Long-Term Care Insurance Act

A Municipality, in the following cases, pays to an Insured Person Requiring Long-Term Care, pursuant to the provisions of Order of the Ministry of Health, Labour and Welfare, an Exceptional Allowance for Long-Term Care Facility Service:

when the Municipality determines it necessary in a case when an Insured Person Requiring Long-Term Care receives Designated Facility Service, etc., prior to the date said Certification of Needed Long-Term Care becomes effective due to an emergency or other compelling reason;

when the Municipality determines it necessary in a case when an Insured Person Requiring Long-Term Care receives Facility Service for Long-Term Care Covered by Public Aid (hereinafter referred to as "Facility Service for Long-Term Care Covered by Public Aid in a Specified Area" in this Article) provided by a Facility Covered by Public Aid Providing Long-Term Care to the Elderly, other than a Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly, that is located in a Specified Area and is found to satisfy, among the number of employees specified by Prefectural Ordinance as set forth in Article 88, paragraph (1) pertaining to a Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly and the standards concerning facilities and management of a Designated Facility Covered by Public Aid Providing Long-Term Care to the Elderly prescribed in paragraph (2) of the same Article, those specified by Prefectural Ordinance (hereinafter referred to as "Facility Covered by Public Aid Providing Long-Term Care to the Elderly in a Specified Area" in the following paragraph);

when the Municipality determines it necessary in a case when an Insured Person Requiring Long-Term Care receives Long-Term Care Health Facility Service provided by a Long-Term Care Health Facility located in a Specified Area (limited to one pertaining to a person that has received the notification under Article 94, paragraph (5); hereinafter referred to as "Long-Term Care Health Facility Service in a Specified Area" in paragraph (4));

when the Municipality determines it necessary in a case when an Insured Person Requiring Long-Term Care receives service at an integrated facility for medical and long-term care provided by an integrated facility for medical and long-term care located in a Specified Area (limited to one pertaining to a person that has received the notification under Article 107, paragraph (5); hereinafter referred to as "Service at an Integrated Facility for Medical and Long-Term Care in a Specified Area" in paragraph (4));

when otherwise provided by a Cabinet Order.

A prefecture, in establishing a Prefectural Ordinance pursuant to the provisions of paragraph (1), item (ii), is to establish the matters listed in item (i) in accordance with the standards specified by Order of the Ministry of Health, Labour and Welfare, taking into consideration the status of population decline in areas that fall under the standards specified by Order of the Ministry of Health, Labour and Welfare prescribed in Article 42, paragraph (1), item (iii), the status of employees engaging in Facility Service for Long-Term Care Covered by Public Aid and other circumstances; is to establish the matters listed in items (ii) and (iii) in accordance with the standards specified by Order of the Ministry of Health, Labour and Welfare; and is to take into consideration the standards specified by Order of the Ministry of Health, Labour and Welfare for other matters.

employees engaging in Facility Service for Long-Term Care Covered by Public Aid in a Specified Area and the number of such employees;

the floor area of residence rooms pertaining to a Facility Covered by Public Aid Providing Long-Term Care to the Elderly in a Specified Area;

matters concerning the operation of a Facility Covered by Public Aid Providing Long-Term Care to the Elderly in a Specified Area that are closely related to ensuring the appropriate use of services, appropriate treatment and safety of Persons Requiring Long-Term Care who are admitted, and maintaining confidentiality, and that are specified by Order of the Ministry of Health, Labour and Welfare.

The amount of Exceptional Allowance for Long-Term Care Facility Service in the cases listed in paragraph (1), item (i) or item (v) is to be specified by the Municipality based on 90 percent of the amount equivalent to the expenses calculated with regard to said Facility Service according to the standards determined by the Minister of Health, Labour and Welfare as set forth in paragraph (2) of the preceding Article (in a case when said calculated expenses exceed the actual expenses required for said Facility Service (excluding the expenses necessary to provide meals, residence, and other necessary expenses for daily life as determined by Order of the Ministry of Health, Labour and Welfare), the base amount is to be the actual expenses required for said Facility Service).

