Long-Term Care Insurance Act

A Municipality, when an Insured Person Requiring Long-Term Care has received, from a person designated by the mayor of said Municipality (including the Municipality Where the Facility Is Located in the case of Specified Community-Based Service for an Insured Person Requiring Long-Term Care who is an Insured Person to Whom the Domicile Exception Applies (hereinafter referred to as an "Insured Person Requiring Long-Term Care to Whom the Domicile Exception Applies")) (hereinafter referred to as a "Designated Community-Based Service Provider"), Community-Based Service provided by a Business Office conducting the Community-Based Service Business pertaining to said designation (hereinafter referred to as "Designated Community-Based Service"), pays to said Insured Person Requiring Long-Term Care an Allowance for Community-Based Long-Term Care Service with regard to the expenses required for said Designated Community-Based Service (excluding, with regard to the expenses required for Community-Based Outpatient Day Long-Term Care, outpatient long-term care for a Dementia patient, Multifunctional Long-Term Care in a Small Group Home, Communal Daily Long-Term Care for a Dementia Patient, Daily Life Long-Term Care for a Person Admitted to a Community-Based Specified Facility, and Daily Life Long-Term Care for a Person Admitted to a Community-Based Facility for the Elderly Covered by Public Aid Requiring Long-Term Care, the expenses necessary to provide meals, residence and other expenses necessary for daily life as determined by Order of the Ministry of Health, Labour and Welfare; the same applies hereinafter in this Article); provided, however, that this does not apply when said Insured Person Requiring Long-Term Care, in a case where he or she has been issued a designation pursuant to the provisions of Article 37, paragraph (1), receives Community-Based Service other than the type pertaining to said designation.

The amount of Allowance for Community-Based Long-Term Care Service is to be the amount provided by each item of following, according to the category of Community-Based Service listed in said item:

Periodic Patrol and On-Demand Home-Visit Long-Term Care and Nursing and combined service: for each type of these Community-Based Services, an amount equivalent to 90 percent of the amount of expenses calculated in accordance with the standards determined by the Minister of Health, Labour and Welfare (when said calculated amount exceeds the amount of expenses actually required for said Designated Community-Based Service, the amount of expenses actually required for said Designated Community-Based Service) in consideration of the average expenses required for said Designated Community-Based Service, calculated in consideration of the content of the Designated Community-Based Service pertaining to the type of said Community-Based Service, the Category of Condition of Need for Long-Term Care, the area where the Business Office conducting said Designated Community-Based Service business is located, etc. (in the case of the expenses required for combined service (limited to that specified by Order of the Ministry of Health, Labour and Welfare; the same applies in paragraph (2) of the following Article), excluding the expenses necessary to provide meals, lodging and other expenses necessary for daily life as determined by Order of the Ministry of Health, Labour and Welfare);

Community-Based Outpatient Day Long-Term Care and outpatient long-term care for a Dementia patient: for each type of these Community-Based Services, an amount equivalent to 90 percent of the amount of expenses calculated in accordance with the standards determined by the Minister of Health, Labour and Welfare (when said calculated amount exceeds the amount of expenses actually required for said Designated Community-Based Service, the amount of expenses actually required for said Designated Community-Based Service) in consideration of the average expenses required for said Designated Community-Based Service, calculated in consideration of the content of the Designated Community-Based Service pertaining to the type of said Community-Based Service, the area where the Business Office conducting said Designated Community-Based Service business is located, etc. (excluding the expenses necessary to provide meals and other expenses necessary for daily life as determined by Order of the Ministry of Health, Labour and Welfare);

Multifunctional Long-Term Care in a Small Group Home, Communal Daily Long-Term Care for a Dementia Patient, Daily Life Long-Term Care for a Person Admitted to a Community-Based Specified Facility, and Admission to a Community-Based Facility for Preventive Daily Long-Term Care of the Elderly Covered by Public Aid:the amount equivalent to 90 percent of the expenses calculated based on standards determined by the Minister of Health, Labour, and Welfare (the actual expenses required for said Designated Community-Based Service in a case said standard amount exceeds the actual expenses required for said Designated Community-Based Service) by considering the average expenses required for said Designated Community-Based Service calculated by considering the Category of Condition of Need for Long-Term Care and the area where the provider that performs said Designated Community-Based Service Business is located, etc. (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), according to the type of Community-Based Service.

The Minister of Health, Labour, and Welfare, when providing standards for each item of the preceding paragraph, must hear the opinion of the Social Security Committee in advance.

A Municipality may, notwithstanding the provisions of each item of paragraph (2), within the limit of the amount calculated in accordance with the standards determined by the Minister of Health, Labour and Welfare in consideration of the type of Community-Based Service and other circumstances, make an amount determined by the Municipality (in the case of the amount of an Allowance for Community-Based Long-Term Care Service (limited to that pertaining to Specified Community-Based Service) for an Insured Person Requiring Long-Term Care to Whom the Domicile Exception Applies who received Designated Community-Based Service from a Designated Community-Based Service Provider for which the mayor of the Municipality Where the Facility Is Located made the designation in the main clause of paragraph (1), the Municipality Where the Facility Is Located) the amount of the Allowance for Community-Based Long-Term Care Service in that Municipality, in lieu of the amount of the Allowance for Community-Based Long-Term Care Service specified in the items of that paragraph.

A Municipality, when it intends to determine the amount of Allowance for Community-Based Long-Term Care Service in said Municipality as prescribed in the preceding paragraph, shall reflect the opinions of Insured Persons of Long-Term Care Insurance undertaken by said Municipality and take necessary measures in order to promote the use of knowledge of persons with relevant knowledge and experience, in advance.

