Article 145Special Medical Expenses
第百四十五条(特別療養費)
If a specially-insured day laborer falls under any of the following items, and three months (two months if the day on which the laborer fell under the item is the first day of the month; the same applies in paragraph (5)) have not elapsed since the first day of the month including the day on which the laborer fell under the item, or the laborer's dependent submitted a special medical expense card for a hospital, clinic or pharmacy that the dependent selected from those listed in Article 63, paragraph (3), item (i) or (ii) and received medical treatment therefrom, or submitted the special medical expense card to a designated home-nursing provider that the dependent selected and received designated home-nursing, special medical expenses required for the medical treatment or designated home-nursing are paid to the specially-insured day laborer; provided, however, that this does not apply if, with respect to the relevant sickness or injury, the specially-insured day laborer is eligible for benefits for medical treatment, for payment of 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, dependent's medical expenses, or dependent's medical expenses for home-nursing, or is eligible for payment of expenses for in-home long-term care services, expenses for special in-home long-term care services, expenses for community-based long-term care services, expenses for special community-based long-term care services, expenses for long-term care facility services, allowance for special long-term care facility service expenses, expenses for services to prevent long-term care, or expenses for special services to prevent long-term care pursuant to the provisions of the Long-Term Care Insurance Act:
次の各号のいずれかに該当する日雇特例被保険者でその該当するに至った日の属する月の初日から起算して三月(月の初日に該当するに至った者については、二月。第五項において同じ。)を経過しないもの又はその被扶養者が、特別療養費受給票を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若しくは薬局のうち自己の選定するものに提出して、そのものから療養を受けたとき、又は特別療養費受給票を指定訪問看護事業者のうち自己の選定するものに提出して、そのものから指定訪問看護を受けたときは、日雇特例被保険者に対し、その療養又は指定訪問看護に要した費用について、特別療養費を支給する。ただし、当該疾病又は負傷につき、療養の給付若しく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、家族療養費若しくは家族訪問看護療養費の支給又は介護保険法の規定による居宅介護サービス費の支給、特例居宅介護サービス費の支給、地域密着型介護サービス費の支給、特例地域密着型介護サービス費の支給、施設介護サービス費の支給、特例施設介護サービス費の支給、介護予防サービス費の支給若しくは特例介護予防サービス費の支給を受けることができるときは、この限りでない。
the specially-insured day laborer receives a specially-insured day laborer's insurance book for the first time;
初めて日雇特例被保険者手帳の交付を受けた者
the relevant specially insured day laborer's insurance book no longer contains blank space for stamps for proof of health insurance in the month in which insurance premiums for 26 days or more have been paid in total in the previous one month or two consecutive months or insurance premiums for 78 days or more have been paid in total in the previous three to six consecutive months, or was returned within the following month pursuant to the provisions of Article 126, paragraph (3), and the specially-insured day laborer then received a new specially-insured day laborer's insurance book; or
一月間若しくは継続する二月間に通算して二十六日分以上又は継続する三月ないし六月間に通算して七十八日分以上の保険料が納付されるに至った月において日雇特例被保険者手帳に健康保険印紙をはり付けるべき余白がなくなり、又はその月の翌月中に第百二十六条第三項の規定により日雇特例被保険者手帳を返納した後、初めて日雇特例被保険者手帳の交付を受けた者
the specially-insured day laborer receives a specially-insured day laborer's insurance book after one year or more has elapsed since the day on which the laborer's previous insurance book ceased to contain blank space for stamps for proof of health insurance or the day on which the laborer's previous insurance book was returned pursuant to the provisions of Article 126, paragraph (3) (the most recent specially-insured day laborer's insurance book if two or more insurance books have been issued).