The amount of Exceptional Allowance for Long-Term Care Facility Service in the cases listed in paragraph (1), items (ii) through (iv) is to be specified by the Municipality, for each Facility Service for Long-Term Care Covered by Public Aid in a Specified Area, Long-Term Care Health Facility Service in a Specified Area or Service at an Integrated Facility for Medical and Long-Term Care in a Specified Area, based on 90 percent of the amount of expenses calculated according to the standards determined by the Minister of Health, Labour and Welfare after taking into consideration the average expenses required for the Facility Service (excluding the expenses required for the provision of meals, the expenses required for residence, and other expenses required for daily life as specified by Order of the Ministry of Health, Labour and Welfare), which average expenses are calculated by taking into consideration the Category of Condition of Need for Long-Term Care and the area, etc., where the Long-Term Care Insurance Facility in a Specified Area pertaining to those Facility Services is located (if that amount exceeds the actual expenses required for the Facility Service (excluding the expenses required for the provision of meals, the expenses required for residence, and other expenses required for daily life as specified by Order of the Ministry of Health, Labour and Welfare), the amount of those actual expenses required for the Facility Service).

The Minister of Health, Labour and Welfare, when intending to determine the standards referred to in the preceding paragraph, must hear the opinion of the Social Security Council in advance.

The mayor of a Municipality, when he or she determines it necessary for the payment of an Exceptional Allowance for Long-Term Care Facility Service, may order a person that is or has been in charge of the Facility Service pertaining to said payment (herein referred to as "Person, etc., in Charge of Facility Service" in this paragraph) to report, to submit or present record books and documents, or to appear, or may direct its personnel to question the relevant persons or to enter the facility of said Person, etc., in Charge of Facility Service pertaining to said payment and inspect the equipment, books, documents, and other items.

The provisions of Article 24, paragraph (3) apply mutatis mutandis to questions or inspections pursuant to the provisions of the preceding paragraph, and the provisions of paragraph (4) of the same Article apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding paragraph.

In the case of applying the provisions specified in the items below to the Long-Term Care Benefit listed in each of those items that is received by an Insured Person Requiring Long-Term Care who is a Primary Insured Person and whose amount of income calculated as specified by Cabinet Order is the amount specified by Cabinet Order or more (excluding an Insured Person Requiring Long-Term Care prescribed in the following paragraph), the term "90 percent" in those provisions is deemed to be replaced with "80 percent".

payment of an Allowance for In-Home Long-Term Care Service:Article 41, paragraph (4), item (i) and item (ii), and Article 43, paragraph (1), paragraph (4) and paragraph (6);

payment of an Exceptional Allowance for In-Home Long-Term Care Service:Article 42, paragraph (4), and paragraph (5), item (i) and item (ii), and Article 43, paragraph (1), paragraph (4) and paragraph (6);

payment of an Allowance for Community-Based Long-Term Care Service:each item of Article 42-2, paragraph (2), and Article 43, paragraph (1), paragraph (4) and paragraph (6);

payment of an Exceptional Allowance for Community-Based Long-Term Care Service:Article 42-3, paragraph (2) and Article 43, paragraph (1), paragraph (4), and paragraph (6);

payment of an Allowance for Long-Term Care Facility Service:Article 48, paragraph (2);

payment of an Exceptional Allowance for Long-Term Care Facility Service:paragraph (3) and paragraph (4) of the preceding Article;

payment of an Allowance for Purchasing Equipment for In-Home Long-Term Care Covered by Public Aid:Article 44, paragraph (3), paragraph (5), and paragraph (8);

payment of an Allowance for Home Modification for In-Home Long-Term Care:Article 45, paragraph (3), paragraph (4) and paragraph (7).

In the case of applying the provisions specified in the items of the preceding paragraph to the Long-Term Care Benefit listed in those items that is received by an Insured Person Requiring Long-Term Care who is a Primary Insured Person and whose amount of income calculated as specified by Cabinet Order is the amount specified by Cabinet Order, which exceeds the amount specified by Cabinet Order in the preceding paragraph, or more, the term "90 percent" in those provisions is deemed to be replaced with "70 percent".

