Section 2 Benefits for Medical Treatment and Payment of Dietary Treatment Expenses for Inpatients
第二節 療養の給付及び入院時食事療養費等の支給
Subsection 1 Payment of benefits for medical treatment, as well as payment of dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, and medical expenses
第一款 療養の給付並びに入院時食事療養費、入院時生活療養費、保険外併用療養費及び療養費の支給
Article 63Benefits for Medical Treatment
第六十三条（療養の給付）
With regard to sickness and injury of insured persons, benefits for medical treatment are paid as listed below:
被保険者の疾病又は負傷に関しては、次に掲げる療養の給付を行う。
medical examinations;
診察
provision of medication or materials for medical treatment;
薬剤又は治療材料の支給
treatment, operations or any other medical treatment;
処置、手術その他の治療
in-home medical care management as well as care and any other nursing involved in in-home medical care; and
居宅における療養上の管理及びその療養に伴う世話その他の看護
hospitalization or visiting a clinic, and care and other nursing involved in medical treatment provided there.
病院又は診療所への入院及びその療養に伴う世話その他の看護
Benefits for the following types of medical treatment are not included in the benefits referred to in the preceding paragraph:
次に掲げる療養に係る給付は、前項の給付に含まれないものとする。
medical treatment consisting of the provision of meals and given in combination with the type of medical treatment listed in item (v) of the preceding paragraph (excluding hospitalization in a sanatorium ward (hereinafter referred to as "sanatorium ward") as prescribed in Article 7, paragraph (2), item (iv) of the Medical Care Act (Act No. 205 of 1948), and care and other nursing involved in the medical treatment there which is provided to an insured person whose 65th birthday is in any month before the month in which the person receives the relevant medical treatment (hereinafter referred to as "insured person undergoing special long-term hospitalization"); hereinafter referred to as "dietary treatment");
食事の提供である療養であって前項第五号に掲げる療養と併せて行うもの（医療法（昭和二十三年法律第二百五号）第七条第二項第四号に規定する療養病床（以下「療養病床」という。）への入院及びその療養に伴う世話その他の看護であって、当該療養を受ける際、六十五歳に達する日の属する月の翌月以後である被保険者（以下「特定長期入院被保険者」という。）に係るものを除く。以下「食事療養」という。）
the following types of medical treatment given in combination with the type of medical treatment listed in item (v) of the preceding paragraph (limited to medical treatment provided to an insured person undergoing special long-term hospitalization; hereinafter referred to as "living support"):
次に掲げる療養であって前項第五号に掲げる療養と併せて行うもの（特定長期入院被保険者に係るものに限る。以下「生活療養」という。）
medical treatment consisting of the provision of meals;
食事の提供である療養
medical treatment consisting of the creation of an appropriate environment for medical treatment in terms of temperature, lighting and water supply;
温度、照明及び給水に関する適切な療養環境の形成である療養
medical treatment using advanced medical care techniques specified by the Minister of Health, Labour and Welfare and other medical treatment which are specified by the Minister of Health, Labour and Welfare as treatment that requires evaluation to determine whether it should be subject to benefits referred to in the preceding paragraph from the viewpoint of efficiently providing appropriate medical care (excluding patient-requested treatment in the following item; hereinafter referred to as "evaluation treatment");
medical treatment using advanced medical care techniques and specified by the Minister of Health, Labour and Welfare as treatment that requires evaluation to determine whether it should be subject to benefits referred to in the preceding paragraph, based on a request by the person who intends to receive the medical treatment, from the viewpoint of efficiently providing appropriate medical care (hereinafter referred to as "patient-requested treatment"); and
高度の医療技術を用いた療養であって、当該療養を受けようとする者の申出に基づき、前項の給付の対象とすべきものであるか否かについて、適正な医療の効率的な提供を図る観点から評価を行うことが必要な療養として厚生労働大臣が定めるもの（以下「患者申出療養」という。）
the provision of a special ward pertaining to the selection of insured persons and other medical treatment prescribed by the Minister of Health, Labour and Welfare (hereinafter referred to as "selective treatment").