前に交付を受けた日雇特例被保険者手帳(前に二回以上にわたり日雇特例被保険者手帳の交付を受けたことがある場合においては、最後に交付を受けた日雇特例被保険者手帳)に健康保険印紙をはり付けるべき余白がなくなった日又は第百二十六条第三項の規定によりその日雇特例被保険者手帳を返納した日から起算して一年以上を経過した後に日雇特例被保険者手帳の交付を受けた者
The amount of special medical expenses is the amount stated in item (i) below for medical treatment provided by a hospital, clinic, or pharmacy listed in Article 63, paragraph (3), item (i) or (ii) (if dietary treatment is included in the treatment, the sum of the amount stated in item (i) below and the amount stated in item (ii); if living support is included in the treatment, the sum of the amount stated in item (i) below and the amount stated in item (iii)), or the amount listed in item (iv) for designated home-nursing provided by a designated home-nursing provider:
an amount equivalent to 0.70 of the amount of expenses calculated for the medical treatment (excluding dietary treatment and living support) (if the amount exceeds the amount of expenses actually incurred in the medical treatment, the amount of expenses actually incurred);
the amount calculated by deducting the amount of standard co-payment for dietary treatment from the amount calculated for the dietary treatment (when the amount exceeds the amount of expenses actually incurred in the dietary treatment, the amount of expenses actually incurred);
the amount calculated by deducting the amount of standard co-payment for living support from the amount calculated for the living support (when the amount exceeds the amount of expenses actually incurred in the living support, the amount of expenses actually incurred); and
an amount equivalent to 0.70 of the amount of expenses calculated for designated home-nursing.
当該指定訪問看護につき算定された費用の額の百分の七十に相当する額
When applying the provisions of the preceding paragraph to a person who receives medical treatment or designated home-nursing referred to in paragraph (1) before the first March 31 after the person's 6th birthday, "0.70" in items (i) and (iv) of the same paragraph is replaced with "0.80".
When applying the provisions of paragraph (2) to a person who receives medical treatment or designated home-nursing referred to in paragraph (1) (excluding insured persons who fall under the cases listed in Article 74, paragraph (1), item (iii) as applied mutatis mutandis to Article 149 and their dependents, and the dependents of insured persons specified by Cabinet Order) after the month following the month which included the person's 70th birthday, "0.70" in paragraph (2), items (i) and (iv) are replaced with "0.80".
An insurer issued a special medical expense card upon application by a specially-insured day laborer who falls under any of the items of paragraph (1) if three months have not elapsed since the first day of the month in which the laborer acquired the eligibility.
The provisions of Article 132 apply mutatis mutandis to the payment of special medical expenses. In this case, the phrases "confirmation prescribed in Article 129, paragraph (3)" and "lack of confirmation" in Article 132, paragraph (2) are deemed to be replaced with "issuance of a special medical expense card" and "lack of issuance".
The provisions of Article 87, paragraphs (2) and (3) apply mutatis mutandis to the calculation of the amount of medical expenses paid pursuant to the provisions of Article 132, paragraph (1) and (2) as applied mutatis mutandis pursuant to the preceding paragraph.
The form and issuance of special medical expense cards and other necessary matters concerning them are specified by Order of the Ministry of Health, Labour and Welfare.
特別療養費受給票の様式及び交付その他特別療養費受給票に関して必要な事項は、厚生労働省令で定める。
第百四十六条
Special medical expenses for a specially-insured day laborer who received approval pursuant to the proviso to Article 3, paragraph (2) are not paid from the day on which the laborer becomes no longer a specially-insured day laborer, and special medical expenses for a specially-insured day laborer who returns the relevant specially-insured day laborer's insurance book pursuant to the provisions of Article 126, paragraph (3) are not paid from the day following the day on which that insurance book was returned.
Article 147High-Cost Medical Expenses
第百四十七条(高額療養費)
When the amount of co-payment made in relation to the payment of benefits for medical treatment or the amount calculated by deducting, from the amount of expenses incurred in medical treatment (excluding dietary treatment and living support), an amount equivalent to the amount paid as medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, dependent's medical expenses, dependent's medical expenses for home-nursing, or special medical expenses (in the following Article referred to as the "amount of co-payment pertaining to specially-insured day laborer") pertaining to a specially-insured day laborer is extremely large, high-cost medical expenses are paid to the specially-insured day laborer who received benefits for that medical treatment, or the payment of the medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing expenses, dependent's medical expenses, or dependent's medical expenses for home-nursing, or special medical expenses.