In a case when a Municipality applies the provisions prescribed in the items of paragraph (1) of the preceding Article to a Long-Term Care Benefit listed in said items received by an Insured Person Requiring Long-Term Care for whom the Municipality has found it difficult to pay the necessary expenses for In-Home Service (including equivalent services; the same applies hereinafter in this Article), Community-Based Service (including equivalent services; the same applies hereinafter in this Article), Facility Service, or Home Modification due to disaster or other special circumstances as determined by Order of the Ministry of Health, Labour and Welfare (excluding a case when the provisions are applied as replaced pursuant to the provisions of that Article), the term "90 percent" in the referenced provisions is deemed to be replaced with "the percentage determined by the Municipality within the range exceeding 90 percent and 100 percent or less".

In a case when a Municipality applies the provisions prescribed in the items of paragraph (1) of the preceding Article to a Long-Term Care Benefit listed in said items received by an Insured Person Requiring Long-Term Care for whom the Municipality has found it difficult to pay the necessary expenses for In-Home Service, Community-Based Service, Facility Service, or Home Modification due to disaster or other special circumstances as determined by Order of the Ministry of Health, Labour and Welfare (limited to a case when the provisions are applied as replaced pursuant to the provisions of that paragraph), the term "80 percent" in the referenced provisions applied as replaced pursuant to the provisions of that paragraph is deemed to be replaced with "the percentage determined by the Municipality within the range exceeding 80 percent and 100 percent or less".

In a case when a Municipality applies the provisions prescribed in the items of paragraph (1) of the preceding Article to a Long-Term Care Benefit listed in said items received by an Insured Person Requiring Long-Term Care for whom the Municipality has found it difficult to pay the necessary expenses for In-Home Service, Community-Based Service, Facility Service, or Home Modification due to disaster or other special circumstances as determined by Order of the Ministry of Health, Labour and Welfare (limited to a case when the provisions are applied as replaced pursuant to the provisions of paragraph (2) of that Article), the term "70 percent" in the referenced provisions applied as replaced pursuant to the provisions of paragraph (2) of that Article is deemed to be replaced with "the percentage determined by the Municipality within the range exceeding 70 percent and 100 percent or less".

When the amount obtained by deducting the total amount of the Allowance for In-Home Long-Term Care Service, Exceptional Allowance for In-Home Long-Term Care Service, Allowance for Community-Based Long-Term Care Service, Exceptional Allowance for Community-Based Long-Term Care Service, Allowance for Long-Term Care Facility Service, and Exceptional Allowance for Long-Term Care Facility Service paid for the expenses from the amount calculated as provided by Cabinet Order as the total amount of expenses required for In-Home Service (including equivalent services), Community-Based Service (including equivalent services), or Facility Service received by an Insured Person Requiring Long-Term Care (hereinafter referred to as "User Charge for Long-Term Care Service" in paragraph (1) of the following Article) is extremely large, a Municipality pays an Allowance for High-Cost Long-Term Care Service to said Insured Person Requiring Long-Term Care.

In addition to the provisions as set forth in the preceding paragraph, requirements for payment of an Allowance for High-Cost Long-Term Care Service, the amount of said allowance, and other matters necessary for the payment of an Allowance for High-Cost Long-Term Care Service are provided by a Cabinet Order after considering the impact on said household budget due to the burden of the expenses necessary for In-Home Service, Community-Based Service, or Facility Service.

A Municipality, when the total sum of the User Charge for Long-Term Care Service of an Insured Person Requiring Long-Term Care (in a case when an Allowance for High-Cost Long-Term Care Service under paragraph (1) of the preceding Article is paid, the amount obtained by deducting the amount equivalent to the amount of said allowance paid), the amount of the co-payment, etc. prescribed in Article 115, paragraph (1) of the Health Insurance Act pertaining to said Insured Person Requiring Long-Term Care (in a case when high-cost medical expenses under that paragraph are paid, the amount obtained by deducting the amount equivalent to the amount of said payment), and other amounts determined by Cabinet Order as amounts equivalent to these as prescribed in the Medical Insurance Acts or the Act on Assurance of Medical Care for Elderly People (Act No. 80 of 1982), is extremely large, pays an Allowance for High-Cost Medical and Long-Term Care Service Combined to said Insured Person Requiring Long-Term Care.

The provisions of paragraph (2) of the preceding Article apply mutatis mutandis to payment of an Allowance for High-Cost Medical and Long-Term Care Service Combined.