被保険者の選定に係る特別の病室の提供その他の厚生労働大臣が定める療養（以下「選定療養」という。）
A person who intends to receive benefits under paragraph (1) is, pursuant to Order of the Ministry of Health, Labour and Welfare, to receive confirmation that the person is an insured person from a hospital, clinic, or pharmacy that the person selects from those listed below, by electronic eligibility confirmation or another method specified by Order of the Ministry of Health, Labour and Welfare (hereinafter referred to as "electronic eligibility confirmation, etc."), and to receive the benefits under that paragraph:
a hospital or clinic designated by the Minister of Health, Labour and Welfare (if the hospital or clinic has received a designation excluding all or some of its beds pursuant to the provisions of Article 65, excluding those beds; hereinafter referred to as "medical institution providing services covered by health insurance") or a pharmacy designated by the Minister of Health, Labour and Welfare (hereinafter referred to as "pharmacy providing services covered by health insurance");
厚生労働大臣の指定を受けた病院若しくは診療所（第六十五条の規定により病床の全部又は一部を除いて指定を受けたときは、その除外された病床を除く。以下「保険医療機関」という。）又は薬局（以下「保険薬局」という。）
a hospital, clinic, or pharmacy which provides medical care or prescriptions 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診療又は調剤を行う病院若しくは診療所又は薬局であって、当該保険者が指定したもの
a hospital, clinic, or pharmacy 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病院若しくは診療所又は薬局
A request referred to in paragraph (2), item (iv), as prescribed by the Minister of Health, Labour and Welfare, is to be made to the Minister of Health, Labour and Welfare and accompanied by statements by the establisher of the core clinical research hospital provided for by Article 4-3 of the Medical Care Act (limited to a medical institution providing services covered by health insurance) which provides the medical treatment to which the request pertains and other necessary documents.
When the Minister of Health, Labour and Welfare receives a request under paragraph (2), item (iv), the Minister of Health, Labour and Welfare is to promptly examine the request and specify the medical treatment pertaining to the request as patient-requested treatment if it is found to require the evaluation provided for in that item.
If Minister of Health, Labour and Welfare determines that the medical treatment to which the application referred to in paragraph (2), item (iv) pertains pursuant to the provisions of the preceding paragraph is patient-requested treatment, the Minister is to promptly notify the applicant to that effect.
If the Minister of Health, Labour and Welfare examines the application referred to in paragraph (2), item (iv) pursuant to the provisions of paragraph (5) and determines that the medical treatment pertaining to the application is not to be specified as patient-requested treatment, the Minister is to promptly notify the applicant to that effect and the reason therefor.
第六十四条（保険医又は保険薬剤師）
A physician or dentist engaged in medical treatment covered by health insurance at a medical institution providing services covered by health insurance or a pharmacist engaged in prescription covered by health insurance at a pharmacy providing services covered by health insurance must be a physician or dentist registered by the Minister of Health, Labour and Welfare (hereinafter collectively referred to as a "physician providing health insurance treatment") or a pharmacist registered by the Minister (hereinafter referred to as a "pharmacist filling health insurance prescriptions").
第六十五条（保険医療機関又は保険薬局の指定）
A designation referred to in Article 63, paragraph (3), item (i) is provided upon an application by the establisher who opened a hospital, clinic, or pharmacy, as specified by Cabinet Order.
第六十三条第三項第一号の指定は、政令で定めるところにより、病院若しくは診療所又は薬局の開設者の申請により行う。
In the case of the preceding paragraph, if the application pertains to a hospital or to a clinic that has beds, the application is to be made by specifying the number of beds for each classification of bed prescribed in Article 7, paragraph (2) of the Medical Care Act (simply referred to as "bed classification" in paragraph (4), item (ii), and paragraph (1) of the following Article).
When an application referred to in paragraph (1) is filed and the application falls under any of the following items, the Minister of Health, Labour and Welfare may determine not to make the designation referred to in Article 63, paragraph (3), item (i):
厚生労働大臣は、第一項の申請があった場合において、次の各号のいずれかに該当するときは、第六十三条第三項第一号の指定をしないことができる。
the hospital, clinic, or pharmacy pertaining to the application is a place of business or facility whose designation under Article 63, paragraph (3), item (i) pertaining to a medical institution providing services covered by health insurance providing services covered by health insurance or a pharmacy providing services covered by health insurance has been rescinded pursuant to the provisions of this Act and five years have not elapsed from the date of the rescission;