When the amount of co-payment, etc. pertaining to a specially-insured day laborer (when high-cost medical expenses referred to in the preceding Article are paid, the amount obtained by deducting an amount equivalent to the amount so paid from the amount of co-payment, etc.) or the sum of the amount to be borne by a user of a long-term care service pursuant to the provisions of Article 51, paragraph (1) of the Long-Term Care Insurance Act (when expenses for high-cost long-term care service referred to in the same paragraph are paid, the amount obtained by deducting the amount so paid from the amount to be borne by the user of long-term care service) and the amount to be borne by a user of a service to prevent long-term care pursuant to the provisions of Article 61, paragraph (1) of the same Act (when expenses for high-cost preventive long-term care service referred to in the same paragraph are paid, the amount obtained by deducting the amount so paid from the amount to be borne by the user of preventive long-term care service) is extremely large, expenses for high-cost medical treatment combined with long-term care are paid to the specially-insured day laborer who received benefits for medical treatment pertaining to the amount of the co-payment, or payment of medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, dependent's medical expenses, dependent's medical expenses for home-nursing, or special medical expenses.
日雇特例被保険者に係る一部負担金等の額(前条の高額療養費が支給される場合にあっては、当該支給額に相当する額を控除して得た額)並びに介護保険法第五十一条第一項に規定する介護サービス利用者負担額(同項の高額介護サービス費が支給される場合にあっては、当該支給額を控除して得た額)及び同法第六十一条第一項に規定する介護予防サービス利用者負担額(同項の高額介護予防サービス費が支給される場合にあっては、当該支給額を控除して得た額)の合計額が著しく高額であるときは、当該一部負担金等の額に係る療養の給付又は保険外併用療養費、療養費、訪問看護療養費、家族療養費、家族訪問看護療養費若しくは特別療養費の支給を受けた日雇特例被保険者に対し、高額介護合算療養費を支給する。
第百四十八条(受給方法)
A person who intends to receive payment of dietary treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, medical expenses, medical expenses for home-nursing, transport expenses, injury and sickness allowance, burial charges, lump-sum allowance for childbirth and childcare, childbirth allowance, dependent's medical expenses, dependent's medical expenses for home-nursing, dependent's transport expenses, dependent's burial charges, lump-sum allowance for dependent's childbirth and childcare, or special medical expenses pertaining to a specially-insured day laborer must submit an application for the payment with a specially-insured day laborer's insurance book, qualified recipient card, or other documents that prove that the person meets the recipient requirements pursuant to Order of the Ministry of Health, Labour and Welfare.
日雇特例被保険者に係る入院時食事療養費、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、傷病手当金、埋葬料、出産育児一時金、出産手当金、家族療養費、家族訪問看護療養費、家族移送費、家族埋葬料、家族出産育児一時金又は特別療養費の支給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、受給要件を備えることを証明できる日雇特例被保険者手帳又は受給資格者票及びその他の書類を添えて、申請しなければならない。
Article 149Application Mutatis Mutandis
第百四十九条(準用)
The provisions listed in the left-hand column of the following table apply mutatis mutandis to affairs pertaining to the specially-insured day laborers listed in the right-hand column of the same table.
