業者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 medical expenses for home-nursing are paid to the insured person.

前項の規定による支払があったときは、被保険者に対し訪問看護療養費の支給があったものとみなす。

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.

第七十五条の規定は、第六項の場合において第四項の規定により算定した費用の額から当該指定訪問看護に要した費用について訪問看護療養費として支給される額に相当する額を控除した額の支払について準用する。

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.

指定訪問看護事業者は、指定訪問看護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 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).

保険者は、指定訪問看護事業者から訪問看護療養費の請求があったときは、第四項の定め及び第九十二条第二項に規定する指定訪問看護の事業の運営に関する基準(指定訪問看護の取扱いに関する部分に限る。)に照らして審査の上、支払うものとする。

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.

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。

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).

指定訪問看護は、第六十三条第一項各号に掲げる療養に含まれないものとする。

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.

前各項に定めるもののほか、指定訪問看護事業者の訪問看護療養費の請求に関して必要な事項は、厚生労働省令で定める。

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