When the payment as prescribed in the preceding paragraph is paid, it is to be deemed that an Allowance for Community-Based Long-Term Care Service is paid to Insured Person Requiring Long-Term Care.

A Municipality, when it receives a claim for an Allowance for Community-Based Long-Term Care Service from a Designated Community-Based Service Provider, is to pay it after examining the claim in light of the standards determined by the Minister of Health, Labour and Welfare under each item of paragraph (2) or the amount determined by the Municipality pursuant to the provisions of paragraph (4) (in the case of a claim for an Allowance for Community-Based Long-Term Care Service (limited to that pertaining to Specified Community-Based Service) for an Insured Person Requiring Long-Term Care to Whom the Domicile Exception Applies who received Designated Community-Based Service from a Designated Community-Based Service Provider for which the mayor of the Municipality Where the Facility Is Located made the designation in the main clause of paragraph (1), the Municipality Where the Facility Is Located), and the standards concerning facilities and management of a Designated Community-Based Service Business (limited to the part concerning the handling of Designated Community-Based Service) determined by the Municipality pursuant to the provisions of Article 78-4, paragraph (2) or (5) (in the case of a claim for an Allowance for Community-Based Long-Term Care Service (limited to that pertaining to Specified Community-Based Service) for an Insured Person Requiring Long-Term Care to Whom the Domicile Exception Applies who received Designated Community-Based Service from a Designated Community-Based Service Provider for which the mayor of the Municipality Where the Facility Is Located made the designation in the main clause of paragraph (1), the Municipality Where the Facility Is Located).

The provisions of Article 41, paragraph (2), paragraph (3), paragraph (10), and paragraph (11) apply mutatis mutandis to the payment of an Allowance for Designated Community-Based Service and the provisions of paragraph (8) of the same Article shall apply mutatis mutandis to a Designated Community-Based Service Provider. In this case, the necessary technical replacement of terms in these provisions specified by a Cabinet Order.

In addition to the provisions as prescribed in each of the preceding paragraphs, necessary matters for payment of an Allowance for Designated Community-Based Service and a request by a Designated Community-Based Service Provider for an Allowance for Designated Community-Based Service is as determined by Order of the Ministry of Health, Labour, and Welfare.

A Municipality, in the following cases, pay an Exceptional Allowance for Community-Based Long-Term Care Service to an Insured Person Requiring Long-Term Care:

when the Municipality determines it necessary in a case when an Insured Person Requiring Long-Term Care receives a Designated Community-Based Service 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 has a domicile on an isolated island or other area where it is significantly difficult to secure Designated Community-Based Service (except for Admission to a Community-Based Facility for Preventive Daily Long-Term Care of the Elderly Covered by Public Aid; the same applies hereinafter in this item) and in a location that qualifies with standards as determined by the Minister of Health, Labour, and Welfare, and an Insured Person receives Community-Based Service other than Designated Community-Based Service (except for Admission to a Community-Based Facility for Preventive Daily Long-Term Care of the Elderly Covered by Public Aid) or an equivalent service to said services;

when provided by a Cabinet Order.

The amount of an Exceptional Allowance for Community-Based Long-Term Care Service is to be specified by a Municipality based on the amount equivalent to 90 percent of the amount of expenses calculated, for said Community-Based Service or equivalent service, by the standards determined by the Minister of Health, Labour and Welfare under each item of paragraph (2) of the preceding Article (when said calculated amount exceeds the amount of the actual expenses required for said Community-Based Service or equivalent service (excluding, with regard to the expenses required for Community-Based Outpatient Day Long-Term Care, outpatient long-term care for a Dementia patient, Multifunctional Long-Term Care in a Small Group Home, Communal Daily Long-Term Care for a Dementia Patient, Daily Life Long-Term Care for a Person Admitted to a Community-Based Specified Facility, Daily Life Long-Term Care for a Person Admitted to a Community-Based Facility for the Elderly Covered by Public Aid Requiring Long-Term Care, and combined service, and services equivalent to these, the expenses necessary to provide meals, residence and other expenses necessary for daily life as determined by Order of the Ministry of Health, Labour and Welfare), said amount is to be the amount of the actual expenses required for said Community-Based Service or equivalent service), or the amount specified by the Municipality pursuant to the provisions of paragraph (4) of the same Article (in the case of an Exceptional Allowance for Community-Based Long-Term Care Service (limited to that pertaining to Specified Community-Based Service) for an Insured Person Requiring Long-Term Care to Whom the Domicile Exception Applies who received Designated Community-Based Service from a Designated Community-Based Service Provider for which the mayor of the Municipality Where the Facility Is Located made the designation in the main clause of paragraph (1) of the same Article, or another person specified by Order of the Ministry of Health, Labour and Welfare, the Municipality Where the Facility Is Located).

The mayor of a Municipality, when he or she determines the necessity of payment of an Exceptional Allowance for Community-Based Long-Term Care Service, orders a person that has been in charge of said Community-Based Service pertaining to said payment or in charge of an equivalent service (herein referred to as "Person, etc., in Charge of Community-Based Service, etc." in this paragraph) to report, submit or present record books and documents, appear, or direct its personnel to question the relevant person or enter the Business Office of the provider of said Person, etc., in Charge of Community-Based Service, etc., pertaining to said payment in order to inspect said equipment, record books and documents, and other items.

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