当該申請に係る病院若しくは診療所又は薬局が、この法律の規定により保険医療機関又は保険薬局に係る第六十三条第三項第一号の指定を取り消され、その取消しの日から五年を経過しないものであるとき。
the hospital, clinic or pharmacy pertaining to the relevant application has received repeated guidance due to a likelihood of inappropriate medical care or prescriptions with respect to insurance benefits pursuant to Article 73, paragraph (1) (including when applied mutatis mutandis to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (4), Article 110, paragraph (7), and Article 149);
the establisher or administrator of the hospital, clinic or pharmacy pertaining to the application has been sentenced to a fine pursuant to the provisions of this Act or other laws pertaining to citizen's health and medical care which are specified by Cabinet Order and the execution of the sentence has not yet been completed or the execution of the sentence still applies;
当該申請に係る病院若しくは診療所又は薬局の開設者又は管理者が、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であるとき。
the establisher or administrator of the hospital, clinic or pharmacy pertaining to the application has been sentenced to imprisonment or a more severe penalty and the execution of the sentence has not been completed or the execution of the sentence still applies;
当該申請に係る病院若しくは診療所又は薬局の開設者又は管理者が、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であるとき。
the establisher or administrator of the hospital, clinic, or pharmacy pertaining to the application has received a disposition of delinquency pursuant to this Act, the Seamen's Insurance Act, National Health Insurance Act (Act No. 192 of 1958), Act on Assurance of Medical Care for Elderly People, Local Public Employees Mutual Aid Association Act (Act No. 152 of 1962), Private School Personnel Mutual Aid Association Act (Act No. 245 of 1953), Employees' Pension Insurance Act (Act No. 115 of 1954), or National Pension Act (Act No. 141 of 1959) (referred to as "the social insurance laws" in Article 89, paragraph (4), item (vii)) with regard to the insurance premiums, contribution charges, or premiums (including national insurance tax pursuant to the provisions of the Local Tax Act (Act No. 226 of 1950); referred to as "social insurance premiums" hereinafter in this item, Article 89, paragraph (4), item (vii) and Article 199, paragraph (2)) which the establisher or administrator is obliged to pay pursuant to the provisions of those Acts, before the application was filed, and has continued to be delinquent, without justifiable grounds, for three months or more from the date on which the establisher or administrator received the disposition with respect to all social insurance premiums the due dates of which came after the date on which the establisher or administrator received the disposition (limited to social insurance premiums which the person who received the disposition is obliged to pay pursuant to laws specifying the obligation to pay social insurance premiums to which the disposition pertains; the same applies in Article 89, paragraph (4), item (vii)); or
当該申請に係る病院若しくは診療所又は薬局の開設者又は管理者が、この法律、船員保険法、国民健康保険法（昭和三十三年法律第百九十二号）、高齢者の医療の確保に関する法律、地方公務員等共済組合法（昭和三十七年法律第百五十二号）、私立学校教職員共済法（昭和二十八年法律第二百四十五号）、厚生年金保険法（昭和二十九年法律第百十五号）又は国民年金法（昭和三十四年法律第百四十一号）（第八十九条第四項第七号において「社会保険各法」という。）の定めるところにより納付義務を負う保険料、負担金又は掛金（地方税法（昭和二十五年法律第二百二十六号）の規定による国民健康保険税を含む。以下この号、第八十九条第四項第七号及び第百九十九条第二項において「社会保険料」という。）について、当該申請をした日の前日までに、これらの法律の規定に基づく滞納処分を受け、かつ、当該処分を受けた日から正当な理由なく三月以上の期間にわたり、当該処分を受けた日以降に納期限の到来した社会保険料の全て（当該処分を受けた者が、当該処分に係る社会保険料の納付義務を負うことを定める法律によって納付義務を負う社会保険料に限る。第八十九条第四項第七号において同じ。）を引き続き滞納している者であるとき。
beyond what is provided for in the preceding items, hospitals, clinics, or pharmacies to which the application pertains are deemed to be extremely inappropriate as a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance.
When an application referred to in paragraph (1) is filed pertaining to a hospital or clinic referred to in paragraph (2) and the application falls under any of the following items, the Minister of Health, Labour and Welfare may make the designation prescribed in Article 63, paragraph (3), item (i) excluding all or some of the beds pertaining to the application:
厚生労働大臣は、第二項の病院又は診療所について第一項の申請があった場合において、次の各号のいずれかに該当するときは、その申請に係る病床の全部又は一部を除いて、第六十三条第三項第一号の指定を行うことができる。
the number of physicians, dentists, nurses and other employees at the hospital or clinic does not meet the requirements for the number specified by Order of the Ministry of Health, Labour and Welfare prescribed in Article 21, paragraph (1), item (i) or paragraph (2), item (i) of the Medical Care Act or the number calculated based on the standards specified by the Minister of Health, Labour and Welfare in consideration of the standards specified by Order of the Ministry of Health, Labour and Welfare prescribed in paragraph (3) of the same Article;