| Articles 56 through 62 | Insurance benefits |
| Article 63, paragraph (2), Article 64, Article 70, paragraph (1), Article 72, paragraph (1), Article 73, Article 76, paragraphs (3) through (6), Article 78, and Article 84, paragraph (1) | 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, dependent medical expenses and special medical expenses |
| Articles 74, 75 and 75-2, Article 76, paragraphs (1) and (2), as well as Article 84, paragraph (2) | Benefits for Medical Treatment |
| Article 77 | Benefits of Medical Treatment and Payment of Medical Expenses Combined with Treatment Outside Insurance Coverage |
| Article 85, paragraphs (2) and (4) | Payment of Dietary Treatment Expenses for Inpatients |
| Article 85, paragraphs (5) and (6) | Payment of dietary treatment expenses for inpatients, living support expenses for inpatients, and medical expenses combined with treatment outside insurance coverage |
| Article 85, paragraph (8) | Payment of Dietary Treatment expenses for inpatients, living support expenses for inpatients, medical expenses combined with treatment outside insurance coverage, dependent medical expenses and special medical expenses |
| Article 85-2, paragraphs (2) and (4) | Payment of Living Support Expenses for Inpatients |
| Article 86, paragraphs (2) and (5) | Payment of Medical Expenses Combined with Treatment Outside Insurance Coverage |
| Article 87, paragraphs (2) and (3) | Payment of medical expenses |
| Article 88, paragraphs (2), (3), (6) through (11) and (13), Article 90, paragraph (1), Article 91, Article 92, paragraphs (2) and (3), as well as Article 94 | payment of medical expenses for home-nursing, dependent medical expenses for home-nursing, and special medical expenses |
| Article 88, paragraphs (4) and (12) | Payment of Medical Expenses for Home-Nursing |
| Article 97, paragraph (2) | Payment of transport expenses and dependent transport expenses |
| Article 103, paragraph (2), Article 108 paragraphs (1) through (3) and (5), as well as Article 109 | Payment of injury and sickness allowance and childbirth allowance |
| Article 110, paragraph (2) | Payment of dependent medical expenses |
| Article 110, paragraphs (3) through (5) and (8), as well as Article 110-2 | Payment of dependent medical expenses and special medical expenses |
| Article 111, paragraph (2) | Payment of Dependent Medical Expenses for Home-Nursing |
| Article 115, paragraph (2) | Payment of High-Cost Medical Expenses and Expenses for High-Cost Benefits for Medical Treatment Combined with Long-Term Care |
| Articles 116 through 121 | Specially-insured day laborer or a dependent thereof |
次の表の上欄に掲げる規定は、それぞれ同表の下欄に掲げる日雇特例被保険者に係る事項について準用する。
| 第五十六条から第六十二条まで | 保険給付 |
| 第六十三条第二項、第六十四条、第七十条第一項、第七十二条第一項、第七十三条、第七十六条第三項から第六項まで、第七十八条及び第八十四条第一項 | 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、家族療養費及び特別療養費の支給 |
| 第七十四条、第七十五条、第七十五条の二、第七十六条第一項及び第二項並びに第八十四条第二項 | 療養の給付 |
| 第七十七条 | 療養の給付及び保険外併用療養費の支給 |
| 第八十五条第二項及び第四項 | 入院時食事療養費の支給 |
| 第八十五条第五項及び第六項 | 入院時食事療養費、入院時生活療養費及び保険外併用療養費の支給 |
| 第八十五条第八項 | 入院時食事療養費、入院時生活療養費、保険外併用療養費、家族療養費及び特別療養費の支給 |
| 第八十五条の二第二項及び第四項 | 入院時生活療養費の支給 |
| 第八十六条第二項及び第五項 | 保険外併用療養費の支給 |
| 第八十七条第二項及び第三項 | 療養費の支給 |
| 第八十八条第二項、第六項から第十一項まで及び第十三項、第九十条第一項、第九十一条、第九十二条第二項及び第三項並びに第九十四条 | 訪問看護療養費、家族訪問看護療養費及び特別療養費の支給 |
| 第八十八条第四項及び第十二項 | 訪問看護療養費の支給 |
| 第九十七条第二項 | 移送費及び家族移送費の支給 |
| 第百三条第二項、第百八条第一項から第三項まで及び第五項並びに第百九条 | 傷病手当金及び出産手当金の支給 |
| 第百十条第二項 | 家族療養費の支給 |
| 第百十条第三項から第五項まで及び第八項並びに第百十条の二 | 家族療養費及び特別療養費の支給 |
| 第百十一条第二項 | 家族訪問看護療養費の支給 |
| 第百十五条第二項 | 高額療養費及び高額介護合算療養費の支給 |
| 第百十六条から第百二十一条まで | 日雇特例被保険者又はその被扶養者 |