当該病院又は診療所の医師、歯科医師、看護師その他の従業者の人員が、医療法第二十一条第一項第一号又は第二項第一号に規定する厚生労働省令で定める員数及び同条第三項に規定する厚生労働省令で定める基準を勘案して厚生労働大臣が定める基準により算定した員数を満たしていないとき。
it is found that the number of beds, according to the bed classification related to the application, at a medical institution providing services covered by health insurance in a region prescribed by Article 7-2, paragraph (1) of the Medical Care Act will, as a result of the designation, exceed the number calculated as specified by the Minister of Health, Labour and Welfare in consideration of the standard number of beds specified in the medical care plan prescribed in Article 30-4, paragraph (1) of the same Act (including where that number is already exceeded), and the establisher or administrator of the hospital or clinic has received a recommendation from the prefectural governor pursuant to the provisions of Article 30-11, paragraph (1) of the same Act but does not comply with the recommendation;
当該申請に係る病床の種別に応じ、医療法第七条の二第一項に規定する地域における保険医療機関の病床数が、その指定により同法第三十条の四第一項に規定する医療計画において定める基準病床数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数を超えることになると認める場合（その数を既に超えている場合を含む。）であって、当該病院又は診療所の開設者又は管理者が同法第三十条の十一第一項の規定による都道府県知事の勧告を受け、これに従わないとき。
it is found that the number of beds at a medical institution providing services covered by health insurance in a regional medical care vision area prescribed by Article 7-3, paragraph (1) of the Medical Care Act will, as a result of the designation pertaining to the application, exceed the number calculated as specified by the Minister of Health, Labour and Welfare in consideration of the required number of beds in the future specified in the medical care plan prescribed in Article 30-4, paragraph (1) of the same Act (including where that number is already exceeded), and the establisher or administrator of the hospital or clinic has received a recommendation from the prefectural governor pursuant to the provisions of Article 30-11, paragraph (1) of the same Act but does not comply with the recommendation; or
医療法第七条の三第一項に規定する構想区域における保険医療機関の病床数が、当該申請に係る指定により同法第三十条の四第一項に規定する医療計画において定める将来の病床数の必要量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数を超えることになると認める場合（その数を既に超えている場合を含む。）であって、当該病院又は診療所の開設者又は管理者が同法第三十条の十一第一項の規定による都道府県知事の勧告を受け、これに従わないとき。
it is found that the use of beds at the hospital or clinic is significantly inappropriate for a medical institution providing services covered by health insurance from the viewpoint of efficiently providing appropriate medical care.
その他適正な医療の効率的な提供を図る観点から、当該病院又は診療所の病床の利用に関し、保険医療機関として著しく不適当なところがあると認められるとき。
第六十六条（保険医療機関の指定の変更）
When intending to increase the number of beds or to alter bed classifications related to the designation pursuant to Article 63, paragraph (3), item (i), the establisher of the hospital or clinic referred to in paragraph (2) of the preceding Article must apply for a change of designation referred to in the same item pertaining to the hospital or clinic pursuant to Order of the Ministry of Health, Labour, and Welfare.
前条第二項の病院又は診療所の開設者は、第六十三条第三項第一号の指定に係る病床数の増加又は病床の種別の変更をしようとするときは、厚生労働省令で定めるところにより、当該病院又は診療所に係る同号の指定の変更を申請しなければならない。
The provisions of paragraph (4) of the preceding Article apply mutatis mutandis to an application for alteration of designation referred to in the preceding paragraph.
Article 67Advisory to Local Social Insurance Medical Councils
第六十七条（地方社会保険医療協議会への諮問）
When the Minister of Health, Labour and Welfare determines to not make a designation referred to in Article 63, paragraph (3), item (i) pertaining to a medical institution providing services covered by health insurance, determines to make a designation excluding all or some of the beds pertaining to that medical institution's application (including an alternation of such a designation), or determines to make a designation referred to in Article 63, paragraph (3), item (i) pertaining to a pharmacy providing services covered by health insurance, the Minister must undergo discussion at the relevant local social insurance medical council.
厚生労働大臣は、保険医療機関に係る第六十三条第三項第一号の指定をしないこととするとき、若しくはその申請に係る病床の全部若しくは一部を除いて指定（指定の変更を含む。）を行おうとするとき、又は保険薬局に係る同号の指定をしないこととするときは、地方社会保険医療協議会の議を経なければならない。
第六十八条（保険医療機関又は保険薬局の指定の更新）
A designation as referred to in Article 63, paragraph (3), item (i) expires when six years have elapsed after the day of designation.
第六十三条第三項第一号の指定は、指定の日から起算して六年を経過したときは、その効力を失う。
With regard to a medical institution providing services covered by health insurance (excluding hospitals and clinics referred to in Article 65, paragraph (2)) or a pharmacy providing services covered by health insurance that are specified by Order of the Ministry of Health, Labour and Welfare, unless otherwise notified during the period from since six months before the expiration date of the designation pursuant to the provisions of the preceding paragraph until three months before that date, the application under Article 65, paragraph (1) is deemed to have been made.